Investigations of ASD symptomatology in children with PLI

Investigations of ASD symptomatology in children with PLI

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Investigations of ASD symptomatology in children with PLI

and those with SLI provide further insight into overlaps in the

behavioural presentations of these conditions. Leyfer, TagerFlusberg, Dowd, Tomblin, and Folstein (2008) reported that

41% of a group of children with SLI met diagnostic thresholds

for ASD in social and communication domains on “gold standard” measures of ASD in addition to showing a structural language deficit. Botting and Conti-Ramsden (1999) reported

similar results for a sample of children with PLI, the finding

that 40% of a sample of children identified as having primary

pragmatic language difficulties was considered to have difficulties in communication, reciprocal social interaction, and RRBI,

that is, the “triad” of autistic impairments.

Two studies have used standardised diagnostic measures of

ASD to determine whether PLI can be distinguished from ASD

and from SLI. Bishop and Norbury (2002) divided children

with communication difficulties into PLI (n = 13) and SLI

(n = 8) subgroups based on their scores on the Children’s Communication Checklist (CCC; Bishop, 1998). These authors then

investigated whether the SLI and PLI groups could be better

characterised as ASD. Bishop and Norbury (2002) found that

eight children (six PLI and two SLI) met diagnostic thresholds

for ASD on the Autism Diagnostic Interview-Revised (ADI-R;

Le Couter, Rutter, & Lord, 2003). While 10 of these children

(eight PLI and two SLI) also scored above the cut-off for PDDNOS on the Autism Diagnostic Observation Schedule-G

(ADOS-G; Lord, Rutter, DiLavore, & Risi, 1999), there was

poor agreement between the ADOS-G and ADI-R scores, with

only four children (all from the PLI group) meeting diagnostic

thresholds for PDD-NOS on both of these measures. Reisinger,

Cornish, and Fombonne (2011) reported similar findings.

While all of the children in the ASD group (n = 22) met

ADOS-G criteria for ASD, only seven of the 19 PLI participants

(36.8%) scored above this cut-off. Identical results were

reported for the Social Communication Questionnaire (SCQ;

Rutter, Bailey, & Lord, 2003), a parent-report measure of the

social and communication characteristics of ASD. The ASD

group also had significantly higher Communication and Reciprocal Social Interaction scores on the ADOS-G, indicating more

severe symptoms than the PLI group. These findings indicate

that while a small proportion of children with PLI meet

L.J. Taylor and A.J.O. Whitehouse Autism, SLI, and social communication disorder

Australian Psychologist 51 (2016) 287–295

© 2016 The Australian Psychological Society

289

diagnostic thresholds for ASD, there is a group of children with

core deficits in pragmatic language distinct from ASD.

The results of a comprehensive investigation of the behavioural and linguistic profiles of children with ASD, children

with SLI, and those with PLI revealed clear distinctions

between these three groups (Gibson, Adams, Lockton, &

Green, 2013). Gibson et al. (2013) recruited children with clinical diagnoses of PLI (n = 22), ASD (n = 21), and SLI (n = 19)

from specialist mental health services, speech and language

therapists, and specialist education providers in England and

Scotland. Inclusion in these groups was confirmed by scores on

the ADOS-G, SCQ, Children’s Communication Checklist-2

(CCC-2; Bishop, 2003a), and Test for Reception of Grammar-2

(TROG-2; Bishop, 2003b). The three groups were compared on

measures of social interaction, RRBI, and language ability, and

odds ratios from a multinomial logistic regression were used to

determine the relative importance of each measure in differentiating ASD, PLI, and SLI. The PLI group could be distinguished

from the SLI group based on more atypical social interactions

and better expressive language skills. These two groups could

not be distinguished in terms of repetitive behaviour. However,

repetitive behaviour, impaired social interaction, and high

expressive language scores were significantly associated with

ASD but not with PLI. These results suggest that there is a

graded pattern of social difficulties, with the SLI group demonstrating the least impairment in this area, followed by the PLI

and then the ASD groups. The findings also indicate that under

rigorous conditions, PLI can be distinguished from ASD based

on the severity of social interaction impairments and repetitive

behaviour in the latter group.

