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Autism Spectrum Disorder, Language Disorder, and Social

(Pragmatic) Communication Disorder: Overlaps,
Distinguishing Features, and Clinical Implications
Lauren J. Taylor1 and Andrew J. O. Whitehouse2
1
School of Psychology, University of Western Australia, and 2Telethon Kids Institute, University of Western Australia

Background: The diagnostic boundaries between autism spectrum disorder (ASD) and specific language impairment (SLI) are not clear-cut.
Evidence of the lack of distinct boundaries between these disorders comes from research identifying a group of children who have pragmatic
language difficulties that can be distinguished from those in children with SLI and those with ASD. These findings have led to the inclusion of
a new diagnostic category, social (pragmatic) communication disorder (SPCD), in the Diagnostic and Statistical Manual of Mental Disorders-
5th Edition DSM-5. While this new diagnostic category appears to capture a subgroup of children who may not have been recognised in the
DSM-IV, SPCD has been criticised due to a lack of empirical evidence, showing that the disorder is distinct from ASD in terms of aetiology,
intervention, and prognosis.
Objective: The purpose of this paper was to summarise the literature that has investigated overlaps in the phenotypes of SLI, ASD, and
SPCD. A secondary objective was to present a framework for the assessment and diagnosis of these three conditions.
Method and Results: In this paper, we review the research that has examined overlaps in the aetiologies and phenotypes of ASD, SPCD,
and SLI. While the results highlighted overlaps in the language profiles and autistic symptomatology, these three conditions could also be dis-
tinguished based on the severity of the social communication deficits and the absence of rigid and repetitive behaviour in strictly defined
cases of SPCD and SLI.
Conclusions: Strictly defined cases of SPCD and SLI can be distinguished from ASD. However, there is a lack of assessment tools that can
reliably distinguish these three conditions. We consider the clinical implications of the findings and present a model of assessment and diag-
nosis for ASD, SLI, and SPCD.

Key words: assessment; autism; diagnosis; social communication disorder; specific language impairment.

What is already known about this topic? What this topic adds

1 The boundaries between autism spectrum disorder (ASD), spe-
cific language impairment (SLI), and social (pragmatic) commu-
nication disorder (SPCD) are not clear-cut.
2 While SPCD was included in the Diagnostic and Statistical Man-
ual of Mental Disorders-5th Edition (DSM-5), it is unclear
whether this disorder is distinct from ASD.
3 Assessment and diagnosis of ASD, SLI, and SPCD is challenging
because there are no measures that can reliably distinguish
these three conditions.
1 In this article, we summarise the evidence regarding overlap
between ASD, SLI, and SPCD in terms of aetiology, language,
autistic symptomatology, and long-term outcomes.
2 Strictly defined cases of SPCD can be distinguished from ASD
based on the severity of social communication deficits.
3 We present a framework for the assessment and diagnosis of
ASD, SLI, and SPCD.

The language phenotype of autism spectrum disorder (ASD) is

Correspondence: Lauren Taylor, School of Psychology, M304, University highly heterogeneous. While some individuals with ASD fail to
of Western Australia, 35 Stirling Highway, Crawley, Western Australia develop functional verbal communication, others have fluent
6009, Australia. language skills, experiencing difficulties only with social com-
Email: lauren.taylor@uwa.edu.au munication. The pragmatic difficulties in ASD contrast with the
Accepted for publication 4 April 2016 structural language impairments, that is, in phonology, mor-
doi:10.1111/ap.12222 phology, and syntax, observed in individuals with specific

