Evaluating social (pragmatic) communication disorder

The fuzzy boundaries of the social (pragmatic) communication disorder (SPCD): Why the picture is still so confusing?

Introduction

Since the introduction of Social (Pragmatic) Communication Disorder (SPCD) in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) in 2013, a debate has arisen in the scientific community about its usefulness in differential diagnosis for other clinical categories such as Autism Spectrum Disorder (ASD) and Specific Language Impairment (SLI). Indeed, SPCD criteria share a common deficit in communication and pragmatic skills with these diagnostic entities. Available assessment tools seem scarce and not sensitive enough to clarify diagnostic criteria and clinical boundaries. This study aims to review the existing literature on diagnostic screening for SPCD to highlight confounding variables in the domains examined, overlap with other diagnostic entities, and lack of specificity of available assessment tools in identifying the core deficits of the disorder.

Methods

The search strategy was defined by combining the following keywords: "social pragmatic communication disorder," "DSM-5," "differential diagnosis," and "child." The search was performed in three databases: Medline (PubMed), Scopus, and Web of Science. All studies published between 2013 and April 2023, written in English, and with a major focus on SPCD were included in the review.

Results

After the screening for the eligibility, 18 studies were included in the review. Most of these studies aimed to investigate the differential diagnosis between SPCD and other diagnostic categories (e.g., specific language impairment and autism spectrum disorder). Of these researches, only 6 were ad hoc experimental studies, while the others were based on previously collected databases.

Conclusions

SPCD seems to have its own peculiarities and characteristics, indicating its clinical relevance, as emphasized by the DSM-5. However, the lack of specific instruments and a number of confounding variables make it difficult to identify and differentiate SPCD from other diagnostic entities. Further research is needed to overcome the lack of specific clinical instruments and lack of empirical studies.

Prevalence and functional impact of social (pragmatic) communication disorders

BACKGROUND

The aim of this study was to evaluate the Children's Communication Checklist-2 (CCC-2) for measuring social-pragmatic communication deficits and to ascertain their prevalence and functional impact in a community sample.

METHODS

We used parent and teacher responses to the CCC-2 to approximate inclusion (poor social-pragmatic skills) and exclusion (poor structural language skills or autistic symptomatology) criteria for social (pragmatic) communication disorder (SPCD). We tested the prevalence of social-pragmatic deficits in a population-based sample of children (n = 386) aged 5-6 years old using CCC-2 algorithms. We also investigated the academic and behavioural profiles of children with broadly defined limitations in social-pragmatic competence on the CCC-2.

RESULTS

Regardless of the diagnostic algorithm used, the resulting prevalence rates for social-pragmatic deficits indicated that very few children had isolated social-communication difficulties (0-1.3%). However, a larger proportion of children (range: 6.1-10.5%) had social-pragmatic skills outside the expected range alongside structural language difficulties and/or autism spectrum symptoms, and this profile was associated with a range of adverse academic and behavioural outcomes.

CONCLUSIONS

A considerable proportion of children in the early years of primary school has social-pragmatic deficits that interfere with behaviour and scholastic activity; however, these rarely occur in isolation. Exclusionary criteria that include structural language may lead to underidentification of individuals with social-pragmatic deficits that may benefit from tailored support and intervention.

Transdiagnostic profiles of behaviour and communication relate to academic and socioemotional functioning and neural white matter organisation

BACKGROUND

Behavioural and language difficulties co-occur in multiple neurodevelopmental conditions. Our understanding of these problems has arguably been slowed by an overreliance on study designs that compare diagnostic groups and fail to capture the overlap across different neurodevelopmental disorders and the heterogeneity within them.

METHODS

We recruited a large transdiagnostic cohort of children with complex needs (N = 805) to identify distinct subgroups of children with common profiles of behavioural and language strengths and difficulties. We then investigated whether and how these data-driven groupings could be distinguished from a comparison sample (N = 158) on measures of academic and socioemotional functioning and patterns of global and local white matter connectome organisation. Academic skills were assessed via standardised measures of reading and maths. Socioemotional functioning was captured by the parent-rated version of the Strengths and Difficulties Questionnaire.

