Prevalence and Impact of Social (Pragmatic) Communication Disorders

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In this podcast, we are joined by Professor Courtenay Norbury, Professor of Developmental Disorders of Language and Communications at Psychology and Language Sciences, University of London, and director of the Literacy, Language, and Communication Lab, LiLaC, and Jo Saul, lecturer in Experimental Psychology at the same institution.

Courtenay and Jo are co-authors of the JCPP paper, ‘Prevalence and functional impact of social (pragmatic) communication disorders’, (doi:10.1111/jcpp.13705). This paper will be the focus of today’s conversation.

With both Courtenay and Jo being members of the LiLaC lab, Courtenay begins by providing insight into what the focus of the LiLaC lab is, before turning to discuss what social pragmatic communication disorders (SPCD) are and how they present.

Jo then turns to their recently published co-authored paper and provides us with a brief overview of the paper, comments on the methods used, and shares some of their findings.

Both Courtenay and Jo stress that social pragmatic deficits rarely occurred in isolation, but often occurred alongside structural language difficulties and/or autism symptoms and share what the implications are of this finding.

Given their findings, Courtenay and Jo also comment on what changes they would recommend to better identify, diagnose, and support children with SPCD and explore what professionals, and those working in education, should take from their paper.

Furthermore, Courtenay and Jo discuss how to go about translating their research into practice and the importance of improving communication between mental health and speech and language professionals.

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Professor Courtenay Norbury
Professor Courtenay Norbury

Courtenay Norbury is Professor of Developmental Disorders of Language and Communication at Psychology and Language Sciences, University College London. She is the Director of the Literacy, Language and Communication (LiLaC) Lab and a Fellow of the Royal College of Speech and Language Therapists.

She obtained her PhD in Experimental Psychology at the University of Oxford, working with Professor Dorothy Bishop on the overlapping language profiles that characterise autism spectrum disorder and ‘specific’ language impairment. Professor Norbury’s current research focuses on language disorders and how language interacts with other aspects of development. She is leading SCALES, a population study of language development and disorder from school entry. She is also a founding member of the RADLD campaign.

Jo Saul
Jo Saul

Jo Saul is a Lecturer in Experimental Psychology at University College London. She has been a member of the Literacy, Language and Communication (LiLaC) Lab (www.lilac-lab.org) since 2016, when she started her ESRC-funded PhD. She obtained her PhD in Language and Cognition at UCL, working with Professor Courtenay Norbury on expressive language development in minimally verbal autistic pre-schoolers. She conducted a longitudinal study exploring what predicts individual differences in expressive language development, in particular the role of speech production skills. She also created and piloted an app which delivered a speech sound intervention. Dr Saul’s current research focuses on drivers of spoken language progress in those with complex communication needs, as well as intervention development and evaluation, particularly exploring how technology may be able to make interventions more accessible to help those with complex neurodevelopmental conditions.

Transcript

[00:00:30.470] Jo Carlowe: Hello welcome to the In Conversation podcast series for the Association for Child and Adolescent Mental Health or ACAMH for short. I’m Jo Carlowe a freelance journalist with a specialism in Psychology. Today, I am interviewing Courtenay Norbury, Professor of Developmental Disorders of Language and Communications at Psychology and Language Sciences, University of London, and director of the Literacy, Language, and Communication Lab, LiLaC.

I also have with me, Jo Saul, lecturer in Experimental Psychology at the same institution. Courtenay and Jo are co-authors of the paper, ‘Prevalence and functional impact of social (pragmatic) communication disorders‘, recently published in the Journal of Child Psychology and Psychiatry. This paper will be the focus of today’s conversation.

The JCPP is one of the three journals produced by the Association for Child and Adolescent Mental Health. ACAMH also produce JCPP Advances and the CAMH. If you’re a fan of about In Conversation series, please subscribe on your preferred streaming platform. Let us know how we did with the rating or review and do share with friends and colleagues. Courtenay and Jo, thank you for joining me. Can you each start with a brief introduction about who you are and what you do?

