Social Communication Disorder

Social Communication Disorder: a new childhood diagnosis

Case

H. F. is an 11-year-old male with a history of major depressive disorder (MDD) and attention deficit disorder (ADHD) who presented to the inpatient child and adolescent mental health unit with suicidal ideation. During an interview with H. F. and family members, it became clear that there were behavior concerns during school, increased difficulties in interpersonal relationships with peers, and increasing use of the Internet and social media to form social relationships. His parents were also concerned about the inappropriate content of his conversations online.

During an interview with H. F. alone, he showed difficulty in conversation with tangents on an odd range of topics, for

example “robo-hamsters,” his pets, and “becoming a bank robber” but was generally redirectable. Throughout conversation he was also excessively fidgety and could not maintain appropriate body station, eye contact or maintained engagement. While hospitalized, he had several incidents of initiating conversation with peers on inappropriate sexual, violent or gross topics, despite clear negative feedback from his peers. When discussed with him, he could not demonstrate understanding of why these conversations were inappropriate or why his peers did not wish to engage in them.
While discussing this behavior during morning rounds, the attending physician posed a question about the new diagnosis of social communication disorder (SCD) and whether it would be appropriate for this patient.

Overview and Diagnosis of SCD

SCD is a new psychiatric diagnosis first included in the 5th edition of the Diagnostic statistical manual of mental disorders (DSM) in the category of neurodevelopmental disorders. It is worthwhile noting that while the diagnosis is new in psychiatry a very similar diagnosis has existed in the field of language and communication disorders called pragmatic language impairment (PLI), which I will discuss later. Diagnostic criteria for SCD are as follows:

“Persistent difficulties in the social use of verbal and nonverbal communication as manifested by all of the following: deficits in using communication for social purposes […] in a manner that is appropriate for the social context; impairment of the ability to change communication to match context or the needs of the listener […]; difficulties following rules for conversation and storytelling […]; and difficulties understanding what is not explicitly stated […] and nonliteral or ambiguous meanings of language […].” (American Psychiatric Association,

2013)
The language and conversation of children with SCD may resemble that of children with high functioning autism spectrum disorder, but these children notably lack the restricted and repetitive behaviors that children with autism spectrum disorder (ASD) demonstrate.
Importantly, children diagnosed with SCD must also demonstrate functional limitations as a result of poor pragmatic communication skills, which may pose barriers to social, interpersonal and academic or occupational success (American Psychiatric Association, 2013). Also, the communication deficit cannot be due to a deficit in structural language skills, or be attributable to another medical or neurological condition. Because the structural language system, including grammar and word choice, must be developed prior to making a diagnosis, the earliest a child could be diagnosed is 4-5 years of age.
The American Psychiatric Association also notes frequent co-occurrence of other neurodevelopmental disorders, especially ADHD, behavioral and emotional problems, and specific learning disorder (2013). However, if a child’s symptoms are better and more completely explained by ASD, intellectual developmental disorder, global developmental delay or another mental disorder, a diagnosis of SCD cannot be made. The absence of restricted and repetitive behaviors is important in appropriately diagnosing a patient with SCD versus ASD.
Formation of a diagnosis
The concept of social communication impairment began in the 1980s (*** Citation); however, for many years it was discussed rarely outside the context of autism. In the field of speech-language pathology “pragmatics” is one of the five components of language, the others being phonology, morphology, syntax and semantics each describing an aspect of the structure and content of language. Pragmatics on the other hand describes the function of language and is defined by the American Speech-Language-Hearing Association (1993) as “the system that combines the [other four] language components in functional and socially appropriate communication.” Furthermore, the American Speech-Language Association describes three skills that contribute to pragmatic language, “using language for different purposes,” “changing language to meet the needs of a listener or situation,” and “following rules for conversations and storytelling.” These three skills align very closely with the specified types of deficits that characterize SCD in the DSM-5.
Gibson, et al (2013) found that when comparing pragmatic language impairment to specific language impairment (deficit in structural language skills) and high functioning autism (defined as children with autism with either normal or elevated IQ scores) distinguishing factors became apparent supporting the creation of a diagnosis distinct from either ASD or specific language impairment. One of these features was the increased expressive language ability in pragmatic language impairment when compared to specific language impairment, but decreased expressive language ability in pragmatic language impairment when compared to high functioning autism. The authors also found differences in both the severity and type of social impairments experienced by each of the three groups. Children with an autism diagnosis, the study demonstrates, do not show improvement in social functioning with acquired language skills, whereas the children in the specific language impairment and pragmatic language impairment did have improvement in social skills with the acquisition of language skills. Congruent with these findings, the study also found that compared with pragmatic language impairment the social and language deficits in ASD are more pervasive. This data supported the creation of a diagnosis that was distinct from either specific language impairment or ASD, and yet also related to both.
More generally, the changes made in the DSM-5 when compared to the DSM-IV reflect an effort to classify diagnoses using their “neurobiologic bases” versus as groupings of symptoms (Grant and Nozyce, 2013).

