Last Modified: November 25, 2023 | Published: October 24, 2023
Is Social Pragmatic Communication Disorder truly distinct from autism? Read this blog to find out the answer.
Pragmatic language is language that is used socially to connect with others. It is an essential communication skill. It includes vocabulary, knowledge, and use of words and how that language is used socially.
Sometimes, children have trouble with pragmatic language. They may not know when to say something, how to say it, or what nonverbal communication is needed to emphasize a point. If you think of language skills as a lecture, think of pragmatic language as a conversation.
What is Social Pragmatic Communication Disorder (SPCD)?
Someone diagnosed with SPCD does not naturally have the pragmatic language skills noted above.
Specifically, according to the DSM-5, a diagnosis of SPCD includes a number of challenges. A diagnosis of SPCD includes the following:
- Difficulty communicating socially
- Difficulty modulating language and tone for various settings
- Trouble following rules in conversation and storytelling
- Trouble understanding inferences, metaphors, and other non-literal language
These challenges must:
- Impact communication
- Begin in childhood
- Not be better explained by autism
Social Pragmatic Communication Disorder (SPCD) is a communication disorder. It is also sometimes known as Social Communication Disorder (SCD). It is a new diagnosis in the most recent diagnostic manual (DSM-5) version. SPCD includes the social communication challenges of autism for those without restricted and repetitive behaviors (Flax et al., 2019).
All of the social challenges of SPCD are also common for autistic children and adults. There are no characteristics of SPCD that are not present in the social communication characteristics of autism.
In summary, SPCD is diagnosed if a person has social communication challenges that are impactful AND they do not meet the criteria for a diagnosis of autism.
Social Pragmatic Communication Disorder vs Autism: What’s the Difference?
Autism is characterized by social communication differences and characteristics like those discussed above. To diagnose autism, a psychologist or medical doctor must also find Restricted and Repetitive Behaviors (RRBs). The difference between ASD and SPCD comes down to the presence or absence of restricted and repetitive behaviors. Those diagnosed with SPCD must not have any RRBs.
Some more classic or unmistakable RRBs are hand flapping, finger flicking, spinning, and bouncing. Less obvious RRBs are pacing, talking about the same topics over and over, and repeating words or phrases in conversation.
Many professionals have argued that this mild distinction between SPCD and autism means that SPCD is merely a broader autism phenotype (Flax et al., 2019; Amoretti et al., 2021). With DSM-5, the umbrella category of PDD-NOS is no more.
Before that change, more mild cases on the Autism Spectrum were diagnosed PDD-NOS. Children or adults were noted to be “on the spectrum” but not meeting the full criteria. With DSM-5, that diagnosis was no longer available to clinicians. Many believe that now those milder ASD cases are being diagnosed as SPCD.
In other words, many clinicians and researchers believe that SPCD is mild autism.
Top Pragmatic Language Skills
Here are the top 8 pragmatic language skills that make for great social language.
- Know how to offer a greeting or say goodbye in a polite manner
- Have a back-and-forth conversation with comments, responses, and questions
- Use tone, volume, and subject matter that is appropriate for a given setting
- Communicate using nonverbal skills like eye contact, gestures, and facial expressions
- Understand the nonverbal communication of others, including body language
- Tell stories in a way that keeps others engaged and offers the right amount of information
- Understand humor, metaphors, or comments not stated literally
- Know if a conversation partner is interested in continuing to chat or not
Social Pragmatic Communication Disorder vs Autism: How to Obtain an Accurate Diagnosis
A tricky element of diagnosing SPCD is that it is often identified by a Speech and Language Pathologist (SLP). In many cases, autism may not have been ruled out as a diagnosis. Most SLPs are not credentialed to diagnose autism independently. Many may diagnose a communication disorder like SPCD.
It is possible that a child with a less obvious RRB, like pacing or repeated language, may be diagnosed with SPCD when they have autism.
