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Social (Pragmatic) Communication Disorders in childrenNew research and intervention practice
Dr Catherine AdamsValencia October 2017
Outline
Social (Pragmatic) Communication
Disorder – what is it?
Existing evidence about intervention
Social Communication
Intervention Project
Therapy method and procedure
Current and future research
Outline
Social (Pragmatic) Communication
Disorder – what is it?
Existing evidence about intervention
Social Communication
Intervention Project
Therapy method and procedure
Current and future research
Type of communication impairment?
• Disproportionate difficulty with pragmatics
• Plus impairment of language to varying degrees
• Some mild social impairment
• No formal autism diagnosis
Pragmatic Language
Impairment
PLI
• Persistent difficulty in pragmatics
• Persistent language impairment
• Not ASD (RRBI)
• Early symptoms
• Limited social participation
Social Communication
Disorder
SCD
DSM-V
Main pragmatic and language impairment
features observed in PLI
From Adams C (2013) Pragmatic language impairment
in F. Volkmar (Ed.) Encyclopedia of Autism, Springer:
New York.
Pragmatics
Responsivity
Initiations
Turn-taking
Verbosity
Topic
Presupposition
Reference
Language impairment
Non-literal language
Inference
Word meaning
Narrative
+ Mild social interaction difficulties
Problems with PLI/SCD as a category
Children often under identified/over-identified as autistic Norbury 2014
Absence of above-sentence level language assessment
Categorical diagnosis leads to categorical treatments?
Equating social communication with social skills
Is SCD an intermediate condition or do different impairments co-exist?
Language impairment
Autism spectrum disorder
Theoretical issues in pragmatics therapy: 1
Social communication
Pragmatics Social skills
Theoretical issues in pragmatics therapy: 2
Social communication
Language development
Pragmatics
Social development
Foundation of social communication intervention
Theory of intervention
Integration of
Social understanding and social interpretation (SUSI)
Language processing (LP)
Pragmatics (PRAG)
Outline
Social (Pragmatic) Communication
Disorder – what is it?
Existing evidence about intervention
Social Communication
Intervention Project
Therapy method and procedure
Current and future research
What methods and evidence exist to support SCD intervention?
ASHA https://www.asha.org/PRPSpecificTopic.aspx?folderid=8589934980§
ion=Treatment
SCERTS—social communication (SC), emotional regulation (ER) and transactional support (TS)
(Prizant, Wetherby, Rubin, Laurent, & Rydell, 2006)
Social Scripts—a prompting strategy used to teach children to use a variety of language during social interactions(Nelson, 1978)
Social Skills Groups—teach ways of interacting appropriately with
typically developing peers through instruction, role-playing,
and feedback
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. (Gray, White, & McAndrew, 2002)
Published evidence and reviews:language and pragmatics
• Bellini, S., Peters, J.K., Benner, L. & Hopf, A. (2007) A meta-analysis of school-based social skills interventions for children with autism spectrum disorders. Remedial and Special Education, 28, 153-162.
• Fujiki.,M., & Brinton, B. (2009) Pragmatics and social communication in children language disorders. In R.Schwartz (Ed.) The Handbook of Child Language Disorders. New York; Psychology Press. p407-423.
• Gerber, S., Brice, A., Capone, N., Fujiki, M., and Timler, G. (2012) Language use in social interactions of school-age children with language impairments: an evidence-based systematic review of treatment. Language, Speech and Hearing Services in the Schools, 43, 235-249.
• Adams, C., Lockton, E., Gaile, J., Freed, J., Earl, G., McBean, K. , Nash, M., Green, J., Vail, A. & Law, J. (2012) The Social Communication Intervention Project: A randomised controlled trial of the effectiveness of speech and language therapy for school-age children who have pragmatic and social communication problems with or without autism spectrum disorder. International Journal of Language and Communication Disorders, 47, 3, 233-244.
Outline
Social (Pragmatic) Communication
Disorder – what is it?