The diagnosis of ASD was made simpler by moving towards a dyad model requiring both social communication deficits and repetitive and restrictive behaviors, and Aspberger’s Disorder and pervasive developmental disorder-not otherwise specified (PDD-NOS) were eliminated (Swineford, et al, 2014). This aligns with goal of making the DSM an evidenced based document, as there was little consensus regarding the distinction between autism disorder, Aspberger’s disorder and PDD-NOS. This change and the addition of SCD as a diagnosis distinct from ASD emphasizes that these children have a pathology that is fundamentally different from, rather than a mild form of,

autism.
Controversy
Examining the development of the SCD diagnosis is an interesting study into the importance of naming and language in psychology. While the above discussion of changes in the DSM may seem like simple semantics, it is important to recognize that specific diagnoses are important in deciding if children and families qualify for specific services and therapies. Of note, children with current, well-established DSM-IV diagnoses of Autistic Disorder, Asperger’s Disorder or PDD-NOS will have a diagnosis of ASD for the purposes of continuity of care and maintaining eligibility for services (CITATION).
However, there is concern that from this point forward, children who would have been diagnosed with PDD-NOS and received multidisciplinary services similar to children with ASD may now be diagnosed with SCD and qualify for a more limited set of services, likely only speech-language therapy. In their article examining the implications of the change, Grant and Nozyce (2013) note, “Applied behavior analysis (ABA) is the most frequently used evidence-based intervention model for young children currently diagnosed with any of the Pervasive Develop- mental Disorders. Children diagnosed with SCD may not be authorized for ABA even if clinically indicated because SCD is essentially a communication disorder diagnosis.” This could be a potential disparity of services and therapies when considering that many of children meeting criteria for SCD diagnosis would have formerly been classified as having PDD-NOS.
Further study should be done to assess whether this more limited therapy and social supports are sufficient for these children. It may be the case where, given the high rates of association with ADHD and behavioral and emotional disorders, that children diagnosed with SCD may receive multiple diagnoses in order to meet needs outside of speech-language therapy.
Case follow-up
While the patient in this case did not receive an official diagnosis of social communication disorder, he did exemplify some of the characteristic features. He also demonstrated the often-associated ADHD and behavioral and emotional difficulties. Were, after more extensive evaluation, a diagnosis of social communication disorder made in his case, it would be prudent to examine whether or not he would benefit from the additional diagnosis for either increased therapies or a better clinical understanding of his condition.
As with any newly named diagnosis, further investigation is needed into the epidemiology, therapeutic options and prognosis for these patients. Multidisciplinary research is also pertinent into how this diagnosis may affect eligibility for services, education, and treatment of co-morbid psychiatric illness. In ASD there is a push for practitioners to diagnose and initiate therapy earlier in childhood or infancy to improve long-term prognosis. However, the diagnosis of SCD cannot be made until 4-5 years of age after structural language skills are developed. Investigation into early warning signs of the disorder and consequences of early therapy should be studied for the potential to improve prognosis in these individuals.