RESULTS

We identified three distinct subgroups of children, each with different levels of difficulties in structural language, pragmatic communication, and hot and cool executive functions. All three subgroups struggled with academic and socioemotional skills relative to the comparison sample, potentially representing three alternative but related developmental pathways to difficulties in these areas. The children with the weakest language skills had the most widespread difficulties with learning, whereas those with more pronounced difficulties with hot executive skills experienced the most severe difficulties in the socioemotional domain. Each data-driven subgroup could be distinguished from the comparison sample based on both shared and subgroup-unique patterns of neural white matter organisation. Children with the most pronounced deficits in language, cool executive, or hot executive function were differentiated from the comparison sample by altered connectivity in predominantly thalamocortical, temporal-parietal-occipital, and frontostriatal circuits, respectively.

CONCLUSIONS

These findings advance our understanding of commonly co-morbid behavioural and language problems and their relationship to behavioural outcomes and neurobiological substrates.

Innovations of the ICD-11 in the Field of Autism Spectrum Disorder: A Psychological Approach

Background

This article aims to explain and elaborate upon the recently released ICD-11 criteria for Autism Spectrum Disorder (ASD, World Health Organization), which endorse a medical model.

Method

We integrate insights from several disciplines (e.g., psychology, linguistics, sociology and lived experiences) to reflect the scientific and ethical insights derived from the biopsychosocial, neurodiversity perspective on autism.

Results

First, we describe the core domains of ASD's behavioural characteristics and then the lifetime, developmental perspective on the manifestations of these behaviours. Subsequently, we discuss potential underlying neuropsychology, related behaviours (i.e. associated features/conditions) and we consider some similarities and differences with the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM 5, American Psychological Association).

Conclusions

Recommendations for clinical application are provided. For instance, diagnostic classification in clinical practise should be a means to provide proper, suitable care, and therefore all diagnostic assessments should be used to tailor interventions and/or care to the capacities and genuine needs of the people that ask for professional help.

Differential diagnosis between autism spectrum disorder and other developmental disorders with emphasis on the preschool period

BACKGROUND

Neurodevelopmental disorders are a heterogeneous group of conditions that manifest as delays or deviations in the acquisition of expected developmental milestones and behavioral changes. Autism spectrum disorder (ASD) is a neurodevelopmental disorder characterized by deficits in communication and social interaction and by repetitive and restricted patterns of behavior, interests and activities. The aim of this review is to discuss the clinical features of the differential diagnoses of ASD that are prevalent among preschoolers, focusing on their similarities and disparities.

DATA SOURCES

The international medical literature search was conducted using PubMed and was revised regarding the subject using single and/or combined keywords as follows: differential diagnosis, preschoolers, diagnostic challenge, attention deficit hyperactivity disorder, intellectual disability, high abilities/giftedness, childhood apraxia of speech, social communication disorder, Landau-Kleffner syndrome, stereotyped movement disorder and excessive screen time.

RESULTS

We describe conditions commonly found in clinical practice, taking ASD as a reference. We addressed converging and divergent aspects of behavior, cognition, communication, language, speech, socialization, and stereotypes for the diagnosis of ASD and other disorders identified as potential differential or comorbid diagnoses.

CONCLUSIONS

The ranking and characterization of symptoms appear to be essential for better understanding the underlying common ground between children with developmental disorders and children with ASD, thus properly diagnosing and directing social, professional, or medication interventions. This detailed discussion adds to the literature since, although ASD differential diagnoses are frequently mentioned and discussed in textbooks and journal articles, they rarely occupy a prominent place as we aimed herein.

Specific Language Impairment, Autism Spectrum Disorders and Social (Pragmatic) Communication Disorders: Is There Overlap in Language Deficits? A Review

Analysing language characteristics and understanding their dynamics is the key for a successful intervention by speech and language therapists (SLT). Thus, this review aims to investigate a possible overlap in language development shared by autism spectrum disorders (ASD), specific language impairment (SLI) and social (pragmatic) communication disorder (SPCD). The sources of this work were the PubMed, PsycInfo and SciELO databases, as well as the Scientific Open Access Repositories of Portugal. The final selection included 18 studies, focused on several linguistic areas. Results suggest that when individuals are matched according to some language or cognitive skills, they will also show similar characteristics in other language domains. Future work should be done based on spontaneous speech.

