Is this “autism lite” or a symptom of ADHD?
Let’s discuss social (pragmatic) communication disorder (SCD/SPCD) and what we know about this label as it stands today. Many have wondered if this diagnosis came out of no where and if it has any real basis other than a “catch-all” label. And the short answer is: sort of. Beginning in the 80’s and 90’s researchers first identified a subset of children who did not meet criteria for autism or Asperger’s disorder, as they has typical prosody (i.e., pattern of speech) and typical use of nonverbal gestures as well as a lack of stereotyped behaviors/restricted interests, while still exhibiting social communication deficits. They labeled this group as having a “semantic-pragmatic” disorder, though no formal diagnosis was ever provided. Similarly, in the 90’s, researchers began to refer to the “broader autism phenotype”, as a set of symptoms often found in relatives of those with autism, while not meeting full criteria of autism. These “symptoms” were said to include some combination of language delay, reduced social interaction skills, aloofness, and/or rigidity, thought to be “milder” or “soft” signs of autism. And thus, in the 2013 version of the DSM-5 (the psychiatric/psychological reference guide), social communication disorder was born. As a result, many children who ultimately received an SCD diagnosis after its inception, were children who were previously diagnosed with PDD-NOS, “mild aspergers” or “severe ADHD.”
A basic description of social competence according to today’s standards would be: the ability to internalize and assess a situation, perceive the behavior and social cues accurately, and respond accordingly and appropriately. For children with SCD, generally, the more structural or rote expressive and receptive language-based skills are preserved (e.g., vocabulary, grammar/syntax, sentence organization etc.) but higher-level language is significantly weaker. SCD can be diagnosed after 4 years of age, once child has demonstrated “typical” basic /low-level language development. Importantly, SCD cannot be diagnosed if ASD is diagnosed; however, ADHD can be diagnosed alongside SCD. Children with SCD often have difficulty with the interpretation of both verbal and nonverbal language including, greeting others, turn-taking in conversations, respecting physical boundaries, and adjusting their behavior according to context/situations (e.g., friend crying, funeral, sick parent etc.). Other social communication deficits can include: poor topic management, inappropriate sharing of information, misunderstandings due to poor perspective-taking, unusual intonation, and difficulties with paralinguistic in language (e.g., eye contact, nonverbal gestures), which can interfere with conversational reciprocity. Academically, many have difficulty with implied sentences and indirect uses of language (e.g., metaphors, sarcasm, inference, negotiation, multiple meanings, and idioms). More specifically, this can look like a child misreading or misinterpreting facial expressions, or tone of voice, not understanding why their class mates find them annoying, and taking jokes or sarcasm literally, resulting in hurt feelings or withdrawal from interested peers.
Though certainly part of the difficulty lies within underdeveloped higher-level language skills, many argue that emotional dysregulation often underlies the ineffectiveness and consistency of employing these skills. In fact, emotional regulation difficulties at age 5 have predicted underdeveloped social skills by age 7, resulting in reduced peer acceptance and friendship quality. Moreover, studies have shown that there is also a strong correlation between those who struggle with response inhibition (e..g, thinking before they speak/act, controlling one’s behaviors) and social communication weaknesses. For example, approximately 54% of those with ADHD experience clinically significant levels of emotional dysregulation and/or disinhibition. Morevover, as evidenced by one study, those with ADHD-hyperactive/impulsive symptoms and restricted/repetitive behaviors were related to reduced social competence via emotional dysregulation, while those with ADHD-inattentive symptoms or social communication/interaction symptoms were more purely related to difficulty with social competence. Without intervention for such dysregulation, these effects often spill over into various domains of functioning and those affect peer relationships, family life, occupational/vocational success, and academic performance and these children get older. Similarly, children with ASD and co-occurring social communication deficits are reported to experience emotional dysregulation, which can result in increased social anxiety, anxiety, depression, withdrawal, aggression, and sensory reactiveness. Both groups experience a high rate (~80%) of peer rejection, which can lead to poor self-esteem and depression in adolescence and young adulthood. SCD and associated disorders can also feed into the cycle of reduced social success, as they may be privy to less social situations/experiences and natural skills development, secondary to rejection, thus further disconnecting them from their peers.
In terms of comorbidities, most common co-occurring disorders are ADHD, speech disorders, or learning disorders. One study found that up to 82% of children with ADHD experience some form of communication impairment that affected social development, further highlighting the strong overlap between ADHD and SCD. Others have also suggested that the SCD profile can be similar to that of proposed (though never formally accepted) NVLD (non-verbal learning disorder), with overall in reduced abstract reasoning, emotional perception, and social communication skills. As mentioned, as it stands presently, SCD requires an exclusion of autism to be diagnosed; however, there appears to be some recent evidence of overlap in neuroanatomical make-up. Researchers have potentially identified two predominant types of autism spectrum using brain imaging: one type being due to hyper-connection (unusually high amount of connections between neurons) and the other hypo-connection (reduced amount connections between neurons) within the brain, resulting in either over or under activity, ultimately affecting communication between neurons. Hyper-connection was more associated with more profound autism and those with more significant genetic abnormalities and/or lack of pruning of neurons during typical development (resulting in disorganization and efficiency within the brain), while hypo-connection tended to be more associated with SCD and what was formerly know as “Aspergers Syndrome.” Further, in terms of neuroanatomy, similar differences within the brain structure have been identified in those with ASD, ADHD, and SCD (e.g., frontal-parietal network, anterior temporal network, and temporoparietal junction). On the other hand, one of the potential differences between those with SCD as compared to autism, is that children with SCD may largely possess the knowledge of social conventions, metalinguistic skills, and ability to demonstrate appropriate pragmatic interactions on formal assessment; however, they are unable to execute this knowledge and skill set consistently secondary to disinhibition, emotional dysregulation, anxiety, or other factors (e.g., knowing the right thing to say but experiencing high levels of frustrated and impulsivity resulting in an inappropriate response). Interestingly, another one of the differences observed is the usage of fillers (“ums”, “uh huh”, “like”, etc.), as those with SCD tend to use fillers more often than those with autism (generally rare use, more pauses or rapid speech).
