social communication disorder: identification with the CCC-2? Courtenay Frazier Norbury University College London

social communication disorder: identification with the CCC-2? Courtenay Frazier Norbury University College London

my PhD plan identify diagnostic criteria for pragmatic language impairment that would reliably differentiate children with PLI from children with specific language impairments children with autism spectrum disorders

find children who have problems with pragmatics/social communication in the absence of intellectual impairments structural language impairments evidence of restricted interests and repetitive behaviours

Norbury (2004) DPhil thesis 95 children aged 8-14 8 excluded for low non-verbal IQ 19 specific language impairment 33 definite ASD 35 pragmatic difficulties 19 had history of RRIBs (PDD-NOS) 12 had current or previous structural language impairment 16 pure social communication disorder of 95 children only 4 had pragmatic difficulties in absence of ASD or other language impairment

either this diagnostic group just doesn t exist.or social/pragmatic deficits in absence of other deficits doesn t significantly impact daily life

my PhD conclusion: pragmatics (social communication) is a dimensional set of skills that can be variably impaired across a range of neurodevelopmental disorders

10 years later introduction of a new diagnostic category: social (pragmatic) communication disorder (SCD)

social communication disorder Deficits (all 4 required) use language for social purposes (e.g. greeting) change language to fit context/listener need follow rules for conversation/narrative go beyond explicit utterance (e.g. idioms, inferences) is there a distinction between pragmatics and social communication? Not accounted for by: vocabulary or grammar deficits non-verbal cognitive deficits restricted repertoire of interests and behaviours what does account for SCD then?

why does it matter? assumptions: Different underlying cause Different prognosis Differential diagnosis Different approach to intervention how many children meet these criteria? Plan service needs

assessing pragmatics is challenging! rely on parent/teacher report coding more naturalistic communication is time-consuming and difficulty to get reliability standardised measures of inferencing, narrative and ambiguity; fewer standard communication metrics

Children s Communication Checklist-2 (Bishop, 2003) parents used as respondents in standardisation, but is being used with teachers (someone who knows child well frequency judgements about concrete behaviours in everyday context deficit items grouped separately to strengths and items from different scales interspersed 10 scales, 7 items each (5 deficit, 2 strength) two composite scores General Communication Composite (GCC) Social-interaction Deviance Composite (SIDC)

CCC-2: purposes screen for language/communication impairment identify pragmatic difficulties in children with language disorder identify children requiring further assessment for autistic spectrum disorder NOT a diagnostic instrument as such use as signpost to possible diagnoses

examples stereotyped language: Uses favourite phrases or sentences in inappropriate contexts. E.g. we went to the park and all of a sudden we had a picnic. Or might habitually start utterances with by the way use of context: Is over-literal. E.g. when told watch your hands when using scissors, child just looks at his fingers

general communication composite A: speech B: syntax C: semantics D: coherence E: inappropriate initiation F: stereotyped language G: use of context H: non-verbal communication I: social relations J: interests mean normative score = 80

70 bottom 10 th centile 60 general communication composite 50 40 30 20 10 0 LI ALI ALN group no group differences

social-interaction deviance composite (SIDC) A: speech B: syntax C: semantics D: coherence E: inappropriate initiation H: non-verbal communication I: social relations J: interests F: stereotyped language G: use of context

A negative score on the SIDC indicates DISPROPORTIONATE social and pragmatic difficulties in relation to structural language abilities

40 social interaction deviance composite 30 20 10 0-10 -20-30 LI > ALN LI ALI ALN group Norbury, Nash, Baird & Bishop (2004) more consistent with SLI profile more consistent with ASD profile more consistent with Asperger profile (esp if GCC > 55)

Population study of children with language impairment at school entry Screen Reception (age 4-5) Assess in detail Year 1 (age 5-6, n = 529) and again Year 3 (age 7-8, n = 499) Population: 7267 children starting mainstream school in 2011 (59% of total) Gender: 51% boys and 49% girls Ethnicity: 5959 children (82%) of white British ethnic origin (83% England; 83% Surrey) English as additional language: 797 (11%) were rated as having English as an additional language (17% UK total; 10% Surrey) Socio-economic status: Income Deprivation Affecting Children Index (IDACI)

Break down of scores using CCC-2 (social interaction deviance composite) Monolingual children in Year 1 aged 5-6 years old 288 Parent CCC-2 24% communication deficit 13% have pragmatic deficit 324 Teacher CCC-2 37% communication deficit 12% have pragmatic deficit 173 both GCC: r(173) =.57; SIDC: r(173) =.46 118/173 cases agree (105 TD) 13/68 non-td agree (10 DLD) In original study: r =.79 special school effect?

of those with pragmatic deficits Parents (n = 26) 18 (69%) boys 10 meet criteria for Language Disorder 6 ASD 12 other diagnosis Teachers (n =34) 27 (79%) boys 14 meet criteria for Language Disorder 8 ASD 13 other diagnosis Functional impact: 12 sig behaviour problems 14 peer problems 23 fail early academic targets 9 persistent academic probs Functional impact: 22 sig behaviour problems 25 peer problems 29 fail early academic targets 14 persistent academic probs

pure SCD: parents 10 20 30 40 50 0 10 20 30 40 LANG PRAG Fitted values

pure SCD: teachers 10 20 30 40 50 0 10 20 30 40 50 LANG_T PRAG_T Fitted values

pure SCD? in both parent and teacher samples, fewer than 2% have pragmatic deficits and no other indicators oversampled for possible communication disorder even fewer in general population all met expected curriculum targets in Year 2 most had mild behaviour problems (particularly with peers)

is the underlying structure of SCD sensible? syntax.79 semantics coherence.80.91 language.92 initiation context non-verbal.87.82.82 pragmatic.88 stereotype social interests.77.75.81 ASD.99 Χ 2 = 89.36 p <.001 RMSEA =.10 CFI =.96

summary (1) social communication disorders do exist BUT they rarely occur in isolation they are not a distinct diagnostic group incur functional (esp. peer) impacts CCC-2 shows promise BUT limited parent compliance (in this context) poor parent-teacher agreement conflates pragmatic and ASD symptoms strong relations with structural language

summary (2) underlying SCD structure not supported why not? pragmatics, language, and social are unitary construct pragmatics, language, and social are distinct Items on CCC-2 not sensitive enough to distinguish Parents/teachers lack knowledge/training to distinguish Relationships inflated in population samples with large TD group difficulties with interpretation: can I.D. problem, but less specific qualitative differences between clinical groups

the field requires: development of reliable & valid measures of assessment and outcome understanding of functional impact development of appropriate interventions

thank you for listening! https://www.youtube.com/rallicampaign c.norbury@ucl.ac.uk www.lilac-lab.org