Existing evidence about intervention
Social Communication
Intervention Project
Therapy method and procedure
Current and future research
The Social Communication Intervention Project
SCIP
Social Communication
Intervention Programme
Randomised controlled trial
SCIP Project aims
Ascertain the effectiveness of an intensive social communication therapy (SCIP)
Compared to treatment-as-usual, for children who have SCD
Study mediation effects
Obtain parent, child participant and teacher perceptions of the process of intervention
Assessed for eligibility (n= 101)
Excluded (n= 13)
•Not meeting inclusion criteria (n=
10)
•Declined to participate (n= 1)
•Other reasons (n= 2)
Randomized (n= 88)
Allocated to SCIP intervention (n= 59)Allocated to TAU (n= 29)
Post intervention T2 (n= 57)
Pre-intervention T1 Pre-intervention T1
Post intervention T2 (n= 28)
6-month follow-up T3 (n= 28)6-month follow-up T3 (n= 57)
SCIP Project Inclusion
6-11 yearsNo formal
autism diagnosis Mainstream
school
Normal range non-verbal IQ
Therapist screen for pragmatic
features
Sites in North West England and Edinburgh
Time 1: Pre-intervention/control assessment . Outcome measures and baseline assessments
SCIP intervention or treatment as usual phase
Time 2: Assessment on outcome measures immediately after therapy
Time 3: Follow-up assessment on outcome measures 6 months after Time 2
Study phases
CELF 4 = standardised language test, receptive and
expressive language
Targeted Observation of Pragmatics in Children’s
Conversation (TOPICC)
Pragmatics and Autism Communication lists from Children’s
Communication Checklist CCC-2
SCIP Parent ratings of social communication
SCIP Teacher ratings of classroom listening and
communication
Outcome measures
Whole group N = 87 SCIP N = 59 TAU N = 28
75 boys, 12 girls 52 boys, 7 girls 23 boys, 5 girls
Mean SD Range Mean SD Range Mean SD Range
Age (months) 100.5 15 71-128 100.9 15.1 71-128 99.6 14.8 74-125
CCC-2 GCC 29.3 12 6-57 29.5 12.1 6-57 28.8 12 7-56
CCC-2 SIDC -1.4 -1.3 -1.5
RCPM percentile 53.5 28.6 5-96 49.2 28.9 5-96 62.6 26.2 17.5-96
CELF-4 CLSS 72.6 18.3 40-114 71.3 16.8 40-112 75.3 21.2 40-114
< 80 (n=56) 61.6 11.2 40-79 62.3 10.5 40-79 59.7 13.2 40-79
≥ 80 (n=31) 92.4 9.9 81-114 91.7 8 81-112 93.3 12.4 81-114
CCC-2 PRAG (n=86) 34.5 10 10-54 34.2 9.9 15-54 35.2 10.3 10-50
CCC-2 AUT 28.1 10.2 6-49 27.9 10.6 8-49 28.4 9.6 6-44ERRNI-I
90.9 17.4 64-135 90.3 17.4 65-135 92.1 17.6 64-122ERRNI-R
86.4 18.2 64-136 85.8 17.2 64-131 87.7 20.3 64-136ERRNI-C
87.7 16 64-125 87.2 16.6 64-125 88.7 14.8 64-115
SCQ (n=84) 20.3 7.9 2-37 20.3 7.7 3-37 20.2 8.3 2-33
Non–ASD ≤14 21 (25%) 14 (24%) 7 (27%)
PDD-NOS 15-22 23 (27%) 17 (29%) 6 (23%)
ASD ≥22 40 (48%) 27 (47%) 13 (50%)
Masked or
not masked?
Intervention
effect?
Standardised language test
CELF-4
Masked
Ratings of conversational skills change
TOPICC
Masked
Parent ratings of pragmatic skills
CCC-2 lists
Not masked
Parent perceptions of improvements in
social communication and related skills
Not masked
Teacher perceptions of change in
classroom listening skills
Not masked
SCIPMain Outcomes Summary
Masked or
not masked?
Intervention
effect?
Standardised language test
CELF-4
Masked No
Ratings of conversational skills change
TOPICC
Masked
Parent ratings of pragmatic skills
CCC-2 lists
Not masked
Parent perceptions of improvements in
social communication and related skills
Not masked
Teacher perceptions of change in
classroom listening skills
Not masked
SCIPMain Outcomes Summary
Targeted Observation of Children’s ConversationSample TOPICC picture
Take aspects shown to be important in previous studies
Each aspect coded in real time from video by trained observer and reliability coder
• Reciprocity
• Listener Knowledge
• Verbosity
• Topic Management
• Discourse style
• Response Problems
Rating scale:
3 = marked evidence of that behaviour across conversation; makes a marked impact on the interaction
2 = makes a moderate but still significant impact on the interaction
1 = is noticeable occasionally but makes only a slight impact on the interaction
0 = is never observed and the behaviour is typical of mature interaction style
Development of TOPICC
0
5
10
15
20
25
30
35
40
45
50
Control Intervention
Improved
Not improved
Worse
Intervention better outcome than control
Masked ratings of overall impression of changein TOPICC between Time 1 and Time 3
46.3 %
25.9%
40.7% no change
Masked or
not masked?
