The scope of this Practice Portal page is social communication disorder across the life span.
See the Social Communication Disorder Evidence Map for summaries of the available research on this topic.
Social communication disorder (SCD) is characterized by persistent difficulties with the use of verbal and nonverbal language for social purposes. Primary difficulties may be in social interaction, social understanding, pragmatics, language processing, or any combination of the above (Adams, 2005). Social communication behaviors such as eye contact, facial expressions, and body language are influenced by sociocultural and individual factors (Curenton & Justice, 2004; Inglebret et al., 2008). There is a wide range of acceptable norms within and across individuals, families, and cultures. Specific communication challenges may become apparent when difficulties arise in the following:
This definition is consistent with the diagnostic criteria for social (pragmatic) communication disorder detailed in the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; American Psychiatric Association, 2013). Please note that certain references cited in this page may predate this definition. Therefore, specific terminology relating to “social (pragmatic) communication disorder” may not be used in all cases, but information may still be relevant and considered for the SCD population.
SCD can result in a wide array of problems, including difficulty participating in social settings, developing peer and/or romantic relationships, achieving academic success, and performing successfully on the job.
SCD may be a distinct diagnosis or may co-occur with other conditions. In the case of autism spectrum disorder, social communication problems are a defining feature, along with restricted, repetitive patterns of behavior. Therefore, SCD cannot be diagnosed in conjunction with autism spectrum disorder.
Social communication encompasses the following components:
Social communication enables individuals to share experiences, thoughts, and emotions. Social communication skills are needed for language expression and comprehension in nonverbal, spoken, written, and visual–gestural (sign language) modalities.
Social communication skills include the ability to
For more details, see the American Speech-Language-Hearing Association’s (ASHA’s) resources on Components of Social Communication and Social Communication Benchmarks.
Incidence of SCD refers to the number of new cases identified in a specified time period.
Prevalence of SCD refers to the number of people who are living with SCD in a given time period.
Precise estimates of the incidence and prevalence of SCD have been difficult to determine because many investigations draw on varied populations and employ inconsistent or ambiguous definitions of the disorder.
Using different definitions of SCD, the preliminary estimates of SCD in eighth graders ranged from 7% to 11% (Ellis Weismer, Tomblin, et al., 2021). A history of developmental language disorder (DLD) was indicated to be a significant risk factor for SCD. The percentage of children with SCD and a history of DLD (30%) was 3 times greater than that of children with SCD without a history of DLD (9%; Ellis Weismer, Tomblin, et al., 2021).
Studies reported results based on gender; however, there were no indications whether the data collected were based on sex assigned at birth, gender identity, or both. A higher proportion of male children were indicated to have SCD. According to Ellis Weismer, Rubenstein, et al. (2021), developmental disability with likely SCD was found to have a male-to-female ratio of 2.5:1.
Social communication problems can be associated with several other disorders and populations. For example, out of a clinical sample of 47 individuals with schizophrenia, 77% were found to have pragmatic impairments (Bambini et al., 2016). Additionally, infants born late or moderately preterm (i.e., 32–36 weeks’ gestation) were 1.3 times more likely to be identified with delayed social competence compared to peers born at term (Johnson et al., 2015). Additional data on incidence and prevalence may be available for co-occurring conditions with other defining symptoms and characteristics.
Signs and symptoms of SCD include deficits in social interaction, social understanding, pragmatics, and language processing (see ASHA’s resource on Components of Social Communication).
Specific behaviors affected by SCD depend on the individual’s age, the expected stage of development (see ASHA’s resource on Social Communication Benchmarks), and the communication context. Some examples of behaviors affected by SCD include
The causes of SCD as a primary diagnosis are unknown. SCD is often defined in terms of the specific condition with which it is associated. See ASHA’s Practice Portal pages on Intellectual Disability, Spoken Language Disorders, Written Language Disorders, Pediatric Traumatic Brain Injury, Traumatic Brain Injury in Adults, Aphasia, and Dementia for information about social communication skills in these populations.
