Pragmatic language impairment
Pragmatic language impairment (PLI), or social (pragmatic) communication disorder (SCD), is an impairment in understanding pragmatic aspects of language. This type of impairment was previously called semantic-pragmatic disorder (SPD). Pragmatic language impairments are related to autism and Asperger syndrome, but also could be related to other non-autistic disabilities such as ADHD and intellectual disabilities. People with these impairments have special challenges with the semantic aspect of language (the meaning of what is being said) and the pragmatics of language (using language appropriately in social situations). It is assumed that autistic people have difficulty with "the meaning of what is being said" due to different ways of responding to social situations. This assumption has been successfully challenged by non-verbal autistic self-advocates who use augmentative assistive communication and maintain on and off-line social relationships.
PLI is now a diagnosis in DSM-5, and is called social (pragmatic) communication disorder. Communication problems are also part of the autism spectrum disorders (ASD); however, the latter also show a restricted pattern of behavior, according to behavioral psychology. The diagnosis SCD can only be given if ASD has been ruled out.
In 1983, Rapin and Allen suggested the term "semantic pragmatic disorder" to describe the communicative behavior of children who presented traits such as pathological talkativeness, deficient access to vocabulary and discourse comprehension, atypical choice of terms and inappropriate conversational skills. They referred to a group of children who presented with mild autistic features and specific semantic pragmatic language problems. More recently, the term "pragmatic language impairment" (PLI) has been proposed.
Rapin and Allen's definition has been expanded and refined by therapists who include communication disorders that involve difficulty in understanding the meaning of words, grammar, syntax, prosody, eye gaze, body language, gestures, or social context. While autistic children exhibit pragmatic language impairment, this type of communication disorder can also be found in individuals with other types of disorders including auditory processing disorders, neuropathies, encephalopathies and certain genetic disorders.
The DSM-5 categorizes SCD as a communication disorder within the domain of neurodevelopmental disorders, listed alongside other disorders of speech and language which typically manifest in early childhood. The DSM-5 diagnostic criteria for social (pragmatic) communication disorder is as follows:
- A. 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, such as greeting and sharing information, 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, 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.
- 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.
- Difficulties understanding what is not explicitly stated (e.g., making inferences) and nonliteral or ambiguous meanings 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 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.
Individuals with PLI have particular trouble understanding the meaning of what others are saying, and they are challenged in using language appropriately to get their needs met and interact with others. Children with the disorder often exhibit:
- delayed language development
- aphasic speech (such as word search pauses, jargoning, word order errors, word category errors, verb tense errors)
- Stuttering or cluttering speech
- Repeating words or phrases
- difficulty with pronouns or pronoun reversal
- difficulty understanding questions
- difficulty understanding choices and making decisions.
- difficulty following conversations or stories. Conversations are "off-topic" or "one-sided".
- difficulty extracting the key points from a conversation or story; they tend to get lost in the details
- difficulty with verb tenses
- difficulty explaining or describing an event
- tendency to be concrete or prefer facts to stories
- difficulty understanding satire or jokes
- difficulty understanding contextual cues
- difficulty in reading comprehension
- difficulty with reading body language
- difficulty in making and maintaining friendships and relationships because of delayed language development.
- difficulty in distinguishing offensive remarks
- difficulty with organizational skills
People with PLI often share additional characteristics consistent with high-functioning autism. For example, they may dislike or avoid eye contact. Many have rigid habits, a shallower range of interests than most people but not as severe as with Asperger syndrome or autism (often with a deep knowledge of their areas of interest), sensory and eating sensitivities, coordination and muscle-tone issues. They may also display striking abilities in an area such as mathematics, computer science, geography, astronomy, reading, history, meteorology, botany, zoology, sports, politics or music.
According to Bishop and Norbury (2002), children with semantic pragmatic disorder have fluent, complex and clearly articulated expressive language but exhibit problems with the way their language is used. These children typically are verbose. However, they usually have problems understanding and producing connected discourse, instead giving conversational responses that are socially inappropriate, tangential and/or stereotyped. They often develop obsessional interests but not as strong or eccentric as people with Asperger's Syndrome or autism.
The current view, therefore, is that the disorder has more to do with communication and information processing than language. For example, children with semantic pragmatic disorder will often fail to grasp the central meaning or saliency of events. This then leads to an excessive preference for routine and "sameness" (seen in autism and Asperger's Syndrome), as PLI children struggle to generalize and grasp the meaning of situations that are new; it also means that more difficulties occur in a stimulating environment than in a one-to-one setting.