Annual Research Review: The transdiagnostic revolution in neurodevelopmental disorders

Practitioners frequently use diagnostic criteria to identify children with neurodevelopmental disorders and to guide intervention decisions. These criteria also provide the organising framework for much of the research focussing on these disorders. Study design, recruitment, analysis and theory are largely built on the assumption that diagnostic criteria reflect an underlying reality. However, there is growing concern that this assumption may not be a valid and that an alternative transdiagnostic approach may better serve our understanding of this large heterogeneous population of young people. This review draws on important developments over the past decade that have set the stage for much-needed breakthroughs in understanding neurodevelopmental disorders. We evaluate contemporary approaches to study design and recruitment, review the use of data-driven methods to characterise cognition, behaviour and neurobiology, and consider what alternative transdiagnostic models could mean for children and families. This review concludes that an overreliance on ill-fitting diagnostic criteria is impeding progress towards identifying the barriers that children encounter, understanding underpinning mechanisms and finding the best route to supporting them.

Sensitivity and specificity of DSM-5 diagnostic criteria for autism spectrum disorder in a child and adolescent sample

BACKGROUND

Controversy exists regarding the DSM-5 criteria for autism spectrum disorders (ASD). Given the mixed results that have been reported, our main aim was to determine DSM-5 sensitivity and specificity in a child and adolescent Spanish sample. As secondary goals, we assessed the diagnostic stability of DSM-IV-TR in DSM-5, and clinical differences between children diagnosed with an ASD or a social (pragmatic) communication disorder (SPCD).

METHODS

This study was carried out in 2017, reviewing the medical records of patients evaluated in our service. Items from a parent report measure of ASD symptoms (Autism Diagnostic Interview-Revised) were matched to DSM-5 criteria and used to assess the sensitivity and specificity of the DSM-5 criteria and current DSM-IV criteria when compared with clinical diagnoses.

RESULTS

DSM-5 sensitivity ranged from .69 to 1.00, and was higher in females. By age, the DSM-5 and DSM-IV-TR criteria showed similar sensitivity. In the case of intellectual quotient, DSM-5 criteria sensitivity was lower for those in the "low-functioning" category. DSM-5 specificity ranged from .64 to .73, while DSM-5 specificity was similar for all phenotypic subgroups. With respect to stability, 83.3% of autism disorder cases retained a diagnosis of ASD using the DSM-5 criteria. With regard to differences between ASD and SPCD, we found that patients diagnosed with ASD received more pharmacological treatment than those diagnosed with SPCD.

CONCLUSIONS

Further research is required to confirm our results. Studies focusing on the SPCD phenotype will be necessary to determine outcome differences with ASD and the most effective diagnostic and therapeutic tools.

A preliminary epidemiologic study of social (pragmatic) communication disorder in the context of developmental language disorder

BACKGROUND

There is extremely limited population-based research on social (pragmatic) communication disorder (SCD). Population-based samples have the potential to better characterize the SCD phenotype by mitigating confounds and biases that are typical of convenience and clinical samples.

AIMS

The aims of this preliminary epidemiologic study were to advance our understanding of the SCD phenotype relative to developmental language disorder (DLD), obtain an estimate of prevalence, identify risk factors and lay the groundwork for future population level research of SCD.

METHODS & PROCEDURES

We analysed existing data from the EpiSLI Database to examine social communication skills in 393 8th grade (13-14 years) children with and without a history of DLD. The primary measure used to evaluate SCD was the Children's Communication Checklist (CCC-2). Two case definitions of SCD reflecting DSM-5 criteria were examined. Both definitions involved significant pragmatic impairment, employing a commonly adopted clinical cut-point of 1.5 SD. In one case, pragmatic deficits could occur along with structural language deficits and, in the other case (established using principal component analysis), pragmatic and social skills were disproportionately lower than structural language abilities.

OUTCOMES & RESULTS

When using the first case definition, SCD was much more common in children with a history of DLD than without DLD and history of language disorder at kindergarten was a significant risk factor for SCD in adolescence. However, it is important to note that SCD could be found in children with no prior deficits in other aspects of language. When the second definition was employed, SCD was equally distributed across children with and without a history of DLD. Male sex was a significant risk factor using this case definition of SCD. The estimated prevalence of SCD ranged from 7% (SE = 1.5%) to 11% (SE = 1.7%), acknowledging that prevalence depends on the cut-point selected to determine communication disorder.