While ASD is distinguished diagnostically from SPCD based

on the absence of rigid and repetitive behaviour in this latter

group, few previous studies have established whether social

communication impairments occur without rigid and repetitive behaviours. In an investigation of the convergence of

DSM-5 criteria for ASD with DSM-IV diagnoses of pervasive

developmental disorders (PDDs), Huerta, Bishop, Duncan,

Hus, and Lord (2014) found that only 1.5% of a sample of

4,453 children with PDD and non-PDD diagnoses met social

communication criteria for ASD without displaying rigid and

repetitive behaviours. In contrast, Mandy, Charman, Gilmour,

and Skuse (2011) reported that 64/66 (97%) of a sample of

children with PDD-NOS displayed one distinct symptom pattern, usually impaired social communication, without displaying stereotyped and repetitive behaviour. The social

communication deficits in these children were of comparable

severity to the pragmatic language deficits observed in ASD.

Direct comparisons of children with PLI and those with ASD

have also yielded discrepant findings. While Reisinger

et al. (2011) found no significant group differences in ADOSG or SCQ scores for rigid, repetitive or stereotyped behaviour,

or restricted interests, a more recent investigation revealed

that the PLI group could be distinguished from the ASD group

based on less severe RRBI (Gibson et al., 2013). These results

indicate that some children with pragmatic language impairments also demonstrate RRBI to a lesser degree than children

with ASD. However, there may also be a group of children

who have “pure” pragmatic impairments and meet the stringent diagnostic criteria for SPCD.

Outcomes for Adults with Developmental

Disorders of Language in Childhood

Longitudinal data have shown that many individuals diagnosed

with SLI as children demonstrate behaviours reminiscent of

autism when reassessed in adolescence and adulthood (Howlin,

Mawhood, & Rutter, 2000; Mawhood, Howlin, & Rutter,

2000). In addition, Conti-Ramsden, Simkin, and Botting (2006)

reported that 3.9% of a sample of adolescents with a history of

SLI exhibited sufficient behavioural characteristics of autism to

warrant an autism diagnosis, a figure that is approximately four

times the current autism prevalence estimates (Rice, 2009).

Diagnostic classifications for children with communication disorders are also unstable over time. Conti-Ramsden, Crutchley,

and Botting (1997) classified children attending specialist language schools into six subgroups of language impairment (see

also Rapin & Allen, 1987). In a subsequent analysis, Botting

and Conti-Ramsden (1999) found that 45% of their sample of

201 children with SLI moved clusters within a 1-yr time period.

These changes represented real, clinical shifts in language profiles and highlighted the dynamic nature of language

impairments.

Several studies have also investigated the outcomes for adults

with childhood diagnoses of ASD, SLI, and PLI (Eales, 1993;

Whitehouse et al., 2007, 2009). In two studies, Whitehouse

and colleagues investigated the language, literacy, and psychosocial outcomes of adults who were classified as having SLI,

PLI, or ASD in childhood (Whitehouse, Line, Watt, & Bishop,

2009; Whitehouse, Watt, Line, & Bishop, 2009). The results

revealed different language and psychosocial profiles of these

three groups in adulthood. In contrast to the individuals with

SLI, who had enduring structural language and literacy difficulties, those with PLI had persistent difficulties with language

use. Whitehouse et al. (2009) also reported a linear relationship

between the pragmatic and structural language abilities (e.g.,

pragmatic skills increased alongside structural language abilities) for those with SLI but not for those with PLI. In adulthood, the individuals with ASD continued to present with

substantial pragmatic difficulties in addition to social impairments and repetitive behaviours. While the ongoing pragmatic

impairment in PLI was qualitatively similar to that in ASD,

those with a childhood diagnosis of PLI could be distinguished

from those with ASD by the severity of the pragmatic and

social impairments as well as the relative absence of repetitive

behaviours in adulthood. These results provide empirical evidence indicating that there is a group of children with ongoing

communication difficulties, who have a language and behavioural profile that differs from SLI and from ASD in childhood

(Bishop & Norbury, 2002; Botting & Conti-Ramsden, 1999,

2003a, 2003b) and also have social and language outcomes that

are distinct from SLI and ASD in adulthood (Whitehouse, Line,

et al., 2009, Whitehouse, Watt, et al., 2009).