[00:01:42.892] Professor Courtenay Norbury:  I’m Courtenay Norbury. I’m a professor, as you said, at University College London, and my area of expertise is in Developmental Disorders of Language and communication. Many years ago, I trained as a speech and language therapist, and then I did a PhD in experimental psychology. And so, my research is really trying to understand the causes and consequences of language disorders in children.

[00:02:10.206] Jo Carlowe: Jo?

[00:02:10.789] Jo Saul: Hi there, Jo Saul. I’m an early career researcher. I completed my PhD at UCL in 2020, and I was lucky enough to be supervised by Courtenay. My project investigated language acquisition in minimally verbal autistic pre-schoolers and looked at what initial factors predicted their language progress. Now I’m a lecturer at UCL and I’m also planning further research on drivers of spoken language progress in those with complex communication needs.

[00:02:36.020] Jo Carlowe: Great, thank you. Now, you’re both members of the LiLaC lab. What is the focus of the LiLaC lab?

[00:02:42.560] Professor Courtenay Norbury: Well, I started the LiLaC lab when I was an early career researcher. And what the LiLaC lab really aims to do is bridge research and practice. And LiLaC is an acronym of Literacy Language and Communication, so we have members who are interested in all those aspects of child’s communication development. And we engage with practitioners, and with families, and young people to try and understand how our research can have more impact in everyday life.

[00:03:14.990] Jo Carlowe: Your paper focuses on social pragmatic communication disorders, and we’re going to look in detail at the paper, but what are social pragmatic communication disorders and how do they present?

[00:03:26.680] Professor Courtenay Norbury: So, if I say a little bit about pragmatics and social communication and then Jo can tell you about the criteria as it stands at the moment that we were trying to test. So, pragmatics is really how we use language in social contexts and it often involves going beyond what somebody literally says, to infer the intended meaning. And our language is very flexible but, sometimes, that makes it ambiguous. So, for example, if I said, she is cold, that can mean various things depending on the context. She’s shivering or it could mean that she’s kind of a standoffish sort of person. And so, pragmatics is really how you integrate your knowledge of language structures with your knowledge of other people and the context in which you are trying to communicate.

[00:04:18.506] Jo Saul: And we’ve known for some time that some children have problems with pragmatic aspects of communication, but social pragmatic communication disorder was first described in the most recent version of the Diagnostic and Statistical Manual, which is known as DSM-5 and this diagnosis aims to describe a condition where a person has relatively isolated social pragmatic difficulties.

What do we mean by social pragmatic difficulties? In the diagnosis, there are four core areas, the first one is using language for social purposes, things like greetings. Secondly, adapting language to the listener, so taking on board what the listener might already know. Thirdly, following discourse rules like taking turns in a conversation. And fourthly, going beyond the explicit utterance, as Courtenay was saying, making inferences about what someone’s saying.

And then they’ve also got to be isolated, so what do we mean by that? You have this profile of symptoms without additional repetitive interests and behaviours associated with autism without clinically significant problems with structural language, so for example, grammar or vocabulary difficulties and without an additional intellectual disability.

[00:05:25.756] Professor Courtenay Norbury: And we were particularly interested in doing this paper because this was exactly the topic of my PhD. Some 10 years before, social pragmatic disorder was a disorder before it came into the DSM-5. It was then we were looking at something that we called pragmatic language impairments, and the ideas behind that were the same. And in my PhD, I find it very difficult to find children who had pragmatic language impairments that didn’t have problems with language or symptoms of autism, so when the DSM-5 was published it caused me to scratch my head a little bit. And we wanted to see really whether you could get these isolated cases in the population because, in my study, I was looking more at clinical cases. That was the motivation for doing this paper.

[00:06:15.732] Jo Carlowe: Let’s dig into the paper a bit then, so that the paper ‘Prevalence and functional impact of social (pragmatic) communication disorders‘, recently published in the JCPP. Can you give us a brief overview of the paper to set the scene?

[00:06:30.183] Jo Saul: The aim of this study was to take an existing instrument called, The Children’s Communication Checklist 2, CCC2 for short and to use it to ascertain the prevalence and functional impact of social pragmatic difficulties in a community sample. Because SPCD is a relatively new diagnosis, we still don’t know much about how prevalent it is in the population, so we wanted to try and estimate this with our sample.