Speech-language pathologists (SLPs) play a central role in the screening, assessment, diagnosis, and treatment of social communication disorder (SCD) in children and adults. The professional roles and activities in speech-language pathology include clinical/educational services (diagnosis, assessment, planning, and treatment); advocacy; and education, administration, and research. See ASHA’s Scope of Practice in Speech-Language Pathology (ASHA, 2016b).
Appropriate roles for SLPs include the following:
As indicated in the ASHA Code of Ethics (ASHA, 2016a), SLPs who serve this population should be specifically educated and appropriately trained to do so.
See the Assessment section of the Social Communication Disorder Evidence Map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.
Screening of social communication skills is conducted whenever SCD is suspected or as part of a comprehensive speech and language evaluation for any individual with communication concerns.
Screening typically includes the use of competency-based tools such as interviews and observations, self-report questionnaires, and norm-referenced report measures completed by parents, teachers, or significant others.
Hearing screening is conducted to rule out hearing loss as a contributing factor to social communication difficulties. Hearing screening is within the Scope of Practice in Speech-Language Pathology (ASHA, 2016b). A referral for a full audiologic evaluation is necessary if the individual fails the hearing screening.
If the individual is deaf or hard of hearing and wears hearing aids or implantable devices, the hearing devices need to be inspected by an audiologist during annual audiology appointments to ensure that they are in working order. The hearing device should be worn by the individual during screening for SCD (and during comprehensive SCD assessment, when recommended).
See ASHA’s Practice Portal pages on Childhood Hearing Screening, Adult Hearing Screening, Hearing Loss in Children, and Hearing Loss in Adults.
Screening is merited for children not previously diagnosed with a specific disorder but who demonstrate remarkable difficulties in social interaction, conversation, or interpreting nonliteral language. This includes children with subclinical deficits with structural language or vocabulary (Adams, 2015).
Children with attention-deficit/hyperactivity disorder (ADHD) tend to display higher rates of pragmatic difficulties when compared with typically developing peers—and different degrees of pragmatic language impairment than children with autism spectrum disorder (ASD; Carruthers et al., 2021). Generally, hyperactivity and inattention are highly associated with pragmatic language difficulties (Green et al., 2014). Given the correlation between ADHD and pragmatic deficits SLPs may consider students/clients with an existing diagnosis of ADHD for screening or potential further assessment for SCD.
Children with an acquired brain injury or a neurological disorder are another population to consider for potential screening for SCD. Such injuries or disorders can lead to impairment in emotion regulation, which may, in turn, affect social skills (Kok et al., 2014). Children with pediatric traumatic brain injury (TBI) may have difficulty with high-level social understanding (e.g., theory of mind, pragmatic language; On et al., 2021), and children with moderate-to-severe TBI are more at risk for social understanding or interaction difficulties (Rosema et al., 2012).
Other children who have been exposed to maltreatment (abuse and/or neglect) are at risk for delayed or low average language development that can include social cognition deficits and pragmatic language delays (Hwa-Frowlich, 2015). Children with disruptive behavior disorder (formerly known as emotional behavior disorder) may have impairments in social cognition, theory of mind, language development (including language delays), executive function, and poor narrative development (Helland et al., 2014; Westby, 2015).
Screening for SCD may help identify a separate diagnosis and/or relevant areas for treatment and further assessment of pragmatic skills even if a diagnosis of SCD is not ultimately applied. Although the references above relate to the pediatric population, an SLP may reasonably infer that adults who have these concurrent diagnoses (e.g., ADHD) should also be considered for screening. In adulthood, SCD can arise secondary to TBI, right hemisphere damage, aphasia, and neurodegenerative disorders such as Alzheimer’s disease (Cummings, 2007, 2021).
