Similar … But Very Different Determining when a child has social communication disorder versus autism spectrum disorder can be tricky. Here are some key considerations. Features
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Features  |   April 01, 2018
Similar … But Very Different
Author Notes
  • Geralyn R. Timler, PhD, CCC-SLP, is associate professor and director of the speech-language pathology master’s residential program at James Madison University in Harrisonburg, Virginia. She is a member of ASHA Special Interest Groups 1, Language Learning and Education; and 16, School-Based Issues. timlergr@jmu.edu
    Geralyn R. Timler, PhD, CCC-SLP, is associate professor and director of the speech-language pathology master’s residential program at James Madison University in Harrisonburg, Virginia. She is a member of ASHA Special Interest Groups 1, Language Learning and Education; and 16, School-Based Issues. timlergr@jmu.edu×
Article Information
Special Populations / Autism Spectrum / Language Disorders / Social Communication & Pragmatics Disorders / Features
Features   |   April 01, 2018
Similar … But Very Different
The ASHA Leader, April 2018, Vol. 23, 56-61. doi:10.1044/leader.FTR2.23042018.56
The ASHA Leader, April 2018, Vol. 23, 56-61. doi:10.1044/leader.FTR2.23042018.56
Brian, a 14-year-old ninth-grader, struggles with peer interactions at school. He misreads facial expressions and tone of voice, often missing the sarcasm behind some of the comments directed to him by his classmates: When Brian forgot to add his section to a Google Doc group assignment, one of his assignment partners quipped, “Way to go, Brian,” in a clearly sarcastic tone. Brian missed the sarcasm and was unaware of his partner’s frustration.
Renee is a 9-year-old who often interrupts others. She answers questions before her conversational partner has finished speaking, and her answers are frequently unexpected or slightly off the mark. When asked what she did over the weekend, Renee responded, “I like shopping,” without continuing to explain how shopping was part of her weekend. Renee’s mom reports that she has no “real” friends at school and that her classmates find her “annoying.”
Children and adolescents like Brian and Renee raise interesting questions about our role as speech-language pathologists in diagnosing, assessing and treating students with challenges in social communication and peer interactions. Some of these children will receive or already have a diagnosis of autism spectrum disorder (ASD). Others may not fit true criteria for ASD and instead may be candidates for a diagnosis of social (pragmatic) communication disorder (SCD).
The two main questions we and others on our clinical team face are:
  • When is it more appropriate to diagnose SCD versus ASD?

  • How do we tailor the treatment plan to best fit each disorder?

The challenge for diagnosticians is that the social-interaction behaviors of children with ASD and SCD may look similar.

Differential diagnosis
ASD and SCD are mutually exclusive disorders—someone with ASD cannot also receive a diagnosis of SCD, and the reverse is also true. The two core diagnostic dimensions for ASD are restricted and repetitive behavior patterns and persistent difficulties in social communication and social interaction. The challenge for diagnosticians is that the social-interaction behaviors of children with ASD and SCD may look similar, because both disorders focus on diagnostic symptoms of functional impairments in verbal and nonverbal social communication skills.
For example, in the Diagnostic and Statistical Manual of Mental Disorders (DSM–5), overlapping descriptors of ASD and SCD include phrases such as difficulties in “social participation” and “social relationships.” Other descriptors are very similar: “difficulties adjusting behavior to suit various social contexts” (ASD) and “impairment of the ability to change communication to match context” (SCD).
Recent studies focused on identifying potential differences in the verbal and nonverbal social communication skills of children with ASD or SCD reveal that observational and parent-report measures of children’s social interactions overlap (see sources). That is, few group differences were found—although some children with SCD show milder deficits than children with ASD.
Unfortunately, even mild deficits in understanding and using verbal and nonverbal social cues can lead to significant functional impairment in peer interactions. Therefore, the distinction between the social interactions of children with ASD and SCD is more likely a difference of degree or severity, rather than a unique communication profile of strengths and weaknesses for each disorder.
One issue, however, is very clear: Social communication skills should be a priority for assessment and intervention with either disorder.

What distinguishes ASD from SCD most clearly is that children who receive an ASD diagnosis must show—or have a history of—restricted and repetitive patterns in behaviors, activities and interests.