CONCLUSIONS & IMPLICATIONS

These findings contribute to our understanding of the association between SCD and DLD by recognizing varying profiles of pragmatic and social communication difficulties, which in turn may help refine our diagnostic categories. Preliminary prevalence estimates of SCD can serve as an initial guidepost for identification and planning for intervention services for this condition.

WHAT THIS PAPER ADDS

What is already known on this subject There is considerable debate about the diagnostic category of SCD and its relation to other neurodevelopmental disorders. What this study adds to existing knowledge Using data from a US-based epidemiologic sample of DLD, this study offers new information about the association between SCD and DLD, provides preliminary estimates of SCD prevalence, and identifies risk factors for SCD. Clinical implications of this study Improved understanding of possible profiles of pragmatic and social communication deficits will help to clarify diagnostic categories and preliminary prevalence estimates may assist with ensuring availability of adequate intervention services.

The DSM-5 introduction of the Social (Pragmatic) Communication Disorder as a new mental disorder: a philosophical review

The latest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) included the Social (Pragmatic) Communication Disorder (SPCD) as a new mental disorder characterized by deficits in pragmatic abilities. Although the introduction of SPCD in the psychiatry nosography depended on a variety of reasons-including bridging a nosological gap in the macro-category of Communication Disorders-in the last few years researchers have identified major issues in such revision. For instance, the symptomatology of SPCD is notably close to that of (some forms of) Autism Spectrum Disorder (ASD). This opens up the possibility that individuals with very similar symptoms can be diagnosed differently (with either ASD or SPCD) and receive different clinical treatments and social support. The aim of this paper is to review recent debates on SPCD, particularly as regards its independence from ASD. In the first part, we outline the major aspects of the DSM-5 nosological revision involving ASD and SPCD. In the second part, we focus on the validity and reliability of SPCD. First, we analyze literature on three potential validators of SPCD, i.e., etiology, response to treatment, and measurability. Then, we turn to reliability issues connected with the introduction of the grandfather clause and the use of the concepts of spectrum and threshold in the definition of ASD. In the conclusion, we evaluate whether SPCD could play any role in contemporary psychiatry other than that of an independent mental disorder and discuss the role that non-epistemic factors could play in the delineation of the future psychiatry nosography.

Clinical presentations of social communication disorder: A case series

Social Communication Disorder (SCD) is a new DSM-5 diagnostic category poorly understood by clinicians. We describe a case series of four individuals diagnosed with SCD to identify common characteristics and differences in presentations of the disorder. All cases had deficits in the area of social communication, and sub-threshold level of restricted and repetitive behaviours, not sufficient to meet criteria for Autism Spectrum Disorder (ASD). All cases presented with at least one mental health co-morbid condition. There are significant overlaps in clinical presentation between SCD and ASD. It is imperative that accurate diagnostic tools and effective intervention approaches of SCD be developed.

A road map for identifying autism spectrum disorder: recognizing and evaluating characteristics that should raise red or "pink" flags to guide accurate differential diagnosis

Objective: Given the high population prevalence of Autism Spectrum Disorder (ASD) and overlapping symptoms with medically complex groups, ASD is a common rule out diagnosis for neuropsychologists even when not identified in the referral or initial presenting concerns. This paper presents practical guidance to support neuropsychologists in their ability to accurately assess, diagnose, and/or rule out ASD, especially in patients with more subtle presentations. Method: This paper combines clinical experience and empirical literature to highlight important assessment measures and related considerations, differential diagnostic considerations, common misconceptions about ASD and person/family characteristics, as well as variability in presentation and comorbidities that can obscure the diagnosis. Characteristics that may be considered "red flags" (clearly diagnostic, classic symptoms) and "pink flags" (associated features and symptoms that are suggestive of ASD but not quite definitive and that may overlap with symptoms seen in other neurodevelopmental or psychiatric diagnoses) will be discussed. Conclusions: Neuropsychologists in all clinical settings should be able to effectively screen for and/or diagnose ASD, even when its presentation is more subtle and/or when symptoms are masked by patient strengths in a way that makes their clinical presentation less obvious. Practical strategies for communicating the diagnosis and next steps/recommendations for interventions are reviewed.