And there’s no gold standard way of establishing diagnosis for SPCD, so we estimated the inclusion criteria with the pragmatic subscale of the CCC2, and we estimated the exclusion criteria with the structural language and autism symptoms [INAUDIBLE] subscales. We also know that many children with social pragmatic deficits have broader social, emotional, and behavioural problems, so we wanted to see what the functional impact of poor social pragmatic skills was in our sample. And we compared those with significant social pragmatic deficits and their typical peers on academic outcomes and teacher-rated behavioural difficulties.

[00:07:30.433] Jo Carlowe: And before we look at the findings, can you tell us a little bit about the methods that you use?

[00:07:36.250] Jo Saul: This study was part of a larger study that followed a large population-based group of children over a number of years and looked at their communicative and academic development. But at the time for this data, the children were aged between five and six years old, and we used parent and teacher responses on the CCC2 to approximate inclusion and exclusion criteria for SPCD, as I mentioned. And we tested the prevalence of social pragmatic deficits in this population-based sample, which had almost 400 children in it. And at the same time, we took measures of their academic performance and behavioural profiles so that we could see if there was an association with social pragmatic deficits.

[00:08:15.370] Jo Carlowe: And what did you find?

[00:08:16.588] Jo Saul: So number one regardless of the criteria that we use to determine prevalence rates for social pragmatic deficits, we found that very few children had isolated social communication difficulties. It was in the range of 0 to 1%, however, a larger proportion of children did have social communication skills outside of the expected range. This was around 6% to 10%, but they also had, either a structural language difficulty or elevated autism symptoms on the CCC2.

The second finding was that having poor social pragmatic skills was associated with a range of adverse academic and behavioural outcomes. Children were more likely to score in the clinical range on the strengths and difficulties questionnaire, which indicates behavioural difficulties, and they were less likely to achieve a good level of progress in the early year’s foundation stage evaluations.

[00:09:06.480] Jo Carlowe: There’s something that you’ve both stressed, and that is that social pragmatic deficits rarely occurred in isolation, but often occurred alongside structural language difficulties and/or autism spectrum symptoms. What are the implications of this?

[00:09:21.920] Professor Courtenay Norbury: So, I think the major clinical implication is that the criteria for SPCD as it stands are challenging and are likely to underestimate the level of need in a population. I think, theoretically, it’s quite interesting because what it’s suggesting is that although we can, to some degree, pull apart structural language and pragmatic language, on the whole, they go together. And that’s really interesting to think about why that is and what the impact of that is.

[00:09:53.290] Jo Carlowe: Does that mean that in DSM-5, they got it wrong?

[00:09:58.620] Professor Courtenay Norbury: Oh, I’m always so very reluctant to say that, but, yeah, I mean, in my PhD, that was kind of the conclusion that trying to carve out this group based on exclusionary criteria probably isn’t the way to go. I think of both structural language and pragmatic language as dimensions, and when we try and make cuts, it doesn’t really capture the clinical reality, I think. And I just feel that there’s the exclusion criteria will miss a lot of children who have significant needs and would probably benefit from support. But because they don’t meet the exclusion criteria, they’re kind of falling through the net. I think that it needs a bit of a rethink, really.

[00:10:46.160] Jo Carlowe: Jo and Courtenay, given your findings, what changes would you recommend then to better identify, diagnose, and support children with SPCD?

[00:10:56.457] Professor Courtenay Norbury: That’s a big question. Well, I think one of the issues is measurement. It’s very, very difficult to measure pragmatic symptoms because they are so contextually bound. The minute you try and make it standardized, you’re taking away a lot of the nuance. Part of the challenge is to be able to come in and read a social situation and try to figure out, well, what does the person I’m communicating with know? What do I need to communicate to them? How is the context going to affect my interpretation of what’s going on? That’s very hard to recreate in a standardized test.

And I would say one of the things that Jo didn’t mention is the complex statistical method she was using to try and understand the measurement. And the measures, we tried to pull apart pragmatics, and autism symptoms, and language, and the measurement model isn’t great. Part of the reason is that the items that, say, are supposed to be pragmatic, will also explain some of the variation in structural language, for example. Things are very intertwined and it’s very difficult to pull them apart. I think there’s quite a lot of work to do and thinking about how we do these assessments.