Intervention
effect?
Standardised language test
CELF-4
Masked No
Ratings of conversational skills change
TOPICC
Masked YES
Parent ratings of pragmatic skills
CCC-2 lists
Not masked
Parent perceptions of improvements in
social communication and related skills
Not masked
Teacher perceptions of change in
classroom listening skills
Not masked
SCIPMain Outcomes Summary
Masked or
not masked?
Intervention
effect?
Standardised language test
CELF-4
Masked No
Ratings of conversational skills change
TOPICC
Masked YES
Parent ratings of pragmatic skills
CCC-2 lists
Not masked YES
Parent perceptions of improvements in
social communication and related skills
Not masked
Teacher perceptions of change in
classroom listening skills
Not masked
SCIPMain Outcomes Summary
• Language Skills (PRO-LS)
• Social Communication (PRO-SC)
• Social Situations (PRO-SS)
• Peer Relationships (PRO-PR)
Parent reported outcome (PRO)
• Child’s behaviour in typical classroom situations - starting or completing a task, problem-solving skills, asking for help, working in a group etc
Teacher reported classroom learning skills (TRO-CLS)
Parent/teacher reported measures
0
10
20
30
40
50
60
70
80
90
100Treatment-as-usual
SCIP
* p < .05
** p < .01
*
*
**
****
**
**
Masked or
not masked?
Intervention
effect?
Standardised language test
CELF-4
Masked No
Ratings of conversational skills change
TOPICC
Masked YES
Parent ratings of pragmatic skills
CCC-2 lists
Not masked YES
Parent perceptions of improvements in
social communication and related skills
Not masked YES
Teacher perceptions of change in
classroom listening skills
Not masked YES
SCIPMain Outcomes Summary
Outline
Social (Pragmatic) Communication
Disorder – what is it?
Existing evidence about intervention
Social Communication
Intervention Project
Therapy method and procedure
Current and future research
S o c i a lC o m m u n i c a t i o nI n t e r v e n t i o nP r o g r a m m e
a s p e c i a l i s t c o m m u n i c a t i o n i n t e r v e n t i o n
Jacqueline Gaile
Catherine AdamsAimed at children aged 6-12 years
Assessment Process
(2-3 hours)
Intervention Mapping(1-2 hours)
Phase 1Intervention(4-6 hours)
Phase 2Intervention(11-14 hours)
Finish SCIP Intervention
Standardised formal tests Non-standard observation Carer and teacher checklists
Identification of core skills Phase 1 needs Identification of Phase 2 needs: SUSI,
PRAG, LP
Direct Phase 1 intervention (core skills) Phase 2 individualised planning
Direct Phase 2 intervention (main intervention phase)
Carer / teacher training Phase 3 planning Personalisation and generalisation of
therapy Carer / teacher further liaison and
training Agree: monitoring schedule and further
SCIP intervention
Phase 3Intervention(11-14 hours)
Assessment (2-3 hours)
Functional measures: Carer checklist Teacher checklist
Standardised assessments
Non-standardised formal and observational measures
Extract gaps in knowledge, performance and impressions of functioning
Extract concerns with peer relationships, play and social situations and priorities for intervention
Evaluate the problematic situation to extract key skills required to meet ‘desirable outcomes’
ASSESSMENT SUMMARY
Write a summary of strengths / needs
Begin to identify priority areas for intervention
Assessment Process
(2-3 hours)
Intervention Mapping(1-2 hours)
Phase 1Intervention(4-6 hours)
Phase 2Intervention(11-14 hours)
SCIP Intervention completed
Phase 3Intervention(11-14 hours)
Assessment Process
(2-3 hours)
Intervention Mapping(1-2 hours)
Phase 1Intervention(4-6 hours)
Phase 2Intervention(11-14 hours)
SCIP Intervention completed
Phase 3Intervention(11-14 hours)
Individualised intervention objectives for Phase 2
Phase 1 InterventionAssessment to Intervention Mapping
CM Comprehension Monitoring
USC Introduction to Understanding Social Context
MPA Basic MetapragmaticAwareness
BN Basic Narrative
EM Introduction to Emotions in Context
FR Introduction to Friendship
• SCIP has established route to Phase 2 intervention
assessment intervention goals
• Prescribed manual of intervention activitiesall specified in the manual
Phase 2 intervention
Assessment Process
(2-3 hours)
Intervention Mapping(1-2 hours)
Phase 1Intervention(4-6 hours)
Phase 2Intervention(11-14 hours)
SCIP Intervention completed