Challenges Surrounding the Diagnosis of Autism in Children

This comprehensive thematic review aims to highlight and familiarize readers with the challenges and pitfalls encountered in differential diagnosis of autism spectrum disorders (ASD) in children to facilitate the process of accurate identification by stakeholders. Accordingly, articles that best answer our questions and highlight our concerns were chosen from well-established publishers with prime peer reviewed journals. Included are studies showing alternate views of the issues so as to point readers to other possibilities. ASD, a complex dynamic biological-neurodevelopmental disorder, is underscored by its heterogeneous symptomology, severity, and phenotypes - all characterized by social communication deficits and presence of restricted interests and repetitive behaviours (RRBs), the core symptoms in ASD. Language and intellectual capacities do not form ASD core symptoms although vary considerably. Accurate identification is challenging as ASD is often enmeshed with other neurodevelopmental disorders, and medical comorbidities, a situation now recognized as the rule rather than the exception in child psychiatry and developmental medicine. ASD is a disorder with varying performance and severity of symptoms over time, including unexpected loss of early skills, and lost diagnosis in some children following treatment. The review reiterates the urgency in accurate diagnosis in face of the rapid rise in ASD prevalence globally, and risk-increase in delayed or denied treatment with undesirable life-long consequences for most of the affected children. In addition, a call for change is advised to circumvent the ethical dilemma posed by the present "deficit model" in ASD diagnosis. Here, ASD prevalence is presented first, followed by emphasis on importance of accurate early diagnosis, and challenges in its accomplishment due to flaws in diagnostic instruments and other contributing factors. Next follow the required criteria for accurate identification, and its difficulties attributed to comorbid conditions, gender differences, and socio-economic and cultural influences. The conclusion includes future directions and a take away message.

How well are DSM-5 diagnostic criteria for ASD represented in standardized diagnostic instruments?

Five years after the publication of DSM-5 in 2013, three widely used diagnostic instruments have published algorithms designed to represent its (sub-)criteria for Autism Spectrum Disorder (ASD) in children and adolescents. This study aimed to: (1) establish the content validity of these three DSM-5-adapted algorithms, and (2) identify problems with the operationalization of DSM-5 diagnostic criteria in measurable and observable behaviors. Algorithm items of the Autism Diagnostic Observation Schedule-Second Edition (ADOS-2), Developmental, Dimensional and Diagnostic Interview (3di) and Diagnostic Interview for Social and Communication Disorders-11th edition (DISCO-11) were mapped onto DSM-5 sub-criteria. The development and decision-making rules integrated in their algorithms were then compared with DSM-5. Results demonstrated significant variability in the number and nature of sub-criteria covered by the ADOS-2, 3di and DISCO-11. In addition to differences in the development of algorithms and cut-off scores, instruments also differed in the extent to which they follow DSM-5 decision-making rules for diagnostic classification. We conclude that such differences in interpretation of DSM-5 criteria provide a challenge for symptom operationalization which will be most effectively overcome by consensus, testing and reformulation.

A Preliminary Epidemiologic Study of Social (Pragmatic) Communication Disorder Relative to Autism Spectrum Disorder and Developmental Disability Without Social Communication Deficits

The goal of this preliminary investigation was to compare demographic and clinical characteristics in a sample of children with likely Social (Pragmatic) Communication Disorder (SCD) (N = 117) to those in children with possible (N = 118) and some (N = 126) SCD traits, other developmental delay (DD) (N = 91) and autism spectrum disorder (ASD) (N = 642). We used data from the Study to Explore Early Development (SEED), a multi-site case-control study. Items reflecting SCD DSM-5 criteria were selected from an autism diagnostic measure, with SCD categories identified by creating quartiles. Our results suggest that SCD may fall along a continuum involving elevated deficits (in comparison to DD with no SCD) in social communication and restricted and repetitive behavior that do not reach the clinical threshold for ASD.

Evaluation of a parent preference-based outcome measure after intensive communication intervention for children with social (pragmatic) communication disorder and high-functioning autism spectrum disorder

BACKGROUND/OBJECTIVES

Children with Social (Pragmatic) Communication Disorder (SPCD) or High-Functioning Autism Spectrum Disorder (HFASD) have persistent deficits in language structure and language use (pragmatics). This feasibility study evaluated a novel parent preference-based outcome measure and secondary outcomes associated with the Social Communication Intervention Programme (SCIP).