Implications for Clinical Practice

Assessment and Diagnosis

The current evidence base overwhelmingly suggests that there

are no clear boundaries between ASD, SLI, and SPCD, with

Autism, SLI, and social communication disorder L.J. Taylor and A.J.O. Whitehouse

290 Australian Psychologist 51 (2016) 287–295

© 2016 The Australian Psychological Society

pragmatic and structural language deficits falling along a continuum rather than in discrete categories. The validity of SPCD

as a distinct diagnostic category has been challenged due to the

lack of empirical evidence supporting the presence of pragmatic

deficits independent of other neurodevelopmental and psychiatric disorders. For instance, pragmatic language impairments

co-occur with attention deficit hyperactivity disorder (Bishop &

Baird, 2001; Geurts & Embrechts, 2008; Geurts et al., 2004),

Williams Syndrome (Laws & Bishop, 2003), conduct disorder

(Gilmour, Hill, Place, & Skuse, 2004), and learning disabilities

(Lapadat, 1991). The overlapping symptomatology and

unknown aetiology of language and communication disorders

presents a diagnostic challenge.

While several parent-report assessments of structural and

pragmatic language have been developed, it is unclear whether

performance on these measures distinguishes the communication impairment in SLI from the pragmatic language impairments and ASD symptomatology that characterise SPCD and

ASD, respectively. Measures such as the CCC-2 can reliably discriminate children with communication difficulties from their

typically developing peers and can identify children with pragmatic and social deficits disproportionate to their structural language skills. However, its ability to distinguish groups of

children with ASD, SLI, and PLI is limited (Norbury, Nash,

Baird, & Bishop, 2004). Nevertheless, the CCC-2 is a useful

screening tool, which may identify children with significant

pragmatic difficulties or ASD symptoms that require further

assessment.

Performance on standardized language assessments also does

not reliably distinguish ASD, SLI, and SPCD. Like the CCC-2,

scores on psycholinguistic markers of SLI, such as non-word

and sentence repetition tasks, can reliably discriminate children

with ASD, SLI, and PLI from their typically developing peers

but not from each other (Botting & Conti-Ramsden, 2003a,

2003b). Sentence repetition deficits appear to be sensitive and

specific markers of communication difficulties, accurately discriminating children with SLI, ASD, and PLI from their typically

developing peers. While these three groups also cannot be distinguished on tests of narrative skills or story comprehension,

children with ASD are more likely to have inferencing deficits

than children with SLI or those with PLI.

Overlapping presentations are also observed on “gold standard” measures of autistic symptoms. Some children with

PLI meet diagnostic cut-offs for ASD on the ADI-R and the

ADOS-G, with a small proportion of this group exceeding

diagnostic thresholds on both of these measures. In addition, a

proportion of children with SLI show autistic symptomatology

when assessed in adolescence or adulthood. However, ASD

may be distinguished from SLI and from PLI based on more

severe impairments in social interaction, indexed by higher

ADOS-G and SCQ scores (Bishop & Norbury, 2002; Reisinger

et al., 2011). While findings regarding the presence of RRBI in

children with SPCD have been mixed, the results of recent

studies indicate that PLI can be distinguished from ASD based

on less severe rigid and repetitive behaviour and restricted

interests (Gibson et al., 2013).

Diagnosis is a challenge without measures that accurately

distinguish subgroups of children with language disorders.

Therefore, comprehensive assessment is required for any child

presenting with language or communication difficulties.

Figure 1 presents a pathway for the assessment and diagnosis

of children presenting with significant language and communication difficulties or ASD symptoms. The assessment process

will differ depending on the results obtained from screening

measures that detect the communication and social deficits that

are indicative of ASD, SPCD, or SLI.

Measures such as the CCC-2 (Bishop, 2003a), which identifies children with pragmatic and social deficits disproportionate

to their structural language skills, or the Social Responsiveness

Scale (SRS; Constantino, 2005; Constantino et al., 2003), a

quantitative measure of the characteristics of ASD, may be useful to include at this screening stage. When the results of the

screening reveal structural language difficulties, these should

be assessed using standardised measures of language ability. An

ASD assessment should be pursued if the screening identifies

pragmatic difficulties or ASD symptoms. SLI may be diagnosed

when results of the comprehensive language assessment reveal

core difficulties in structural language. While children presenting with structural and pragmatic difficulties may have cooccurring diagnoses of SLI and SPCD, if repetitive behaviour is

also present, ASD with a language impairment specifier should

be considered (American Psychiatric Association, 2013). Children with pragmatic difficulties and RRBI may meet diagnostic

thresholds for ASD on “gold-standard” measures of ASD symptomatology, and pragmatic difficulties that occur in the absence

of repetitive behaviour would characterise SPCD diagnoses.

