Over the past few months, several of my patients have had something in common. All were teens or young adults, highly intelligent and often high-achieving academically. Yet all, over the years, have found social interactions often quite challenging. More than one noted that it was a skill that had to be learned, like math, or writing, not something that happened spontaneously and intuitively. While they often managed to navigate through the early years, eventually the social difficulties led them, or their parents, to seek an evaluation wondering if they may have an autism spectrum disorder (ASD). While ASD can in fact be so mild that the diagnosis is missed until later in life, when we dug deeper into the early development, there was no evidence of another hallmark of ASD, a pattern of restrictive or repetitive interests or behaviors. Their parents were reasonably certain that as young children, these patients were not unusually stressed by changes in routine, nor did they engage in the same ritualistic or repetitive activities. Some parents recalled sensitivities to loud noises or occasional preoccupations with certain objects, toys, or topics, like dinosaurs or a favorite book series, but those were short-lived and not unusually intense or disruptive. In short, these individuals did not quite fit the diagnostic picture of ASD, yet their communication and social interactions were clearly setting them back and causing distress.
A few years ago, patients with these patterns of behavior would have been diagnosed with pervasive developmental disorder not otherwise specified, or PDD-NOS, which was essentially a way of saying they seem to be “on the spectrum” but don’t quite fit the diagnostic mold of ASD. Now, a more precise diagnosis for someone with this behavioral pattern is available – Social (Pragmatic) Communication Disorder or S(P)CD.
Difficulty in social communication, also referred to as pragmatics, is the basis for the SCD diagnosis. The communication challenges go beyond verbal skills, also affecting the ability to understand and use nonverbal communication. A young child with SCD may, for instance, need to be explicitly taught to make eye contact when speaking to another person. When older, they may misread facial expressions, or not pick up on nonverbal cues, such as gestures, in conversations. While some people with SCD may show delays in language development as young children, others can be quite precocious, with advanced expressive and receptive skills measured in isolation when they do not need to be integrated in social context. Yet, despite their often very strong language skills, they still struggle with the basic rules of conversation. They may have difficulty taking turns, interrupting others, or not waiting for an answer after asking a question. They may speak too fast or abruptly jump from one topic to another so that others find them hard to follow. They may struggle to pick up on humor or sarcasm or subtle changes in tone and what it may convey. Understanding others’ perspective can often be a challenge for them as well.
How is SCD diagnosed?
A comprehensive evaluation is particularly important when SCD is suspected because it needs to be differentiated from other neurodevelopmental conditions with common symptoms, most notably ASD, which shares many characteristics with SCD, but also ADHD, social anxiety, language disorders, and nonverbal learning disabilities. Underlying medical issues that can affect communication, such as hearing loss, must also be ruled out. SCD also tends to frequently co-occur with others developmental conditions, such as ADHD and language disorders. It is, therefore, imperative to assess and distinguish among these and other related conditions. A neuropsychologist is uniquely qualified to provide a comprehensive diagnostic evaluation. Often, a multidisciplinary evaluation that combines the expertise of several clinicians, such as a psychologist, speech/language therapist, and occupational therapist is needed to not only accurately diagnose but develop an effective intervention plan.
How is SCD Treated?
Because SCD often causes marked difficulties not only in social interactions, but also in academic, vocational, and emotional functioning, interventions are often needed in several different areas and various settings. Explicit social communication training can be effectively done one-on-one and in social skills groups. Related cognitive and emotional difficulties, such as attention, executive functions, and anxiety, can be addressed through behavioral interventions, including psychotherapy, coaching, and modifications at home, school, or work. While SCD is a neurodevelopmental condition, and as such, cannot be prevented or cured, with appropriate support and interventions, individuals with SCD can substantially improve their social interactions and communication skills and functioning in other related areas.