Disorder differences
What distinguishes ASD from SCD most clearly is that children who receive an ASD diagnosis must show—or have a history of—restricted and repetitive patterns in behaviors, activities and interests. These patterns include, for example, echolalia, lining up toys rather than using them in ways that other children do, becoming severely upset with transitions and interruptions in routines, showing extremely focused interests on one or more topics, and displaying significant under- or over-sensitivity to sights, sounds and textures.
Brian, the 14-year-old who doesn’t “get” sarcasm, had an early developmental history with behaviors that supported his diagnosis of ASD. As a young child, Brian spent hours playing with Legos and became extremely upset when his parents tried to change activities. He was so sensitive to loud sounds that his family had to change routines to accommodate his sensitivities. For example, his mother vacuumed the house when Brian was at school, and Brian chose to wear noise-reducing headphones when the neighbors mowed the lawn.
Although Brian spoke in phrases by 24 months, he showed little interest in playing with his preschool peers, often talking to himself rather than engaging with other children. Brian’s early difficulties in social interaction in the presence of reaching typical language milestones—such as the acquisition of first words by 12 months and phrasal speech by 24 months—is typical of children who were previously diagnosed with Asperger syndrome, based on earlier editions of the DSM.
The DSM-5 (fifth edition), released in 2013, excludes the category of Asperger syndrome from the description of autism spectrum disorder (see the Leader article on DSM-5 changes to the ASD category). Previous studies of children with ASD and children with Asperger syndrome did not reveal consistent and reliable differences in the social interaction of the two groups (see sources). As such, Brian’s social-interaction behaviors and history of restricted and repetitive patterns fit the DSM-5 diagnostic criteria for ASD.
On the other hand, Renee—the 9-year-old with disjointed conversational skills—has a diagnosis of SCD. Although Renee and Brian show social-interaction difficulties that negatively affect their peer interactions in similar ways, Renee does not show—and has no reported history of—significant restricted and repetitive patterns.
SLPs’ role
ASHA’s position is that SLPs can diagnose ASD independently, although typically they do so as part of a team (see the ASHA Practice Portal on ASD). Obviously SLPs need to follow state law, and many states provide specific guidelines about who can make a diagnosis of ASD. In New York, for example, only a licensed psychologist or physician can diagnose ASD.
States do not have specific guidelines for the diagnosis of SCD. Clearly, SLPs have the skills and expertise to diagnose this disorder because the symptoms of SCD fall under language use or pragmatics. SLPs have been assessing and treating people with primary deficits in pragmatic language since the “pragmatic revolution” four decades ago. We have the expertise to provide comprehensive assessment of pragmatic language skills in those with SCD and ASD.
So, even in states with prohibitions on SLPs confirming an ASD diagnosis, SLPs still play an important role in screening and referring children who may have ASD because they assess the children’s communication skills, including pragmatic language skills. Moreover, SLPs can provide comprehensive descriptions of restricted and repetitive patterns in play and other behaviors in assessment and treatment progress reports. If an SLP sees these patterns or receives reports of a history of these patterns from family members, the SLP should document the information and forward it to the child’s designated provider responsible for diagnosing ASD. This documentation will trigger a recommendation for the provider to rule out ASD.
Even in states that do not allow SLPs to diagnose ASD, SLPs are often part of an interdisciplinary or interprofessional diagnostic team that evaluates children referred for possible ASD and other neurodevelopmental disorders. The SLP’s contribution is to provide an in-depth communication profile of the referred children, including a description of the children’s speech, language and social-communication skills.

Best practices for social-communication assessment include a combination of parent/teacher and child self-report measures, observations of peer interactions, and conversation and narration samples.

Assessment considerations
Children with ASD and SCD often have a co-occurring diagnosis of developmental language disorder (DLD, also known as language disorder). When evaluating children with autism spectrum disorder or social communication disorder, SLPs should also assess for DLD. Tools such as norm-referenced language tests and conversational language samples are useful for assembling a comprehensive assessment of language content (vocabulary and semantic relationships, for example) and form (such as syntax and morphology comprehension and production).
Assessing social-communication skills requires multiple tools. Best practices for social-communication assessment include a combination of parent/teacher and child self-report measures, observations of peer interactions, and conversation and narration samples. Norm-referenced tests can help identify deficits in the comprehension of nonliteral language, such as understanding sarcasm, idioms or words with multiple meanings.
However, for students like Brian and Renee—who are performing well academically—norm-referenced tests may be of limited value. Both Brian and Renee scored within the normal range on a social language test, despite their parents’ concerns with their social interactions. Real-time social interaction requires dynamic monitoring of a communication partner’s facial expression, tone of voice, emotional affect and intention. Norm-referenced tests—such as the Test of Pragmatic Language-2 or the Social Language Development Test-Elementary: Normative Update—frequently fail to tap into this dynamic monitoring. As a result, these tests can fail to capture the social interaction difficulties noted by the child’s parents and teachers.