When screening results indicate the need for further evaluation, individuals are referred for a comprehensive speech and language assessment or to other professionals as needed. When the individual has a diagnosed co-occurring condition, the SLP’s role is to be aware of overlapping or similar signs and symptoms and to assess specifically for social communication components.
Assessment of social communication should be culturally sensitive; be functional; and involve the collaborative efforts of families, caregivers, classroom teachers, SLPs, special educators, psychologists, employers, communication partners, the treatment team, and other professionals as needed (e.g., vocational counselors).
Social norms and constructs vary across environments, individuals, and communities, and there is a wide range of acceptable social norms that exist within each. This variability makes the assessment of SCD challenging. It is critical for an evaluator to demonstrate sensitivity to the wide range of acceptable norms that exist within each setting by increasing their familiarity with the specific social norms defined by each of the individual’s social groups.
SLPs develop self-awareness of core elements of social communication (i.e., pragmatics, social interaction, social understanding, and language processing). SLPs also reflect on the setting, context, and resulting expectations of social communication on a case-by-case basis. Differences in social communication norms are not disorders. Diagnosis considers an individual’s ability to adapt to the social norms of their environment or community.
Please see ASHA’s resource on Cultural Competence Checklist: Personal Reflection [PDF] for further information.
Consistent with the World Health Organization’s International Classification of Functioning, Disability and Health (ICF) framework (ASHA, 2016a; World Health Organization, 2001), comprehensive assessment is conducted to identify and describe
See ASHA’s resource on the International Classification of Functioning, Disability, and Health (ICF) for examples of handouts featuring assessment data consistent with the ICF framework. Social determinants of health can influence how individuals access all areas within the ICF framework. Please see the Social Determinants of Health Workgroup for further information.
The following items are listed in order of less complex to more complex. SLPs may assess the individual’s ability to
Both formal and informal assessments are used to assess social communication skills. A mixture of contexts should be considered during assessment. As with screening, competency-based tools, self-report questionnaires, norm-referenced direct assessments, and report measures (e.g., parent, teacher, employer, and significant other) are frequently used. Tasks that mimic real-world situations and naturalistic observations can be used to gather information about an individual’s communication skills in simulated social situations or in everyday social settings. Review evidence for each assessment’s validity and reliability as part of evidence-based assessment selection. See ASHA’s resource on Assessment Tools, Techniques, and Data Sources for general information about assessment options.
Assessment may result in
Assessment of social communication skills considers the individual’s age, cultural norms and values, and expected stage of development. See ASHA’s resource on Social Communication Benchmarks for age-specific social communication skills. See also ASHA’s Practice Portal page on Cultural Responsiveness. Evidence-based and culturally responsive practice takes client/student/caregiver perspective into consideration in both assessment and treatment. This is especially relevant in the assessment of SCD. SLPs recognize that neurodiversity and differences in communication behaviors are inherent to an individual’s identity. SLPs work in collaboration with the individual and their caregivers to assure that services align with the client’s values and goals.
Izaryk et al. (2021) propose that best practice for the assessment of SCD may include the combination of several different approaches and the inclusion of data from multiple sources. There is a noted lack of ecological validity in standardized assessments given the dynamic nature of social communication, so SLPs may combine both formal (i.e., standardized) and informal assessments. Further challenges in the assessment of SCD include that (a) it is difficult to conceptualize, (b) it crosses diagnoses, and (c) there is a lack of understanding of the typical development of social communication (Izaryk et al., 2021).
It is important to consider the age of onset and the duration of hearing loss when assessing social communication skills in individuals who are deaf or hard of hearing. These factors play a role in the development of language and communication skills.
SLPs play an important role in the differential diagnosis of SCD and other disorders. When differentially diagnosing between SCD and ASD, consider that older children may no longer exhibit overt repetitive behaviors, interests, or activities. However, subtle repetitive patterns may still be present (e.g., patterns of speech or compulsive retracing over letters while writing). Accurate diagnosis is essential for planning an effective intervention strategy. Per Brukner-Wertman et al. (2016), SCD should be considered after ruling out ASD as a potential diagnosis.
