Social Communication Disorders in School-Age Children
See the Social Communication Disorders Evidence map for summaries of the available research on this topic.
The scope of this page is limited to social communication disorders in school-age children (5-21 years old); social communication resources for preschool and early adult populations will be developed at a later date. While the four domains of social communication function in an integrated way, this document focuses on disorders of social interaction, social cognition, and pragmatics, because these are unique to social communication. Disorders of receptive and expressive language will be addressed in a separate Practice Portal page.
Social communication can be defined as "the synergistic emergence of social interaction, social cognition, pragmatics (verbal and nonverbal), and receptive and expressive language processing" (Adams, 2005, p. 182). See components of social communication [PDF] and social communication benchmarks [PDF] across the age span.
Social communication disorders may include problems with social interaction, social cognition, and pragmatics. A social communication disorder may be a distinct diagnosis or may occur within the context of other conditions, such as autism spectrum disorder (ASD), specific language impairment (SLI), learning disabilities (LD), language learning disabilities (LLD), intellectual disabilities (ID), developmental disabilities (DD), attention deficit hyperactivity disorder (ADHD), and traumatic brain injury (TBI). Other conditions (e.g., psychological/emotional disorders and hearing loss) may also impact social communication skills. In the case of ASD, social communication problems are a defining feature along with restricted, repetitive patterns of behavior.
Social communication includes interactions with a variety of communication partners, including family, caregivers, child care providers, educators, and peers. Social communication behaviors such as eye contact, facial expressions, and body language, are influenced by sociocultural and individual factors (Curenton & Justice, 2004; Inglebret, Jones, & Pavel, 2008), and there is a wide range of acceptable norms within and across individuals, families, and cultures. For example, preferences for maintaining or averting eye contact, expectations for adult-child interactions, or norms for personal space may vary. The rules of interaction are highly dependent on the situation and condition in which the child is involved (Kayser, 1989; Wolfram, 1986). Clinically and culturally appropriate assessment must examine variations in norms and distinguish these variations from a disorder(s).
Coding for social communication disorders can be complicated. For guidance, refer to the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5; American Psychiatric Association, 2013), ASHA's Billing and Reimbursement, and ASHA's Speech-Language Pathology Billing Codes.
Incidence and Prevalence
"Incidence" of social communication disorders refers to the number of new cases identified in a specified time period. "Prevalence" of social communication disorders refers to the number of people who are living with social communication disorders in a given time period.
There are no reliable data on incidence and prevalence of social communication disorders, at least partly as a result of inconsistency of definitions across sources. However, data on incidence and prevalence may be available for disorders in which social communication problems co-occur with other defining symptoms and characteristics.
Signs and Symptoms
Signs and symptoms of social communication disorders include problems with social interaction (e.g., speech style and context, rules for linguistic politeness), social cognition (e.g., emotional competence, understanding emotions of self and others), and pragmatics (e.g., communicative intentions, body language, eye contact).
See components of social communication [PDF] and social communication benchmarks [PDF] across the age span.
A social communication disorder may be a distinct diagnosis or may be associated with other conditions (e.g., ASD, SLI, etc.), some of which have a known etiology and some of which are idiopathic. The causes of social communication disorders are often defined in terms of these specific conditions. Links to disorder- and condition-specific Practice Portal pages will be included as those pages are developed.
Roles and Responsibilities
Speech-language pathologists (SLPs) play a critical role in the screening, assessment, diagnosis, and treatment of school-age children with social communication disorders. Social communication challenges can result in far-reaching problems, including difficulties with shared enjoyment, social reciprocity in verbal and nonverbal interactions, play, peer interactions, comprehension of others' intentions, emotional regulation, spoken and written narratives, and literacy skills. Social communication norms may vary significantly across individuals and cultures. SLPs determine a child's norms within the context of his or her environment to differentiate a language difference from a disorder.
Family members, peers, and other communication partners may encounter barriers in their efforts to communicate and interact with individuals with social communication disorders. Therefore, the SLP's role is critical in supporting the individual, the environment, and the communication partner in order to maximize opportunities for interaction and assist in overcoming barriers that might lead to social isolation if left unmitigated.
SLPs play a central role in the screening, assessment, diagnosis, and treatment of social communication disorders in children. The professional roles and activities in speech-language pathology include clinical/educational services (diagnosis, assessment, planning, and treatment), advocacy, education, administration, and research. See ASHA's Scope of Practice in Speech-Language Pathology (ASHA, 2007).