Intervention

The results of longitudinal investigations of ASD, SLI, and PLI

indicate that the communication impairments that define these

groups can be severe and persistent, impacting quality of life in

adulthood. While individual outcomes are variable, the effectiveness of the early behavioural intervention for ASD is well

established. Young children who access early intervention

make gains in IQ, language, adaptive behaviour, and social

skills (Dawson et al., 2010; Remington et al., 2007, see also

Howlin, Magiati, & Charman, 2009 and Warren et al., 2011,

for systematic reviews of the literature). While there is some

evidence supporting the effectiveness of language intervention

for children with SLI, the literature is limited by a lack of

research that has investigated the efficacy of specific types of

interventions tailored for specific profiles of language impairment (Ebbels, 2014).

Children with pragmatic language impairments also benefit

from individualised intervention tailored to their specific communication needs (Adams et al., 2012). In a randomised controlled trial, Adams et al. (2012) assigned 88 children with

pragmatic language impairments to receive 16–20 sessions of

an intensive, manualised social communication intervention or

treatment as usual (TAU). The social communication intervention was aimed at improving semantic and high-level language

skills, pragmatic abilities, and social interaction. Children

assigned to the TAU condition continued with their usual

speech and language therapy. While there was no effect of the

treatment on Clinical Evaluation of Language Fundamentals-4

(CELF-4; Semel, Wiig, & Secord, 2006) scores, significant treatment effects were observed for conversational competence and

L.J. Taylor and A.J.O. Whitehouse Autism, SLI, and social communication disorder

Australian Psychologist 51 (2016) 287–295

© 2016 The Australian Psychological Society

291

parent-reported social communication, social behaviour, and

language skills. Children in the social communication intervention had significantly higher scores on these measures than the

TAU group, and these gains were retained at 6-month followup. Therefore, the results of this study indicate that children

with social communication deficits derive benefit from individualised, tailored interventions.

Concluding Remarks

Undoubtedly, some children with marked language difficulties

will fall between the boundaries of conventional diagnostic criteria for ASD and SLI and may meet criteria for SPCD. It is

likely that SLI, SPCD, and ASD are related disorders that vary

according to the degree of difficulty with structural language,

pragmatic language, and circumscribed interests (Whitehouse,

Line, et al., 2009). The marked heterogeneity within the language profiles of children with communication disorders highlights the need for comprehensive, individual evaluation of the

communication strengths and weakness, socio-cognitive skills,

and cognitive profile for each child that presents for a diagnostic evaluation. These assessments may help in discerning

whether the child’s difficulties relate primarily to structural language or pragmatic language impairments or ASD. Regardless

of the origin of the language impairment, or the diagnostic

label, all children who have language and communication difficulties that interfere with academic and social functioning

require individualised intervention that is tailored to their

unique cognitive and linguistic profile.

Notes

1 While the Language Disorder category contained in the

DSM-5 closely resembles SLI, much of the literature in this area

refers to SLI. Therefore, we have used this latter term throughout the review.

2 Researchers and clinicians have historically used the terms

social communication and pragmatic language interchangeably,

with descriptions of social communication and pragmatic language encompassing the same behaviours (Norbury, 2014).

Therefore, in this paper, we use the terms Pragmatic Language

Impairment (PLI) and Social (Pragmatic) Communication Disorder (SPCD) synonymously.

References

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(2012). The: A randomized controlled trial of the effectiveness of

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pragmatic and social communication problems with or without

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Disorders, 47, 233–244. doi:10.1111/j.1460-6984.2011.00146.x

Alarcón, M., Abrahams, B. S., Stone, J. L., Duvall, J. A., Perederiy, J. V.,

Bomar, J., … Geschwind, D. H. (2008). Linkage, association, and geneexpression analyses identify CNTNAP2 as an autism susceptibility

gene. The American Journal of Human Genetics, 82, 150–159.

doi:10.1016/j.ajhg.2007.09.005

American Psychiatric Association (2013). Diagnostic and statistical

manual of mental disorders (5th ed.). Washington, DC: Author.

Arking, D. E., Cutler, D. J., Brune, C. W., Teslovich, T. M., West, K.,

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