Friday, December 27, 2013

Social (Pragmatic) Communication Disorder

The new Autism Spectrum Disorder diagnostic criteria state:  If have the social communication symptoms of ASD, but that's all (no stereotyped  behaviors, sensory issues), then the correct diagnosis for you might be:S(P)CD: Social (Pragmatic) Communication Disorder.  [Yep, that's formal, official diagnostic label, including the parenthesis.]

Controversy, or old news?
It has always been the case that you needed more than just social communication issues to be labeled with Autism or Asperger's; what's new in the DSM 5 is that if you do not meet the full criteria, there is now a new diagnostic option to consider.  

Implications for assessing ASD:  Find the RRBs and sensory issues
What does this mean for people with ASD fearing the loss of their diagnosis?  What is certain is that this will require people to assess more carefully for the category B symptoms of ASD, the restricted and repetitive patterns of behavior and sensory issues.  These may not be as prominent as the social and communication and theory of mind issues in ASD, but they may still be there. 

Not quite the same social/communication problems: 
    Notice in the criteria, pasted below, that the descriptions of social communication difficulties, though they overlap with the criteria for Autism Spectrum Disorder, are not quite the same.  My overall impression is that there is more emphasis here on language and communication rather than the ASD emphasis on theory of mind issues and other problems caused by difficulty managing complex streams of information (e.g. reading nonverbals and verbal simultaneously).  

Different populations, different origins, different brains?
This difference in the criteria suggests a different origin for similar behaviors. 
There may be kids out there who have some of the same social communication problems as a person with ASD but no general problems with coordinating sensory and perceptual and symbolic and motor information and action.  Instead, this may be a more focused language disability, caused by a problem with certain parts of the brain rather than caused by coordination problems among different areas of the brain as in ASD. 

Treatment/Support differences: The obvious

One of the functions of a diagnosis is to guide treatment/support. Kids with both S(P)CD, and ASD will often be helped by language pragmatics instruction (e.g. how to join a conversation without ending it).  With S(P)CD, based on the criteria, there may be many occasions of needing to explain idioms and sarcasm.  With either diagnosis, here may be social, mood, anxiety, and behavioral issues which will be helped by counseling, psychotherapy, coaching, and empathetic loved ones.  Kids with S(P)CD are not as likely to need occupational therapy/sensory integration work. 

Treatment/Support differences: The Speculative
If I am right that there are two populations with two different kinds of brain differences, then beyond the language social pragmatics instruction, the two groups might need different kinds of therapy, one focused on social and symbolic language and the other, with ASD, focused* more broadly on cognitive/emotional/motor/symbolic integration and adaptability *(at least in my model of ASD treatment and support... a subject for another post). 

Diagnostic Criteria for Social (Pragmatic) Communication Disorder

A. Persistent difficulties in the social use of verbal and nonverbal communication as manifested by all of the following:
1. Deficits in using communication for social purposes, such as greeting and sharing information, in a manner that is appropriate for social context.
2. Impairment in the ability to change communication to match context or the needs of the listener, such as speaking differently in a classroom than on a playground, talking differently to a child than to an adult, and avoiding use of overly formal language.
3. Difficulties following rules for conversation and storytelling, such as taking turns in conversation, rephrasing when misunderstood, and knowing how to use verbal and nonverbal signals to regulate interaction.
4. Difficulties understanding what is not explicitly stated (e.g., making inferences) and nonliteral or ambiguous meaning of language (e.g., idioms, humor, metaphors, multiple meanings that depend on the context for interpretation.)
B. The deficits result in functional limitations in effective communication, social participation, social relationships, academic achievement, or occupational performance, individually or in combination.
C. The onset of the symptoms is in the early developmental period (but deficits may not become fully manifest until social communication demands exceed limited capacities).
D. The symptoms are not attributable to another medical or neurological condition or to low abilities in the domains of word structure and grammar, and are not better explained by autism spectrum disorder, intellectual disability (intellectual developmental disorder), global developmental delay, or another mental disorder. 

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