social (pragmatic) communication disorders in children new ... jornada/ponencia adams.pdf · skills...

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

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


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








What methods and evidence exist to support SCD intervention?

ASHA https://www.asha.org/PRPSpecificTopic.aspx?folderid=8589934980&sect

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








The Social Communication Intervention Project

SCIP


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?


CELF-4

Masked No


TOPICC

Masked


CCC-2 lists

Not masked



Not masked



Not masked


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?


CELF-4

Masked No


TOPICC

Masked YES


CCC-2 lists

Not masked



Not masked



Not masked


Masked or

not masked?

Intervention

effect?


CELF-4

Masked No


TOPICC

Masked YES


CCC-2 lists

Not masked YES



Not masked



Not masked


• 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?


CELF-4

Masked No


TOPICC

Masked YES


CCC-2 lists

Not masked YES



Not masked YES



Not masked YES


Outline








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)


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


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)




SCIP Intervention completed


Assessment Process

(2-3 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)






Assessment Process

(2-3 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






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






Includes excess information

Referents are sometimes unclear

Talk is over-precise

Talks about things either not established or already known

Pragmatics






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






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






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)






Assessment Process

(2-3 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)






Assessment Process

(2-3 hours)






Joe video

Outline








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

[email protected]

www.napierhillpress.co.uk

• @napierhillpress #SCIPManual

• @JacquelineGaile

• @Cathy_adams1

Laura Clitheroe

Jacqueline Gaile

http://www.scip2.bmh.manchester.ac.uk

mailto:[email protected]

https://www.napierhillpress.co.uk

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

social (pragmatic) communication disorders in children new ... jornada/ponencia adams.pdf · skills...

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