Appropriate roles for speech-language pathologists include
- providing prevention information to individuals and groups known to be at risk for social communication disorders and to individuals working with those at risk;
- educating other professionals on the needs of children with social communication disorders and the role of SLPs in screening, assessing, diagnosing, and managing social communication disorders;
- screening of social communication skills for early detection, when a social communication disorder is suspected and as part of a comprehensive speech-language evaluation for a child with communication concerns;
- conducting a culturally and linguistically relevant comprehensive assessment of social cognition, social interaction, pragmatics, and language processing for the purpose of communication;
- diagnosing the presence or absence of social communication disorders;
- referring the patient/client to other professionals to rule out other conditions, determine etiology, and facilitate access to comprehensive services;
- developing culturally and linguistically relevant treatment and intervention plans focused on helping the child achieve social communication competence, providing treatment, documenting progress, and determining appropriate dismissal criteria;
- recommending related services when necessary for daily classroom management and therapy;
- counseling individuals with social communication disorders and their families and providing education aimed at preventing further complications related to social communication disorders;
- consulting and collaborating with families, individuals with social communication disorders, other professionals, support personnel, peers, and other invested parties to identify priorities and build consensus on an intervention plan focused on functional outcomes;
- remaining informed of research in the area of social communication disorders and advancing the knowledge base of the nature of the disability, screening, diagnosis, prognostic indicators, assessment, treatment, and service delivery for individuals with social communication disorders;
- advocating for individuals with social communication disorders and their families at the local, state, and national levels.
As indicated in the Code of Ethics, SLPs who serve this population should be specifically educated and appropriately trained to do so.
See the Assessment section of the social communication evidence map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.
Screening of social communication skills is conducted whenever a social communication disorder is suspected or as part of a comprehensive speech and language evaluation for any child with communication concerns.
Screening typically includes
- norm-referenced parent and teacher report measures,
- competency-based tools such as interviews and observations,
- hearing screening to rule out hearing loss as a possible contributing factor to social communication difficulties.
Individuals suspected of having a social communication disorder based on screening results are referred to an SLP, and other professionals as needed, for a comprehensive assessment. Assessment of social communication should be culturally sensitive and functional and involve the collaborative efforts of families, caregivers, classroom teachers, SLPs, special educators, and psychologists as needed. Assessment is sensitive to the wide range of acceptable social norms that exist within and across communities.
Typically, SLPs assess a child's
- initiation of spontaneous communication and reciprocal turn-taking in functional activities across communication partners and settings;
- willingness to initiate and maintain conversation;
- ability to manipulate conversational topics and repair communication breakdowns;
- comprehension of verbal and nonverbal discourse in social, academic, and community settings;
- communication for a range of social functions that are reciprocal and promote the development of friendships and social networks, including differentiation of one's own feeling from the feelings of others (Theory of Mind [ToM]);
- verbal and nonverbal means of communication, including natural gestures, speech, signs, pictures, and written words, as well as other AAC systems;
- ability to access literacy and academic instruction, as well as curricular, extracurricular, and vocational activities.
See social communication benchmarks [PDF] for age-specific social communication skills. SLPs consider cultural diversity of social communication when they examine eye gaze, orienting to one's name, pointing to or showing objects of interest, pretend play, imitation, nonverbal communication, and language development.
Comprehensive assessment of communication skills typically includes
Standardized Assessment—an empirically developed evaluation tool with established reliability and validity. Coexisting disorders/diagnoses are considered when selecting standardized assessment tools as deficits vary from population to population (e.g., ADHD, TBI, ASD). Formal testing may be useful for assessing the structure and form of language but may not provide an accurate assessment of an individual's use of language (i.e., pragmatics).
Parent/Teacher Child Report Measures—rating scales, checklists, and/or inventories completed by the family member(s)/caregiver(s), teacher(s), and/or child. Findings from multiple sources (e.g., family member, teacher, self-report) may be compared to obtain a comprehensive profile of social communication skills.
Ethnographic Interviewing—an interview technique using open-ended questions, restatement, summarizing for clarification, and avoidance of leading questions and "why" questions in order to develop an understanding of the client's and the family's perceptions, views, desires, and expectations.
Analog Task(s)—observation of the child in simulated social situations that mimic real world events, including peer group activities.