Phase 3Intervention(11-14 hours)
Assessment Process
(2-3 hours)
Intervention Mapping(1-2 hours)
Phase 1Intervention(4-6 hours)
Phase 2Intervention(11-14 hours)
SCIP Intervention completed
Phase 3Intervention(11-14 hours)
Foundation of social communication intervention
Theory of interventionIntegration of
Social understanding and social interpretation (SUSI)
Language processing (LP)
Pragmatics (PRAG)
Assessment to Intervention Mapping
PHASE 2Intervention Components
SUSI
PRAG
LP
Pragmatics
PRAG 1: Conversation and metapragmatic skills
PRAG 2: Understanding information requirements
PRAG 3: Improving turn-talking skills
PRAG 4: Understanding and managing topic in conversation
PRAG 5: Understanding and improving discourse style
Pragmatics
PRAG 1: Conversation and metapragmatic skills
PRAG 2: Understanding information requirements
PRAG 3: Improving turn-talking skills
PRAG 4: Understanding and managing topic in conversation
PRAG 5: Understanding and improving discourse style
Conversational flow is problematic with frequent clashes or misinterpretations
Shows lack of reciprocity in conversation
Ignores speaker and / or does not look at person he is speaking to
CCC-2: Ignores conversation overtures from others
Pragmatics
PRAG 1: Conversation and metapragmatic skills
PRAG 2: Understanding information requirements
PRAG 3: Improving turn-talking skills
PRAG 4: Understanding and managing topic in conversation
PRAG 5: Understanding and improving discourse style
Includes excess information
Referents are sometimes unclear
Talk is over-precise
Talks about things either not established or already known
Pragmatics
PRAG 1: Conversation and metapragmatic skills
PRAG 2: Understanding information requirements
PRAG 3: Improving turn-talking skills
PRAG 4: Understanding and managing topic in conversation
PRAG 5: Understanding and improving discourse style
Lack of reciprocity in conversation
Frequent clashes during conversation
Does not take up his turn in conversation
Difficult to interrupt the child’s flow of talk in conversation
Pragmatics
PRAG 1: Conversation and metapragmatic skills
PRAG 2: Understanding information requirements
PRAG 3: Improving turn-talking skills
PRAG 4: Understanding and managing topic in conversation
PRAG 5: Understanding and improving discourse style
Frequently changes topic in conversation
Does not signal topic change
Dominates conversation
CCC-2: talks repetitively about things no-one is interested in
Talks about lists of things he has memorised; Moves the conversation to a favourite topic even though other don’t seem interested
Pragmatics
PRAG 1: Conversation and metapragmatic skills
PRAG 2: Understanding information requirements
PRAG 3: Improving turn-talking skills
PRAG 4: Understanding and managing topic in conversation
PRAG 5: Understanding and improving discourse style
Can appear overly familiar in conversation
Talks to unfamiliar people too readily
Cannot change style to match different types of interactions
CCC-2: Stands too close to people when talking to them
• Clip 1 and 3
SCIP PHASE 2 PLANNING SUMMARY AND PRIORITIES
SUSI PRAG LPSUSI 1 Understanding social context cues in interactions
PRAG 1Conversation and metapragmaticskills
LP 1 Vocabulary and word knowledge
SUSI 2Understanding emotion cues in interactions
PRAG 2Understanding informationrequirements
LP 2 Improving narrative construction
SUSI 3Understanding and practising flexibility
PRAG 3Improving turn-taking skills
LP 3Non-literal language
SUSI 4Understanding thoughts and intentions of others
PRAG 4Understanding and managing topic in conversation
LP 4Discourse comprehension
SUSI 5Understanding friendship
PRAG 5Understanding and improvingdiscourse style
LP 5Enhanced comprehension monitoring
Individualization of therapy via Assessment to Intervention Mapping
Heterogeneous presentation
Comprehensive set of therapy targets and
activities
Assessment at baseline – Joe
10 years 4 months
Year 5 mainstream school
Teaching assistant support 5 hours / week
Lives at home with parents and two older sisters
Autism spectrum disorder preschool
Assessment overview: Joe SCIP pre-screening checklist 4/5 features of PLI/SCD
Children’s Communication Checklist CCC-2 score
Cut-off for DLD ≤55
GCC = 31
SIDC = -16
Ravens CPM
centile midpoint
75
Test for Reception of Grammar TROG-2 standard score