METHODS

15 UK speech and language practitioners identified 20 children aged 5-11 years with pragmatics/language needs. Practitioners received SCIP training and supervision. Children received 20 SCIP therapy sessions. Primary endpoint was a goal attainment scale (SCIP-GAS). Before intervention (T1), parents provided three prioritised communication goals, refined into a series of steps. After intervention (T2) parents and practitioners rated each goal compared to T1 and parents provided a narrative on outcomes.

SECONDARY OUTCOMES

Children's Communication Checklist-2, Social Language Development Test (SLDT), and observational ratings of conversational interaction (TOPICC-2).

RESULTS

All children except one progressed on T2 SCIP-GAS parent outcomes. All children progressed on practitioner SCIP-GAS ratings. 82.5 % of parent comments supported their own SCIP-GAS ratings. Secondary outcomes measures: Only SLDT Making Inferences scores and TOPICC-2 ratings showed improvement at T2.

CONCLUSIONS

A preference-based social communication measure showed feasibility as an outcome measure following social communication intervention for children who have HFASD or SPCD.

Evaluation of a manualised speech and language therapy programme for children with social communication disorder: the SCIP feasibility study

Background

Children with Social (Pragmatic) Communication Disorder (SPCD) have long-term needs in using and processing social language and have a high risk of later mental health difficulties. A manualised speech and language therapy programme, the Social Communication Intervention Programme (SCIP) provides therapy content for SPCD. A feasibility study is required to derive more precise estimates of key parameters for a future trial of SCIP.

Aims

To assess the feasibility of conducting a substantive randomized controlled trial of SCIP for children with SPCD.

Methods

A questionnaire was distributed to paediatric speech and language therapists in England. Survey questions addressed number of eligible children, routine intervention provision and trial recruitment factors. In the second phase, a single-arm intervention feasibility study was completed. Fifteen speech and language practitioners identified 24 children aged 5-11 years with SPCD. Practitioners received training/supervision to deliver 20 SCIP therapy sessions to each child. At time 1, parents of participating children provided three communication goals; expected steps in each goal were defined. After intervention, parents and practitioners independently rated each goal compared to baseline ability. Two research practitioners compared parent post-intervention commentaries with outcome scores to derive guidance about clinical significance. All practitioners recorded audio commentaries on therapy experiences. Post-intervention interviews were conducted with 6 practitioners and 6 parents. An expert panel completed a Delphi consultation on trial design.

Results

Routine practice for SPCD varies widely. Children tend to be embedded in autism provision. Participation in a future trial was well supported provided resources are available to services. Outcomes analysis indicated all children except one made some progress on parent ratings; all children made progress on practitioner ratings. A power analysis for a future trial was carried out using current outcome measure as putative primary endpoint. Practitioners' audio-diaries provided suggestions for training and adaption in a future trial. Outcomes and therapy methods were acceptable to practitioners and parents.

Conclusions

The feasibility study evaluated a novel outcome measure of social communication skills in SPCD. A power calculation indicated a feasible framework for a trial within a realistic period of time. Recommendations for recruitment methods, adaptation of manual and training were supported by practitioners and an expert panel.

Trial registration

Title: Speech-language therapy for child social communication disorderTrial ID: ISRCTN48030419. Date registered: January 1, 2017. Registered retrospectively.

Autism spectrum disorder: definition, epidemiology, causes, and clinical evaluation

Autism spectrum disorder (ASD) is a neurodevelopmental disorder characterized by deficits in social communication and the presence of restricted interests and repetitive behaviors. There have been recent concerns about increased prevalence, and this article seeks to elaborate on factors that may influence prevalence rates, including recent changes to the diagnostic criteria. The authors review evidence that ASD is a neurobiological disorder influenced by both genetic and environmental factors affecting the developing brain, and enumerate factors that correlate with ASD risk. Finally, the article describes how clinical evaluation begins with developmental screening, followed by referral for a definitive diagnosis, and provides guidance on screening for comorbid conditions.