Naturalistic Observation—observation of the child in everyday social settings with other individuals.
Assessment may result in
- diagnosis of social communication disorder,
- description of the characteristics and severity of the disorder,
- recommendations for intervention and support,
- referral to other professionals as needed.
As mandated by the Individuals with Disabilities Education Improvement Act (IDEA; 2004), SLPs should avoid applying a priori criteria (e.g., discrepancies between cognitive abilities and communication functioning, chronological age, or diagnosis) in making decisions on eligibility for services. In the schools, children and adolescents with social communication disorders are eligible for speech-language pathology services, due to the pervasive nature of the social communication impairment, regardless of cognitive abilities or performance on standardized testing of formal language skills.
See the treatment section of the social communication disorders evidence map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.
The ultimate goal of intervention is to improve social interactions, not to teach specific behaviors or skills. While it is ideal to address all skill areas concurrently, this is not always possible due to a number of factors, including time constraints and the patient's/client's unique needs.
The broad impact of social communication disorders-specifically problems with generalization of skills- necessitates service delivery models and individualized programs that lead to increased active engagement and build independence in natural learning environments. When developing a treatment program, SLPs consider service delivery options that include both direct and indirect ways to mediate social exchanges. Clinician-mediated interventions may be useful for teaching new skills, but are more limited in promoting generalization of those skills. Where appropriate, intervention settings include environmental arrangement, teacher-mediated interventions, and peer-mediated interventions (Timler, 2008).
- recognizes the importance of
- family involvement,
- cultural values and norms,
- collaboration with a variety of professionals and communication partners,
- facilitation of peer-mediated learning,
- continuity of services across environments,
- addressing functional needs,
- matching service delivery to meaningful outcomes;
- provides services that are connected with functional and meaningful outcomes, such as
- the child being included in social settings with greater frequency,
- the child experiencing less frustration with problem solving, etc.;
- provides services in natural learning environments to the extent possible
- using one-on-one or individual services only when repeated opportunities do not occur in natural learning environments,
- ensuring that any pull-out services are tied to meaningful, functional outcomes and incorporate activities that relate to natural learning environments (Timler, 2008),
- using one-on-one services in conjunction with group services to teach specific-skills that the child will then use in the group setting;
- incorporates the collaborative efforts and input from families, classroom teachers, special educators, psychologists, and SLPs.
The treatment modes/modalities described below may be used to implement various treatment options.
Augmentative And Alternative Communication (AAC)—supplementing, or using in the absence of, natural speech and/or writing with aided (e.g., picture communication symbols, line drawings, Blissymbols, and tangible objects) and/or unaided (e.g., manual signs, gestures, and finger spelling) symbols. Aided symbols require some type of transmission device; unaided symbols require only the body to produce.
Computer-Based Instruction—the use of computer technology and/or computerized programs to teach social skills and social understanding.
Video-Based Instruction—a form of observational learning in which video recordings of desired behaviors are observed and then imitated by the individual (also called video modeling).
Treatment for social communication disorders in childhood addresses the areas of need identified during assessment, as well as the specific goals of the child. Treatment involves providing information and guidance to patients/clients, families/caregivers, and other significant persons about the nature of disorders of social communication and the course of treatment. Intervention strategies can be used to supply the communication partner with information about the individual's subtle bids for communication, help them interpret problem behavior, and modify the environment to foster social engagement. Recommended treatment strategies are relevant, specific to the child's communication norms, and in the language(s) used by the child. A bilingual service provider or the assistance of a trained interpreter may be necessary.
Below are brief descriptions of both general and specific treatments for addressing social communication disorders. This list is not exhaustive, and the inclusion of any specific treatment approach does not imply endorsement from ASHA.
Below are examples of interventions and techniques designed to reduce problem behaviors and teach functional alternative behaviors using the basic principles of behavior change.
Applied Behavioral Analysis (ABA)—interventions based on the theory of behaviorism. This approach focuses on the relationship between observable behaviors and the environment; ABA methods are used to make environmental modifications to affect changes in behavior.
Functional Communication Training (FCT)—a behavioral intervention program that combines the assessment of the communicative functions of maladaptive behavior with procedures to teach alternative responses. FCT methods are used to reduce problem behaviors by replacing them with more appropriate forms of communicating needs or wants.