Differential diagnosis of children with developmental language disorder and SCD is challenging. However, children with SCD have more difficulty with the ability to identify a social or an emotional state associated with pragmatic errors (Adams et al., 2018). Children with SCD have relative strengths in structural aspects of language (e.g., syntax and morphology) compared to children with developmental language disorder.
The Individuals with Disabilities Education Improvement Act of 2004 (IDEA) requires the use of a variety of assessment tools and strategies, consultation with parents/guardians, and administration of technically sound instruments to determine eligibility for special education services. IDEA also stipulates that assessments must be administered in a language or form that is most likely to provide accurate information. No tools that discriminate on a racial or cultural basis should be used in any context, including determining eligibility for services.
Children and adolescents with SCD are eligible for speech-language pathology services, regardless of performance on cognitive or language assessments. ASHA does not support such cognitive referencing (i.e., comparing IQ scores to language scores to determine eligibility).
SLPs may encounter Diagnostic and Statistical Manual of Mental Disorders (5th ed.; American Psychiatric Association, 2013) codes related to SCD; however, these cannot be used for billing and payment purposes. See ASHA’s billing and reimbursement resources for information on billing, coding, and coverage of speech-language pathology services.
See the Treatment section of the Social Communication Disorder Evidence Map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.
Consistent with the World Health Organization (2001) framework, intervention is designed to
See ASHA’s resource on the International Classification of Functioning, Disability, and Health (ICF) for examples of handouts featuring goals consistent with the International Classification of Functioning, Disability and Health framework.
Treatment typically involves collaboration with a variety of professionals (e.g., classroom teachers, special educators, psychologists, and vocational counselors). See ASHA’s resources on Collaboration and Teaming and Interprofessional Education/Interprofessional Practice (IPP/IPE).
Treatment strategies for SCD focus on increasing active engagement and building independence in natural communication environments. One-on-one, clinician-directed interventions are useful for teaching new skills. Group interventions are used in conjunction with one-on-one services to practice skills in functional communication settings and to promote generalization. In school settings, intervention often includes environmental arrangements, teacher-mediated interventions, and peer-mediated interventions (Timler, 2008).
The treatment modalities described below may be used to implement various treatment options.
Augmentative and alternative communication—an area of clinical practice that supplements or compensates for impairments in speech-language production and/or comprehension, including spoken and written modes of communication. Augmentative and alternative communication falls under the broader umbrella of assistive technology, or the use of any equipment, tool, or strategy to improve functional daily living in individuals with disabilities or limitations. See ASHA’s Practice Portal page on Augmentative and Alternative Communication for further information.
Computer-based instruction—use of computer technology and/or computerized programs for teaching language skills, including vocabulary, social skills, social understanding, and social problem solving.
Video-based instruction (also called “video modeling”)—an observational mode of teaching that uses video recordings to provide a model of a target behavior or skill. Video recordings of desired behaviors are observed and then imitated by the individual. The learner’s performance of the desired behavior(s) can be videotaped for later review.
Below are brief descriptions of both general and specific treatments for addressing SCD. This list is not exhaustive, and the inclusion of any specific treatment approach does not imply endorsement from ASHA.
For additional treatment options that address social communication skills in school-age children, see ASHA’s Practice Portal pages on Autism Spectrum Disorder, Spoken Language Disorders, and Pediatric Traumatic Brain Injury. For treatment options in adult populations, see ASHA’s Practice Portal pages on Traumatic Brain Injury in Adults, Aphasia, and Dementia.
Behavioral interventions and techniques can be used to modify existing behaviors or teach new behaviors. These approaches are based on principles of learning that include identifying desired behaviors (e.g., social skills), gradually shaping these behaviors through selective reinforcement, and fading reinforcement as behaviors are learned.