My view also is sometimes I think people get really hung up on those diagnostic criteria, and particularly the exclusion criteria. When we’re trying to support kids, it’s often more useful to think about their relative strengths and their relative challenges regardless of what the diagnosis is. So, what our findings are saying is that, actually, many kids who have structural language difficulties are also going to have some challenges with social communication. Maybe children who are identified because of their social communication deficits are also going to have some challenges with structural language, so we shouldn’t be too focused on these really specific diagnostic criteria, but maybe thinking about the profile of language, and pragmatic, and social-communicative strengths and then where those things are breaking down because that will tell us what we need to do to try and support them.

[00:13:13.592] Jo Carlowe: Given what you’ve just said, I mean, what learning then can professionals and also those working in education take from your paper?

[00:13:22.970] Professor Courtenay Norbury:  I think it’s– one thing that’s really important to highlight is that children who have language or pragmatic difficulties are at much greater risk of having adverse mental health. And the referrals to child and young person mental health services, a high proportion of those children will have exactly the kinds of pragmatic issues that Jo has picked up in her paper.

I think when children are presenting as having bad behaviour or poor peer relationships, practitioners and educators need to think, is there an underlying language or communication issue here? Should we be thinking about their ability to communicate and their understanding of pragmatics? Unfortunately, at the moment, our mental health services and our speech and language therapy services rarely talk to one another. That’s something that I would be very keen to change because I think most of our therapies for mental health involve language and many children are having language and pragmatic difficulties are struggling with their well-being, so greater cross-disciplinary work would be fantastic.

[00:14:30.430] Jo Carlowe: Such an important point to highlight. Is there anything else in the paper that you’d like to highlight?

[00:14:36.078] Professor Courtenay Norbury: The one thing was about the parent and teachers and how well they agree on children’s communication skills. Do you want to say anything about that, Jo?

[00:14:44.740] Jo Saul: Yeah, I mean, that’s– it’s not specific to the instrument we use, so the CCC2. It’s quite commonly found that you ask parents and teachers to rate the behaviour or the skills of a child and they disagree. That might be for a lot of reasons. For example, say, with something like autism symptoms, maybe the child feels the structure of a school day is actually very beneficial and supportive, but then when they’re at home, you’re with your parents, so you can kind of let loose. They may actually be seeing different profiles.

And also, teachers are comparing each child to like, 30 other children whereas you get used to your own child and you– they set the benchmark for that, so it’s quite common that we see this disagreement. But it does make our measurement models a lot trickier, especially in a study like ours where we at some joint responses and some responses from just parents and some from just teachers.

[00:15:32.550] Jo Carlowe: Any thoughts about what you can do about that?

[00:15:36.240] Jo Saul: Just get a very large sample, number one.

[00:15:39.720] Professor Courtenay Norbury: Yeah, and I think it is like Jo said, it’s common across any kind of measure where you’re asking different respondents for the same thing and for the reason Jo says. One of the things to think about is how does having challenges like this affect children in different contexts. I think it’s just something– kind of trying to tease apart language and pragmatics. It’s hard to do because that’s the way it is, so it’s more thinking about, what does this tell us about how kids are functioning in different contexts?

[00:16:10.140] Jo Carlowe: Are you planning some follow-up research or is there anything else in the pipeline that you can share with us?

[00:16:16.022] Professor Courtenay Norbury: As Jo said, this study was part of a much larger study where we took measures of many, many things. And in the paper that Jo and I wrote, we were looking very much at this parent and teacher report, but we also have been, in the study, more objective measures. We used a task that Alex Wilson and Dorothy Bishop developed that is a computerized sampling of kids pragmatic understanding and more objective measures of their grammar, so we have an opportunity to say, well, if you use something that isn’t relying on ratings, do you get the same pattern of responses?