Incidental Teaching—a teaching technique in which naturally occurring opportunities for learning are maximized, and the child's attempts to behave in a desired way are reinforced the closer they get to the desired behavior.
Milieu Therapy—a range of methods integrated into a child's natural environment, including training during activities that take place throughout the day, rather than only at "therapy time."
Pivotal Response Training (PRT)—a treatment based on the belief that development of "pivotal" behavioral skills (e.g., ability to respond to multiple cues, motivation to initiate and respond appropriately to social and environmental stimuli, and self-regulation of behavior) results in collateral behavioral improvements.
Positive Behavior Support (PBS)—an approach that uses the functional assessment of problem behaviors to target the relationship between challenging behavior and communication; it integrates the principles of applied behavior analysis with person-centered values to foster skills that replace challenging behaviors through positive response/support.
Cognitive Behavioral Therapy (CBT)
Cognitive Behavioral Therapy (CBT) is an intervention that combines cognitive and behavioral learning principles to shape and encourage desired behaviors. The underlying assumptions of CBT are that an individual's behavior is mediated by cognitive events and that change in thinking or cognitive patterns can lead to changes in behavior.
The Denver Model is a play-based treatment approach that focuses on the development of social communication skills through intensive one-on-one therapy, peer interactions in the school setting, and home-based teaching (Rogers & Dawson, 2009).
Parent-mediated or implemented interventions consist of parents using direct, individualized intervention practices with their child to increase positive learning opportunities and acquisition of skills.
Peer-mediated or implemented interventions are those in which typically developing peers are taught strategies to facilitate play and social interactions with children who have social communication disorders.
Social Communication Treatments
Below are examples of interventions designed specifically to increase social communication skills. There continues to be research in the development of similar treatment programs, such as the Social Communication Project (SCIP) for school-age children with pragmatic and social communication problems (Adams et al., 2012). SLPs are encouraged to research additional social communication treatment programs and approaches.
SCERTS—social communication (SC), emotional regulation (ER) and transactional support (TS) is a model of service provision, rather than a specific program, that focuses on how to regulate emotions and communicate with others (Prizant, Wetherby, Rubin, Laurent, & Rydell, 2006).
Social Scripts—a prompting strategy used to teach children to use a variety of language during social interactions. Scripted prompts (visual and or verbal) are gradually faded out, as children use them more spontaneously (Nelson, 1978).
Social Skills Groups—teach ways of interacting appropriately with typically developing peers through instruction, role-playing, and feedback. Groups typically consist of two to eight individuals with social communication disorders and a teacher or adult facilitator.
Social Stories™—a highly structured intervention that uses stories to explain social situations to children and to help them learn socially appropriate behaviors and responses. Initially developed for use with children with autism, it is now being used with children with other disorders (Gray, White, & McAndrew, 2002).
Score Skills Strategy—is a social skills program that takes place in a cooperative small group and focuses on five social skills: share ideas (S), compliment others (C), offer help or encouragement (O), recommend changes nicely (R), and exercise self-control (E) (Vernon, Schumaker, & Deshler, 1996).
Relationship-based practices in early intervention are aimed at supporting parent-child relationships (Edelman, 2004).
Greenspan/Dir/Floortime—is a model that promotes development by encouraging children to interact with parents and others through play. The model focuses on following the child's lead; challenging the child to be creative and spontaneous; and involving the child's senses, motor skills, and emotions (Greenspan, Weider & Simons, 1998).
TEACCH (Treatment and Education of Autistic and related Communication Handicapped Children)
TEACCH is a university-based system of community regional centers that provides clinical services, such as diagnostic evaluations, parent training and parent support groups, social play and recreation groups, individual counseling, and supported employment (Mesibov, Shea, & Schopler, 2007).
See the service delivery section of the social communication disorders evidence map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.
In addition to determining the type of speech and language treatment that is optimal for children with social communication disorders, SLPs consider other service delivery variables—including format, provider, dosage and timing—that may impact treatment outcomes.
Format refers to the structure of the treatment session (e.g., group vs. individual) provided.
Provider refers to the person providing the treatment (e.g., SLP, trained volunteer, caregiver).
Dosage refers to the frequency, intensity, and duration of service.
Setting refers to the location of treatment (e.g., home, community-based).
Components of Social Communication [PDF]
Consumer Information Page: Social Language Use
Self-Assessment for Cultural Competence
Social Communication Benchmarks [PDF]
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