Behavioral approaches can be used to modify or teach social communication behaviors in one-on-one, discrete trial instruction or in naturalistic settings with peers or other communication partners. Positive behavior support is one example of a behavioral intervention approach that can be used to foster appropriate and effective social communication (Carr et al., 2002).
Peer-mediated or peer-implemented interventions are those in which typically developing peers are taught strategies to facilitate play and social interactions with children who have SCD.
The interventions below specifically aim to improve social communication skills.
Comic strip conversations—conversations between two or more people illustrated by simple drawings in a comic strip format. The drawings illustrate what people are saying and doing and what they might be thinking. The process of creating the comic strip slows the conversation down, allowing more time for an individual to understand the information being exchanged. Comic strip conversations can be used for conflict resolution, problem solving, communicating feelings and perspectives, and reflecting on something that happened (Gray, 1994; Hutchins & Prelock, 2006).
SCORE skills strategy—a social skills program that takes place in a cooperative small group and focuses on five social skills: (S) share ideas, (C) compliment others, (O) offer help or encouragement, (R) recommend changes nicely, and (E) exercise self-control (Vernon et al., 1996; Webb et al., 2004).
Social communication intervention—an intervention program that focuses on functional social communication goals and carries out the intervention in a “plan, do, and review” framework. There is a particular emphasis on how those involved in an interaction feel about the interaction and motivations for reaching social goals. The “do” phase may involve the child learning social scripts. The “review” phase encourages the child to reflect on the social encounter they completed and how their activities and those of others contributed to the outcomes (Fujiki & Brinton, 2017).
Social Communication Intervention Project—speech and language therapy for school-age children with pragmatic and social communication needs. The Social Communication Intervention Project focuses on social understanding and social interpretation (e.g., understanding social context cues and emotional cues), pragmatics (e.g., managing conversation, improving turn-taking), and language processing (e.g., improving narrative construction, understanding nonliteral language; Adams et al., 2012).
Social scripts—a prompting strategy to teach children how to use varied language during social interactions. Scripted prompts (visual and/or verbal) are gradually faded as children use them more spontaneously (K. Nelson, 1978).
Social skills groups—an intervention that uses instruction, role play, and feedback to teach ways of interacting appropriately with peers. Groups typically consist of two to eight individuals with SCD and a teacher or an adult facilitator. Social skills groups can be used across a wide range of ages, including school-age children and adults.
Social Stories™—a highly structured intervention that uses stories to explain social situations to children and help them learn socially appropriate behaviors and responses. Initially developed for use with children with autism, it has been shown to benefit children with other disorders (Gray et al., 2002; Schneider & Goldstein, 2009).
Social norms are an intrinsic part of culture and communication. These norms may vary across and within cultures. It is essential that clinicians acquire knowledge of their client’s individual cultural norms to determine what is typical for that client within their environment. There is no universal norm for appropriate social behaviors that exists across all cultures. This can be observed in how we modify our communication rules with our partners, coworkers, peers, and family elders. Once the clinician is able to determine the rules of communication for a client, the clinician can determine if variations in patterns reflect communication differences or a disorder. See ASHA’s Practice Portal page on Cultural Responsiveness. There are, however, some universal elements of pragmatic development that are observed in children across cultures, such as the need to develop joint attention skills and the understanding that others’ thoughts may differ from one’s own (this is known as “theory of mind”).
Treatment is conducted in the language(s) used by the individual. A bilingual service provider or the assistance of a trained interpreter may be necessary to provide treatment. See ASHA’s Practice Portal pages on Bilingual Service Delivery and Collaborating With Interpreters, Transliterators, and Translators. See also ASHA’s resource on Person- and Family-Centered Care.
Social communication skills are crucial for adolescents as they explore peer relationships and learn about friendship, loyalty, and individual differences (Seltzer, 2009). Social communication skills are equally important beyond the high school years—in postsecondary school, on the job, and in social settings.