I think, for the field, generally, one thing that we need to do is understand the longitudinal course of something like social pragmatic communication disorder. We just really don’t know whether the condition, as it’s laid out in DSM-5, how stable that is. And if you were able to identify those kids at one point in time, do they continue to have that profile later in development? So that would be interesting. And family studies to try and understand how this relates to other things like autism and language disorder would be really interesting.

And you touched on intervention, I mean, intervention is a really useful way to test out some of these theoretical ideas. And I would say that Jo and I both want to stress, when we think about intervention, what we’re not saying is that there’s one model of social communication that everybody needs to adhere to. It’s more how can you facilitate communication in the most optimal ways. And it seems to me rather unusual to separate social communication interventions from structural language interventions. You wouldn’t want to work on language without thinking about how kids can use that language socially. And actually, language facilitates social communication because it’s helpful to have a shared language code in order to communicate effectively. I think I’m thinking about the components of interventions and how they address both of those issues will be really useful in the future. But it’s not to make everybody the same, it’s just to make everybody able to communicate most effectively in their environments.

[00:18:32.500] Jo Carlowe: Jo, anything to add in terms of your future plans or any research that you’re planning or currently doing?

[00:18:39.085] Jo Saul: Just to come back to the point about pragmatic skills having shown a link with mental health outcomes. That’s another thing that our team are interested in pursuing as well.

[00:18:50.730] Jo Carlowe: I should ask, I mean, you’ve talked about interventions. Is there anything more you want to say about how you go about translating your research into practice?

[00:18:59.490] Professor Courtenay Norbury: Well, it’s a good question. We do spend an awful lot of time talking to practitioners and getting them to think about how this plays out in the real world. I think we learn a lot from them in terms of how they make this work. I think one of the interesting conversations we’ve had in more recent times is thinking about whether you work on the young person who has the identified difficulties, or whether you can work with peers in the environment to help them understand some of the challenges that kids are having and work out ways that together they can support each other rather than just trying to change the individual.

I think that’s a really interesting and exciting idea. We certainly know from research, there are lots of peer effects on kid’s language development anyway, but, certainly, you would need more research in that area. But I think it’s an interesting and exciting idea. As Jo said, the other thing is to really think about how you can bring ideas about improving language and communication into interventions that are more aimed at targeting mental health, or emotion regulation, or things like that.

[00:20:11.127] Jo Carlowe: When we’re talking about communication, you also touched earlier on the poor communication, really, between mental health and speech and language. What would you like to see there? What would you recommend?

[00:20:24.690] Professor Courtenay Norbury: Yes, I think, to me, it’s really astonishing, really, that there aren’t speech and language therapists on mental health teams. I think, for most kids, multidisciplinary assessment and management is going to be the way to go because most kids have complex needs. It’s not possible for one clinician to have expertise in all of that. It requires a change of thinking and better understanding of professional boundaries, but I think that’s the way to go, a more efficient way of delivering interventions that’s going to take a more holistic view of what the child needs.

[00:21:07.810] Jo Carlowe: Finally, Jo and Courtenay, what is your take-home messages for our listeners?

[00:21:13.125] Jo Saul: Our take home messages will be that researchers have spent a lot of time and energy trying to separate pragmatics and core language, but it’s shown that it’s clearly hard to do that. And in terms of intervention, maybe it’s not even the right way to go. Maybe it’s actually best to think holistically about interventions that target social pragmatics and structural language, or at least interventions that, bear in mind, that the person may have poor structural language skills, so there’s no point pitching it at a level that they’re not going to be able to understand and vice versa.

[00:21:44.967] Jo Carlowe: Thank you, Courtenay?

[00:21:46.300] Professor Courtenay Norbury: And just along those lines, to really think about whether we need these exclusion criteria or whether we need to be thinking more dimensionally, and mapping out children’s strengths, and then the challenges that they’re having and how we can best support those.

[00:22:02.220] Jo Carlowe: Jo and Courtenay, thank you both so much. For more details on Professor Courtenay Norbury and Jo Saul, please visit the ACAMH website, www.acamh.org, and Twitter, @acamh. ACAMH is about A, C, A, M, H. And don’t forget to follow us on your preferred streaming platform. Let us know if you enjoyed the podcast with a rating or review and do share with friends and colleagues.

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