Working with the child with ASD or SCD alone is not sufficient—the child’s peers should be involved as well.

Intervention
After the clinical team agrees on an ASD or SCD diagnosis, the next step, obviously, is developing the treatment plan. The ASHA Practice Portal pages for autism and SCD provide descriptions for a variety of evidence-based intervention strategies and programs. At this time, no evidence is available to suggest that children and adolescents with ASD or SCD require different intervention approaches. In the absence of recommendations for one approach, SLPs should do what they have always done: select an intervention approach or strategy that will address the social communication challenges of the child or adolescent in front of them.
When the goal is to support successful peer interactions, it’s important to remember that working with the child with ASD or SCD alone is not sufficient—the child’s peers should be involved as well. Peer-mediated approaches focus on teaching peers to initiate—and maintain—interactions with children who have social-communication difficulties. It’s also important to teach peers about neurodiversity, and accepting and appreciating the unique strengths of children with ASD and SCD.
Sources
Baird G., & Norbury, C. F. (2016). Social (pragmatic) communication disorders and autism spectrum disorder. Archives of Disease in Childhood, 101, 745–751. http://adc.bmj.com/content/101/8/745 [Article] [PubMed]
Baird G., & Norbury, C. F. (2016). Social (pragmatic) communication disorders and autism spectrum disorder. Archives of Disease in Childhood, 101, 745–751. http://adc.bmj.com/content/101/8/745 [Article] [PubMed]×
Barahona-Corrêa, J. B., & Filipe, C. N. (2016). A concise history of Asperger Syndrome: The short reign of a troublesome diagnosis. Frontiers in Psychology, 6, 2024. doi: 10.3389/fpsyg.2015.02024 [Article] [PubMed]
Barahona-Corrêa, J. B., & Filipe, C. N. (2016). A concise history of Asperger Syndrome: The short reign of a troublesome diagnosis. Frontiers in Psychology, 6, 2024. doi: 10.3389/fpsyg.2015.02024 [Article] [PubMed]×
Brukner-Wertman, Y., Laor, N. & Golan, O. J. (2016). Social (pragmatic) communication disorder and its relation to the autism spectrum: Dilemmas arising from the DSM-5 classification. Journal of Autism and Developmental Disorders, 46, 2821–2829. https://doi.org/10.1007/s10803-016-2814-5 [Article] [PubMed]
Brukner-Wertman, Y., Laor, N. & Golan, O. J. (2016). Social (pragmatic) communication disorder and its relation to the autism spectrum: Dilemmas arising from the DSM-5 classification. Journal of Autism and Developmental Disorders, 46, 2821–2829. https://doi.org/10.1007/s10803-016-2814-5 [Article] [PubMed]×
Gibson, J., Adams, C., Lockton, E., & Green, J. (2013). Social communication disorder outside autism? A diagnostic classification approach to delineating pragmatic language impairment, high functioning autism and specific language impairment. Journal of Child Psychology and Psychiatry, 54, 1186–1197. doi:10.1111/jcpp.12079 [Article] [PubMed]
Gibson, J., Adams, C., Lockton, E., & Green, J. (2013). Social communication disorder outside autism? A diagnostic classification approach to delineating pragmatic language impairment, high functioning autism and specific language impairment. Journal of Child Psychology and Psychiatry, 54, 1186–1197. doi:10.1111/jcpp.12079 [Article] [PubMed]×
Mandy, W., Wang, A., Lee, I., & Skuse, D. (2017). Evaluating social (pragmatic) communication disorder. Journal of Child Psychology and Psychiatry, 58, 1166–1175. doi:10.1111/jcpp.12785 [Article] [PubMed]
Mandy, W., Wang, A., Lee, I., & Skuse, D. (2017). Evaluating social (pragmatic) communication disorder. Journal of Child Psychology and Psychiatry, 58, 1166–1175. doi:10.1111/jcpp.12785 [Article] [PubMed]×
Swineford, L. B., Thurm, A., Baird, G., Wetherby, A. M., & Swedo, S. (2014). Social (pragmatic) communication disorder: A research review of this new DSM-5 diagnostic category. Journal of Neurodevelopmental Disorders, 6(1), 41. doi:10.1186/1866-1955-6-41 [Article] [PubMed]
Swineford, L. B., Thurm, A., Baird, G., Wetherby, A. M., & Swedo, S. (2014). Social (pragmatic) communication disorder: A research review of this new DSM-5 diagnostic category. Journal of Neurodevelopmental Disorders, 6(1), 41. doi:10.1186/1866-1955-6-41 [Article] [PubMed]×
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April 2018
Volume 23, Issue 4