88
Social Communication Questionnaire
Autism spectrum disorder
CELF Core Language Score 91
• Reciprocity/Turn-taking– Is responsive but does not initiate; minimal answers given,
conversation is ‘hard work’
• Taking account of listener knowledge – Too much and too little information
• Verbosity– stereotyped or learned phrases – you don’t want anybody to be sick
• Topic Management– difficulties with topic maintenance
• Discourse Style– Possibly unaware of intonation - yeah, of course
• Response problems– overly literal comprehension – it comes from the kitchen
TOPICC to intervention mapping
PRAG 1
PRAG 5
LP 3
PRAG 4
PRAG 2LP 2LP 1
SCIP PHASE 2 PLANNING SUMMARY AND PRIORITIES Joe
SUSI PRAG LPSUSI 1 Understanding social context cues in interactions
√ PRAG 1Conversation and metapragmaticskills
√ LP 1 Vocabulary and word knowledge
X
SUSI 2Understanding emotion cues in interactions
√ PRAG 2Understanding informationrequirements
√ LP 2 Improving narrative construction
√
SUSI 3Understanding and practising flexibility
√ PRAG 3Improving turn-taking skills
X LP 3Non-literal language
√
SUSI 4Understanding thoughts and intentions of others
√ PRAG 4Understanding and managing topic in conversation
√ LP 4Discourse comprehension
√
SUSI 5Understanding friendship
√ PRAG 5Understanding and improvingdiscourse style
√ LP 5Enhanced comprehension monitoring
√
Intervention content153 therapy activities
Assessment Process
(2-3 hours)
Intervention Mapping(1-2 hours)
Phase 1Intervention(4-6 hours)
Phase 2Intervention(11-14 hours)
SCIP Intervention completed
Phase 3Intervention(11-14 hours)
Assessment Process
(2-3 hours)
Intervention Mapping(1-2 hours)
Phase 1Intervention(4-6 hours)
Phase 2Intervention(11-14 hours)
SCIP Intervention completed
Phase 3Intervention(11-14 hours)
PHASE 3
Uses real-life problematic situations reported by• parents / carers• teachers
Unlike Phase 1 and Phase 2 (where all activities are available and prescribed), Phase 3 has no prescribed therapy content
Creates the context for personalised intervention
Phase 3: Transfer knowledge & skills to everyday experiences
Assessment Process
(2-3 hours)
Intervention Mapping(1-2 hours)
Phase 1Intervention(4-6 hours)
Phase 2Intervention(11-14 hours)
SCIP Intervention completed
Phase 3Intervention(11-14 hours)
Assessment Process
(2-3 hours)
Intervention Mapping(1-2 hours)
Phase 1Intervention(4-6 hours)
Phase 2Intervention(11-14 hours)
SCIP Intervention completed
Phase 3Intervention(11-14 hours)
Joe video
Outline
Social (Pragmatic) Communication
Disorder – what is it?
Existing evidence about intervention
Social Communication
Intervention Project
Therapy method and procedure
Current and future research
Current research = SCIP 2
Preparing for implementation
Getting evidence into practice
Application in context of real
practice
Complex intervention
Is a clinical trial feasible?
Feasibility study work schedule
Work package 1 Survey of current practice and outcomes
Work package 2 N of 1 parallel studies using new outcome measures
Work package 3 Qualitative study plus Delphi consensus study
• Practitioner survey (England) N = 76
• NHS respondents (78%)
• non-NHS practitioners (22%)
Number of resources used for children with Social Communication Disorder= ?
Number of different outcome measures used for capturing progress in social communication
> ?
service delivery ?
• Practitioner survey (England) N = 76
• NHS respondents (78%)
• non-NHS practitioners (22%)
Number of resources used for children with Social Communication Disorder= 55
Number of different outcome measures used for capturing progress in social communication
= 31
Large variation in service delivery
Evidence – practice gap
Development of evidence
Pragmatic trial Implementation
Promotion of evidence use by professional
bodies
SCIP 2Additional information
www.scip2.bmh.manchester.ac.uk
catherine.adams@manchester.ac.uk
www.napierhillpress.co.uk
• @napierhillpress #SCIPManual
• @JacquelineGaile
• @Cathy_adams1
Laura Clitheroe
Jacqueline Gaile
Social Communication InterventionThere is evidence available that speech
and language therapy is effective!
Complex intervention +
theoretical rationale
Evidence of effect for some
pragmatic behaviours
Manual of therapy
Refinement and implementation
Recommended