Do Parental Interviews for ASD Converge with Clinical Diagnoses? An Empirical Comparison of the 3di and the DISCO in Children with ASD, a Clinically-Referred Group, and Typically Developing Children

Two semi-structured parental interviews are available with algorithms developed to measure DSM-5 criteria of ASD, namely the Developmental, Dimensional and Diagnostic Interview (3di) and the Diagnostic Interview for Social and Communication Disorders (DISCO-11). The main aim of this study was to examine the agreement between classification according to both interviews, and their convergence with the clinical diagnosis. Therefore, the 3di and DISCO-11 were administered from three groups of parents of a 4-18 year old. Results showed 75% agreement between both instruments, but in the ASD group only 16% of the children scored above threshold on both instruments. Exploratory analyses suggested that the 3di failed to detect rigid and repetitive behaviors, whereas the DISCO-11 was insufficiently sensitive in detecting socio-communicative problems.

Identification, Evaluation, and Management of Children With Autism Spectrum Disorder

Autism spectrum disorder (ASD) is a common neurodevelopmental disorder with reported prevalence in the United States of 1 in 59 children (approximately 1.7%). Core deficits are identified in 2 domains: social communication/interaction and restrictive, repetitive patterns of behavior. Children and youth with ASD have service needs in behavioral, educational, health, leisure, family support, and other areas. Standardized screening for ASD at 18 and 24 months of age with ongoing developmental surveillance continues to be recommended in primary care (although it may be performed in other settings), because ASD is common, can be diagnosed as young as 18 months of age, and has evidenced-based interventions that may improve function. More accurate and culturally sensitive screening approaches are needed. Primary care providers should be familiar with the diagnostic criteria for ASD, appropriate etiologic evaluation, and co-occurring medical and behavioral conditions (such as disorders of sleep and feeding, gastrointestinal tract symptoms, obesity, seizures, attention-deficit/hyperactivity disorder, anxiety, and wandering) that affect the child's function and quality of life. There is an increasing evidence base to support behavioral and other interventions to address specific skills and symptoms. Shared decision making calls for collaboration with families in evaluation and choice of interventions.  This single clinical report updates the 2007 American Academy of Pediatrics clinical reports on the evaluation and treatment of ASD in one publication with an online table of contents and section view available through the American Academy of Pediatrics Gateway to help the reader identify topic areas within the report.

Sensitivity and specificity of DSM-5 diagnostic criteria for autism spectrum disorder in a child and adolescent sample

BACKGROUND

Controversy exists regarding the DSM-5 criteria for autism spectrum disorders (ASD). Given the mixed results that have been reported, our main aim was to determine DSM-5 sensitivity and specificity in a child and adolescent Spanish sample. As secondary goals, we assessed the diagnostic stability of DSM-IV-TR in DSM-5, and clinical differences between children diagnosed with an ASD or a social (pragmatic) communication disorder (SPCD).

METHODS

This study was carried out in 2017, reviewing the medical records of patients evaluated in our service. Items from a parent report measure of ASD symptoms (Autism Diagnostic Interview-Revised) were matched to DSM-5 criteria and used to assess the sensitivity and specificity of the DSM-5 criteria and current DSM-IV criteria when compared with clinical diagnoses.

RESULTS

DSM-5 sensitivity ranged from 0.69 to 1.00, and was higher in females. By age, the DSM-5 and DSM-IV-TR criteria showed similar sensitivity. In the case of intellectual quotient, DSM-5 criteria sensitivity was lower for those in the "low-functioning" category. DSM-5 specificity ranged from 0.64 to 0.73, while DSM-5 specificity was similar for all phenotypic subgroups. With respect to stability, 83.3% of autism disorder cases retained a diagnosis of ASD using the DSM-5 criteria. With regard to differences between ASD and SPCD, we found that patients diagnosed with ASD received more pharmacological treatment than those diagnosed with SPCD.

CONCLUSIONS

Further research is required to confirm our results. Studies focusing on the SPCD phenotype will be necessary to determine outcome differences with ASD and the most effective diagnostic and therapeutic tools.

The Need for a Developmentally Based Measure of Social Communication Skills

The ability to demonstrate and quantify changes in social communication skills has been hindered by a lack of existing measures with appropriate standardization and psychometric properties. Such a measure would be helpful for research in many populations but would be particularly crucial for detecting incremental changes in youth with neurodevelopmental disorders who might gain skills but still lag substantially behind same-age peers. Although study designs and statistical methods are under development to try to account for slow and/or nonlinear, but potentially meaningful, improvements,¹ there is a dearth of measures designed to capture growth and loss of social communication skills. This opinion piece outlines the argument for such a measure and the primary issues to consider in its development.

