08 - 31.4d Social (Pragmatic) Communication Disord

31.4d Social (Pragmatic) Communication Disorder

distraction, relaxation techniques, and directed speech modification. Stutterers who have poor self-image, comorbid anxiety disorders or depressive disorders are likely to require additional treatments with cognitive-behavioral therapy (CBT) and/or pharmacologic agents such as one of the selective serotonin reuptake inhibitor (SSRI) antidepressants. An approach to stuttering proposed by the Speech Foundation of America is labeled self-therapy, based on the premise that stuttering is not a symptom, but a behavior that can be modified. Stutterers are told that they can learn to control their difficulty partly by modifying their feelings about stuttering and attitudes toward it and partly by modifying the deviant behaviors associated with their stuttering blocks. The approach includes desensitizing; reducing the emotional reaction to, and fears of, stuttering; and substituting positive action to control the moment of stuttering. 31.4d Social (Pragmatic) Communication Disorder Social (pragmatic) communication disorder is a newly added diagnosis to DSM-5 characterized by persistent deficits in using verbal and nonverbal communication for social purposes in the absence of restricted and repetitive interests and behaviors. Deficits may be exhibited by difficulty in understanding and following social rules of language, gesture, and social context. This may limit a child’s ability to communicate effectively with peers, in academic settings, and in family activities. To successfully achieve social and pragmatic communication, a child or adolescent would be expected to integrate gestures, language, and social context of a given interaction to correctly infer its meaning. Thus, the child or adolescent would be able to understand another speaker’s “intention” of the communication with verbal and nonverbal cues as well as through an understanding of the environmental and social context of the interaction. One of the reasons that social (pragmatic) communication disorder was introduced into the DSM-5 was to include those children with social communication impairment who do not exhibit restrictive and repetitive interests and behaviors, and therefore do not fulfill the criteria for autism spectrum disorders. Pragmatic communication encompasses the ability to infer meaning in a given communication by not only understanding the words used, but also integrating the phrases into their prior understanding of the social environment. Social (pragmatic) communication disorder is a new disorder; however, the concept of children with social communication deficits without repetitive and restrictive interests and behaviors has been identified for many years, and is often associated with delayed language acquisition and language disorder. EPIDEMIOLOGY It is difficult to estimate the prevalence of social (pragmatic) communication disorder. Nevertheless, a body of literature has documented a profile of children who present with these persistent difficulties in pragmatic language, who do not meet criteria for autism spectrum disorder.

COMORBIDITY Social (pragmatic) communication disorder is commonly associated with language disorder, consisting of diminished vocabulary for expected age, deficits in receptive skills, as well as impaired ability to use expressive language. Attentiondeficit/hyperactivity disorder (ADHD) is often concurrent with social (pragmatic) communication disorder. Specific learning disorders with impairments in reading and writing are also commonly comorbid disorders with social (pragmatic) communication disorder. Although some symptoms of social anxiety disorder may overlap with social (pragmatic) communication disorder, the full disorder of social anxiety disorder may emerge comorbidly with social (pragmatic) communication disorder. ETIOLOGY A family history of communication disorders, autism spectrum disorder, or specific learning disorder all appear to increase the risk for social (pragmatic) communication disorder. This suggests that genetic influences are contributing factors in the development of this disorder. The etiology of social (pragmatic) communication disorder, however, is likely to be multifactorial, and given its frequent comorbidity with both language disorder and ADHD, developmental and environmental influences are likely to also play a role. DIAGNOSIS The diagnosis of social (pragmatic) communication disorder can be difficult to distinguish from mild variants of autism spectrum disorder in which repetitive and restricted interests and behaviors are minimal. There have been largely discrepant data regarding how many children previously diagnosed with autism would be excluded from the DSM-5 criteria, which now focus on only two symptom domains: social communication deficits and restricted repetitive interests and behaviors. In one study, only 60.6 percent of children who had previously met the criteria for autistic spectrum disorder in the previous edition of the DSM met DSM-5 criteria for autistic spectrum disorder. However, in another study, up to 91 percent patients with of autism continued to meet the same DSM-5 criteria. The essential features of social (pragmatic) communication disorder are persistently impaired social pragmatic communication resulting in limited effective communication, compromised social relationships, and difficulties with academic or occupational achievement. CLINICAL FEATURES Social (pragmatic) communication disorder is characterized by impaired ability to effectively use verbal and nonverbal communication for social purposes and occurs in the absence of restricted and repetitive interests and behaviors. According to the DSM-5,

all of the following features must be present in order to meet diagnostic criteria: (1) Deficits in using appropriate communication such as greeting, or sharing information in a social situation or context. (2) Impaired ability to modulate the tone, level, or vocabulary used in social communication to match the listener and the situation, such as inability to simplify communication when speaking to a young child. (3) Impaired ability in following the rules for conversations such as taking turns or rephrasing a statement for clarification and failure to recognize and respond socially appropriately to verbal and nonverbal feedback. (4) Difficulty understanding things that are not explicitly stated, impaired ability to make inferences, understand humor, or interpret socially ambiguous stimuli. Although the preceding deficits begin in the early developmental period, the diagnosis is rarely made in a child younger than 4 years of age. In milder cases, the difficulties may not become apparent until adolescence when the demands for language and social understanding are increased. The deficits in social communication lead to impairment in function in social situations, in developing relationships, and in family and academic settings. DIFFERENTIAL DIAGNOSIS The primary diagnostic consideration in social (pragmatic) communication disorder is autism spectrum disorder. The two disorders are most easily distinguished when the prominence of restricted and repetitive interests and behaviors characteristic of autistic spectrum disorder is present. However, in many cases of autism, the restrictive interests and repetitive behaviors manifest more prominently in the early developmental period and are not obvious in older childhood. However, even when these features are not observable, if they are obtained by history, social (pragmatic) communication disorder is not diagnosed, rather autism is the diagnosis. Social (pragmatic) communication disorder is considered only when the restricted interests and repetitive behaviors have never been present. ADHD may overlap with social (pragmatic) communication disorder in social communication disturbance; however, the core features of ADHD are not likely to be confused with autism spectrum disorder. In some cases, however, the two disorders may coexist. Another childhood disorder with socially impairing symptoms that may overlap with social (pragmatic) communication disorder is social anxiety disorder. In social anxiety disorder, however, social communication skills are present, but not manifested in feared social situations. In social (pragmatic) communication disorder, appropriate social communication skills are not present in any setting. Both social anxiety disorder and social (pragmatic) communication disorder may occur comorbidly, however, and children with social (pragmatic) communication disorder may be at higher risk for social anxiety disorder. Finally, intellectual disability may be confused with social (pragmatic) communication disorder, in that social communication skills may be deficits in children with intellectual disability. A diagnosis of social (pragmatic) communication disorder is made only when social communication skills are clearly more severe than the intellectual disability.