A further problem caused by PLI is the assumption of literal communication. This would mean that obvious, concrete instructions are clearly understood and carried out, whereas simple but non-literal expressions such as jokes, sarcasm and general social chatting are difficult and can lead to misinterpretation. Lies are also a confusing concept to children with PLI as it involves knowing what the speaker is thinking, intending and truly meaning beyond a literal interpretation.
Relationship to autism
Prior to the DSM-5, SCD was not differentiated from a diagnosis of autism. However, there was a large number of cases of children experiencing difficulties with pragmatics that did not meet the criteria for ASD. The differential diagnosis of SCD allows practitioners to account for social and communication difficulties that occur at a lesser degree than in children with ASD.
There is debate over the relationship between semantic pragmatic disorder and autistic disorder as the clinical profile of semantic pragmatic disorder is often seen in children with high-functioning autism.
Pragmatic language impairment is distinguished from autism by the absence of any history (current or past) of restricted/repetitive patterns of interest or behavior in PLI.
Hyperlexia is a similar but different disorder where main characteristics are an above–average ability to read with a below-average ability to understand spoken and/or written language. Joanne Volden wrote an article in 2002 comparing the linguistic weaknesses of children with nonverbal learning disability to PLI.
- High-functioning autism
- PDD not otherwise specified
- Specific language impairment
- Speech and language pathology
- Speech and language pathology in school settings
- Asperger Syndrome
- Wretches & Jabberers
- Ahmed Mohammed Alduais; Rasha Mohammed Shoeib; Fayza Saleh Al Hammadi; Khalid Hassan Al Malki; Farah Hameid Alenezi (2012). "Measuring Pragmatic Language in Children with Developmental Dysphasia: Comparing Results of Arabic Versions of TOPL-2 and CELF-4 (PP and ORS Subtests)". International Journal of Linguistics. 4 (2): 475–494. doi:10.5296/ijl.v4i2.1685.
- "Social (Pragmatic) Communication Disorder" (PDF). Retrieved September 28, 2013.
- Rapin I., and D. Allen (1983). "Developmental language disorders: Nosologic considerations", in U. Kirk (ed.), Neuropsychology of language, reading, and spelling (pp. 155–184). Academic Press.
- Conti-Ramsden G.; N. Botting (1999). "Classification of children with specific language impairment: longitudinal considerations". J. Speech Lang. Hear. Res. 42 (5): 1195–204. doi:10.1044/jslhr.4205.1195. PMID 10515515.
- Bishop, D. V. M. (2000), "Pragmatic language impairment: A correlate of SLI, a distinct subgroup, or part of the autistic continuum?" In D. V. M. Bishop and L. B. Leonard (eds.), Speech and Language Impairments in Children: Causes, characteristics, intervention and outcome (pp. 99–113). Hove, UK: Psychology Press.
- Bishop, D. V., and C. F. Norbury (Oct 2002). "Exploring the borderlands of autistic disorder and specific language impairment: a study using standardised diagnostic instruments". Journal of child psychology and psychiatry, and allied disciplines. 43 (7): 917–29. doi:10.1111/1469-7610.00114. ISSN 0021-9630. PMID 12405479.
- Mash, Eric. (2016). Abnormal Child Psychology, 6e, 6th Edition. [VitalSource Bookshelf Online]. Retrieved fromhttps://cengagebrain.vitalsource.com/#/books/9781305445765/
- Bishop, D. V.M. and Norbury, C. F. (2002). "Exploring the borderlands of autistic disorder and specific language impairment: a study using standardised diagnostic instruments" Journal of Child Psychiatry, 43: 917–929. doi: 10.1111/1469-7610.00114. [Wiley Online Library]. Retrieved from http://onlinelibrary.wiley.com/doi/10.1111/1469-7610.00114/full
- American Psychiatric Association, ed. (2013). "Social (Pragmatic) Communication Disorder, 315.39 (F80.89)". Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. American Psychiatric Publishing. pp. 47–49.
- Volden, Joanne (October 22, 2002). "Nonverbal learning disability: What the SLP needs to know". The ASHA Leader. American Speech-Language-Hearing Association. Retrieved February 14, 2013.