Assessing Autism in Adults: An Evaluation of the Developmental, Dimensional and Diagnostic Interview-Adult Version (3Di-Adult)

We developed a brief, informant-report interview for assessing autism spectrum conditions (ASC) in adults, called the Developmental, Dimensional and Diagnostic Interview-Adult Version (3Di-Adult); and completed a preliminary evaluation. Informant reports were collected for participants with ASC (n = 39), a non-clinical comparison group (n = 29) and a clinical comparison group (n = 20) who had non-autistic mental health conditions. Mean administration time was 38 min (50 min for ASC). Internal consistency (αs ≥ 0.93) and inter-rater agreement (ICCs ≥ 0.99) were high. When discriminating ASC from non-ASC, the 3Di-Adult showed excellent sensitivity (95%) and specificity (92%). The 3Di-Adult shows promise as a psychometrically sound and time-efficient interview for collecting standardised informant reports for DSM-5 assessments of ASC in adults, in research and clinical practice.

Social (Pragmatic) Communication Disorder: Another name for the Broad Autism Phenotype?

The Diagnostic and Statistical Manual of Mental Disorders' (5th ed.) Social (Pragmatic) Communication Disorder is meant to capture the social elements of communication dysfunction in children who do not meet autism spectrum disorder criteria. It is unclear whether Social (Pragmatic) Communication Disorder captures these elements without overlapping with Autism Spectrum Disorder or the Diagnostic and Statistical Manual of Mental Disorders' (5th ed.) Language Disorder. Standardized behavioral assessments administered during a family genetics study were used to evaluate the social communication impairment and the restricted interests and repetitive behaviors in persons with autism spectrum disorder, language impairment, or neither. Social communication impairment and restricted interests and repetitive behavior were significantly correlated in all family members regardless of affection status. Rates of social communication impairment and restricted interests and repetitive behavior were highest in individuals with autism spectrum disorder. One-third of family members with language impairment presented with at least mild/moderate levels of social communication impairment (36.6%) and restricted interests and repetitive behavior (43.3%). A subset of unaffected members also presented with mild/moderate levels of social communication impairment (parents = 10.1%, siblings 11.6%) and restricted interests and repetitive behavior (parents = 14.0%, siblings = 22.1%). The majority of child family members with mild/moderate levels of social communication impairment had similar restricted interest and repetitive behavior levels reflecting criteria representing the Broad Autism Phenotype. These data suggest that social pragmatic communication disorder does not capture the profiles of children who have both social communication impairment and restricted interests and repetitive behavior but are in need of clinical services.

Cognitive aspects of social competence in the current New South Wales Kindergarten to Grade Six Syllabuses

BACKGROUND/AIM

Occupational therapists are commonly referred children who find reduced social competence a barrier to participation in school activities. Little is known about the social skills expected of children at school and the thinking strategies children use during social interactions. This study aimed to investigate the social skills expected of children during school-based learning activities in the current NSW K-6 Syllabuses and the types of cognitive strategies expected during social interactions.

METHODS

A qualitative text-based approach was adopted to explore the range of social skills expected of children at school. A content analysis of text-based data was used to identify specific social skills represented in the current NSW K-6 Syllabuses and the types of cognitive strategies required. Cognitive strategy use items from the PRPP System of Task Analysis were used to identify expected ways of thinking that related to social competence outcomes as stated in the Syllabus.

RESULTS

Findings revealed a high number of social skills represented in expected learning outcomes for all six subjects included in the analysis. Four categories representing expected social behaviours across the syllabuses were identified: intrapersonal skills: communication by language; interpersonal skills and responding to others. Each desired social competence phrase embedded within syllabus objectives aligned with at least one item from the PRPP System of Task Analysis. The highest representation of expected strategy use was items from Recall (memory) and Planning (problem solving and evaluating) Quadrants.

CONCLUSION

Investigation into the types of cognitive strategies embedded within Syllabus objectives which relate to social competence can assist therapists more accurately target social skills and associated cognitive strategies required for occupational performance at school. Findings from the study support the use of the PRPP System of Task Analysis for identifying and addressing cognitive strategy use during occupational therapy assessment and intervention.