Autism is diagnosed by a medical doctor, licensed psychologist, or team of professionals that includes one of these (doctor or psychologist). Other team members may be SLPs, Occupational Therapists, and Learning Specialists. As noted above, an autism diagnosis includes the presence of at least 2 RRBs.
One RRB that is characteristic of autism is sensory processing difference. For an autism diagnosis, a child must also have a special interest, a pattern of rigid behavior (insistence on sameness), or repetitive motor movements or speech patterns. These motor movements and speech patterns may be very subtle. Special interests and idiosyncratic phrases can also be harder to notice.
In many cases, a child diagnosed with SPCD has not had an autism evaluation and thus may meet the criteria for both diagnoses. According to the DSM-5, when this is the case, autism should be diagnosed.
Negative Impact of SPCD
Researchers would argue that a problem with this change is the availability of treatment and support. Because SPCD is listed as a communication disorder and not an Autism Spectrum Disorder, speech therapy is likely to be the only service provided. Treatments with strong support, like Cognitive Behavioral Therapy, Social Group Therapy, and Applied Behavior Analytic Therapy (ABA), will likely not be covered for children with SPCD.
Many diagnoses of SPCD may come from a professional who could not rule out autism. The result is that the diagnostic accuracy is not likely to be high. Also, many RRBs, like pacing, repeated phrasing, or special interests, may fly under the radar.
For females especially, research has shown more social masking in autism. Females are more likely to have socially acceptable special interests like a love of dolls or horses. The diagnosis of SPCD may disservice women who have already been under-diagnosed. If girls and women with autism are more likely to be given this autism-lite diagnosis, they are less likely to qualify for treatments.
Positive Impact of SPCD
One positive aspect of this diagnosis may be language support. Parents unwilling to pursue or accept that their child is on the Spectrum may appreciate SPCD. A parent who is not willing to meet with a psychologist might be ready to see a speech therapist. In this case, a child could obtain a diagnosis and some level of support.
The flip side is that PDD-NOS used to be known to parents as a form of mild autism. It is not clear that parents understand the relationship between SPCD and autism. We may be misleading caregivers with this diagnosis.
An example of a helpful SPCD diagnosis
As a licensed psychologist, I have diagnosed one child over the last decade with SPCD. In that case, I spent sessions with the little girl ruling out autism. I could not identify a single RRB for the child. In her report, I also noted the broader autism phenotype because I genuinely believed that to be the case. The child did have an autistic sibling.
As autism is a spectrum, I felt very comfortable noting that she had some very mild symptoms that fit that phenotype. The reason I wanted to diagnose SPCD in this case was so the child could be referred to a Speech and Language Pathologist. This little girl thrived with regular therapy. Her treatment focused on developing and practicing the pragmatic skills noted at the start of this blog. It was successful.
Some children may have mild enough symptoms to need only speech and language support. It is nice to have a diagnosis that can capture these cases. In my clinical experience, SPCD is not a stand-alone diagnosis. I expect in the next diagnostic manual, it will be treated differently and may fall on the Autism Spectrum.
Book Resources on Pragmatic Language In Childhood
American Psychiatric Association. (2013). Autism Spectrum Disorder. In Diagnostic and Statistical Manual of Mental Disorders (5th ed.).
American Psychiatric Association. (2013). Communication disorders. In Diagnostic and Statistical Manual of Mental Disorders (5th ed.).
Amoretti, M. C., Lalumera, E., & Serpico, D. (2021). The DSM-5 introduction of the Social (Pragmatic) Communication Disorder as a new mental disorder: a philosophical review. History and Philosophy of the Life Sciences, 43(4), 108.
Flax, J., Gwin, C., Wilson, S., Fradkin, Y., Buyske, S., & Brzustowicz, L. (2019). Social (pragmatic) communication disorder: Another name for the broad autism phenotype?. Autism, 23(8), 1982-1992.
Kroncke, Willard, & Huckabee (2016). Assessment of autism spectrum disorder: Critical issues in clinical forensic and school settings. Springer, San Francisco.