Considering the notable overlap between ASD, ADHD, and SCD, many researchers and clinicians have advocated for a continuum that include ASD and ADHD, especially given the underlying genetic and environmental overlap in etiology and symptomatology. In fact, in looking at twin studies in which both children were diagnosed with autism, there were often weak correlations between the severity of social communication and restricted/repetitive behavior difficulties, demonstrating the significant variability, even within families. Because of this, some argue that SCD should either fit along the ASD/ADHD continuum (e.g., dimensional vs. categorical or “fit in a box” system) or be considered as a “symptom” (e.g., trans-diagnostic feature) of either diagnosis, when can be qualified in terms of severity, rather than a separate disorder. Others have expressed concern with the current classification system in terms of resolving this “grey area”, for which a child may have clear social communication deficits but also has some mild restricted/repetitive behaviors (e.g., perhaps tied to ADHD or anxiety), which may disqualify them for a SCD diagnosis, but at the same time the behaviors are not seen as severe enough to meet criteria for autism. Finally, there is also concern that there are so many supports for children with autism, that those with SCD may not be eligible, as they would not receive a formal autism diagnosis, even if they also exhibit significant barriers to quality of life.
In terms of diagnosing SCD, as of today there are no formal measures that are specific to SCD. Typically, interviews or questionnaires that are commonly administered when ASD and/or ADHD referral questions (e.g., ADI-2, DISCO, 3di, CCC-2, SRS-2) are employed in addition to conceptualization of the overall neurocognitive profile. Those with SCD typically (though not always) present with average or higher IQ, age-appropriate concrete language skills, and grade-level or higher academic skills (unless a separate learning disability is present) in addition to reduced social communication/pragmatic language skills. When a neuropsychologist or speech/language pathologist is looking specifically at social communication or pragmatic language skills, the most common tests include: CASL-2, CELF-5-META, SLDT-E:NU, RESCA-E, and TOPL-2; however, even with several of these measures used, some of these tests are not sensitive enough to pick up on pragmatic deficits, especially for those children with high IQ and problem-solving skills. As such, a detailed developmental/social history and in-depth behavioral observations are critical for this diagnosis to be accurate. It can be challenging for clinicians to diagnose based upon similar profiles, without really understanding the quality, frequency, and severity of social communication deficits in the context of the larger neuropsychological profile. Typically, a diagnosis of autism or ADHD requires a psychologist, psychiatrist, or neurologist; however, SLPs are able to diagnose SCD with confidence and often refer cases in which both ASD and SCD are on the table to neuropsychologists. If SCD continues to be a stand-alone diagnosis, it is likely that specific questionnaires may ultimately be developed.
So probably not too surprisingly based on the above information, many of the interventions for SCD are in line with those for autism and ADHD. But the key here is really to ensure that the interventions selected are as individualized as their specific presentation of SCD (including underlying factors and barriers). The combination of targeting emotional regulation and social communication deficits may be most important in terms of specific intervention frequencies and intensities, dependent upon the child’s specific diagnostic profile. As such, it beneficial to understand what the actual barriers are to social success; for example, inattention, rigidity, emotional reactivity, reduced social communication skills, and/or impulsivity. Goals of treatment may include: facilitating activities for pro-social interactions to build new skills, addressing barriers that interfere with effective social communication, and building independence across environments/situations. Speech/language (individual and/or group-based), social stories/comic strips (where the therapist or child can draw and play out social scenarios) and drama therapy (reenacting social scenarios through storytelling, puppetry, and theatre) have been found to prove beneficial for children with SCD. Some children have also benefitted from video-based modeling of themselves or others demonstrate effective and thoughtful social interactions. Many benefit from role-playing and feedback with a group instructor/facilitator with peers with similar profiles (e.g., social skills group). It can also be helpful for parents to ask many open-ended questions when reading a book or discussing a recent event. Structured 1:1 play dates where the parent can provide helpful and gentle feedback afterward can also be beneficial. Recent research has also shown possible benefit from NAC or saffron in terms of improving emotional regulation and social inferencing. Finally, current research seems to point to minimal effect from augmentative and alternative communication (AAC) or theory of mind-based interventions, but there has not been enough research conducted with large and varied clinical samples to say for sure yet- so stay tuned!