The expectations for social communication change or evolve as the individual’s social settings or opportunities change. For example, expectations for social communication in a high school classroom are different from social communication expectations in a postsecondary classroom or in a workplace. Adolescents must learn to adapt and evolve their social communication style/skills as they adjust to these new social settings and their roles in these settings. Social communication problems tend to persist as adolescents transition to these new roles (Whitehouse et al., 2009).
School-based SLPs are often involved in transition planning to help mitigate the impact of social communication difficulties and to ease the transition to adulthood. See ASHA’s resource on Transitioning Youth. Social communication assessments with adequate psychometric properties are available for this age range (Poll et al., 2021).
Intervention and supports for adults with social communication needs may be available in various forms (e.g., social skills groups, conversation groups, life skills groups, and workshops) and from a variety of providers (e.g., SLPs, psychologists, college counselors, and vocational counselors). Intervention for these populations often focuses on improving conversational skills, navigating social situations, and encouraging participation in daily activities to the fullest extent possible. See ASHA’s Practice Portal pages on Traumatic Brain Injury in Adults, Aphasia, and Dementia.
Deaf or hard of hearing children are at greater risk for developing social skills difficulties when they experience periods of linguistic/cognitive deprivation and sensory fatigue (Szarkowski et al., 2020; Yoshinaga-Itano et al., 2020). SLPs should be aware of these potential causes of social challenges, which may fall outside the parameters of a true SCD, particularly to avoid possible misdiagnosis.
Many social language skills are learned through exposure to events that are witnessed or overheard (i.e., incidental learning). Some of these avenues for learning are not readily available to individuals who are deaf or hard of hearing, and this can have a negative impact on the development of social competencies (Calderon & Greenberg, 2003).
Programs to help children overcome these challenges begin early by promoting parent–child communication. Parents can help “fill in the gaps” by helping children understand and interpret what they have not directly heard (Calderon & Greenberg, 2003). Parents can also help by modeling healthy ways to interact and by teaching acceptable social behaviors (Schlesinger & Meadow-Orlans, 1972; Yoshinaga-Itano et al., 2020).
It is important for adolescents who are deaf or hard of hearing to feel that they are a part of their social network and to be able to interact effectively within this network (Calderon & Greenberg, 2003).
Interventions during the adolescent years include
See the Service Delivery section of the Social Communication Disorder 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 individuals with SCD, SLPs consider other service delivery variables—including format, provider, dosage, and setting—that may affect treatment outcomes.
Format refers to the structure of the treatment session (e.g., group and/or individual). The appropriateness of the treatment format often depends on the relevant communication setting and goal of therapy. For example, one-on-one treatment sessions can be used to teach specific social communication skills. Group sessions (e.g., group conversation therapy, classroom-wide interventions, and integrated social interaction groups) provide opportunities to practice these skills with a variety of communication partners in natural communication settings.
Provider refers to the person providing treatment. Treatment for individuals with SCD often involves collaborative efforts that include families and other communication partners, classroom teachers, special educators, psychologists, vocational counselors, and SLPs. It can also include family- or peer-meditated learning.
Treatment is conducted in the language(s) used by the individual. A bilingual service provider or the assistance of a trained interpreter may be necessary when there is not a client–clinician language match. See ASHA’s Practice Portal pages on Bilingual Service Delivery and Collaborating With Interpreters, Transliterators, and Translators.
Dosage refers to the frequency, intensity, and duration of service. Dosage depends on factors such as the age of the individual, their communication needs, and the presence of comorbid disorders or conditions. Regardless of the specific dosage parameters, social skills intervention addresses the functional communication needs of the individual and provides continuity of services across settings.
Setting refers to the location of treatment (e.g., SLP’s office, classroom, community, inpatient rehabilitation facility). To the extent possible, treatment is provided in naturalistic environments and incorporates activities that typically relate to those environments (e.g., group projects in the classroom setting).
This list of resources is not exhaustive, and the inclusion of any specific resource does not imply endorsement from ASHA.
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