Australian Psychologist (2016) 1

© 2016 The Australian Psychological Society
Autism, SLI, and social communication disorder
language impairment (SLI). A substantial body of empirical lit-
erature has been dedicated to understanding the phenomenol-
ogy of SLI. However, this label has not previously been
included in the diagnostic nomenclature (see Rapin, 1996 for a
practitioner review of developmental language disorders).
Research studies have used a range of criteria to identify chil-
dren with SLI, which is generally accepted to occur when chil-
dren experience a clinically significant delay in language
development despite having adequate hearing, non-verbal
intelligence, and educational opportunities (Bishop, 2003c;
Stark & Tallal, 1981).1
While “textbook” cases of ASD and SLI can be readily distin-
guished, in clinical practice, the boundaries between these two
disorders are not clear-cut. Extensive evidence now indicates
that a subgroup of children with ASD has a language impair-
ment that resembles SLI (Kjelgaard & Tager-Flusberg, 2001;
Lewis, Murdoch, & Woodyatt, 2007; Lloyd, Paintin, & Botting,
2006; Rapin & Dunn, 2003; Rapin, Dunn, Allen, Stevens, &
Fein, 2009). For example, in one important study, Kjelgaard
and Tager-Flusberg (2001) divided children with ASD into
“normal” (ALN; standard scores greater than 85), “borderline”
(standard scores between 70 and 84), and “impaired” (ALI;
standard scores less than 70) language groups based on their
scores on a series of standardised language assessments. The
ALI subgroup demonstrated poor performance on tests of pho-
nological processing, vocabulary, and higher-order grammatical
and semantic skills, with deficits in these areas closely resem-
bling the SLI phenotype. There is substantial empirical support
for these findings, with a language impairment specifier out-
lined in the most recent revision of the Diagnostic and Statisti-
cal Manual of Mental Disorders (DSM-5). This specifier will
capture children who present with ASD and comorbid lan-
guage impairment.
Further evidence for the lack of clear-cut boundaries
between ASD and SLI comes from studies that have identified
children with communication characteristics that are interme-
diate between “textbook” ASD and SLI. Substantial research
has provided an evidence base for a subgroup of children with
primary pragmatic language impairments (PLI) who can be dis-
tinguished from children with SLI and those with ASD
(Bishop & Norbury, 2002; Botting & Conti-Ramsden, 1999,
2003a, 2003b). The DSM-5 contains a new category of neuro-
developmental disorders, Social (pragmatic) communication
disorder (SPCD), which may capture children previously con-
sidered to have PLI.2 SPCD is identified when children demon-
strate deficits in using verbal and non-verbal communication
for social purposes (American Psychiatric Association, 2013).
Key diagnostic features include difficulties using communica-
tion for social purposes, understanding verbal and non-verbal
conversational rules, and understanding social nuances. The
pragmatic difficulties that characterise SPCD are likely to
resemble the core communication deficits of ASD, which may
suggest that ASD and SPCD are variable manifestations of the
same disorder (Tanguay, 2011). The distinguishing feature,
though, is rigid, repetitive, and stereotyped behaviour and
restrictive interests (RRBIs), which must be absent in SPCD
diagnoses. While this new diagnostic category appears to cap-
ture a subgroup of children who may not have been recognised
in the DSM-IV, social communication disorder has been
2 Australian Psychologist (2016)
L.J. Taylor and A.J.O. Whitehouse
criticised due to a lack of empirical evidence showing that the
disorder is distinct from ASD (Ozonoff, 2012; Skuse, 2012; Tan-
guay, 2011).
ASD, SLI, and SPCD: Genes, Behaviour,
and Longitudinal Outcomes
While extensive evidence has investigated aetiological and
behavioural overlaps between ASD and SLI, relatively less
attention has focused on SPCD. In this section, we review the
research that has investigated overlaps between ASD, SLI, and
SPCD at the genetic and behavioural levels.
Genes and the Familial Aggregation of Structural
and Pragmatic Language Deficits
While numerous twin studies have shown that both ASD and
SLI are highly heritable (Bailey et al., 1995; Bishop, North, &
Donlan, 1995; Constantino & Todd, 2003; Folstein & Rutter,
1977a, 1977b), no published literature has examined the herit-
ability of SPCD, likely reflecting the recent addition of this label
to the diagnostic nomenclature. Evidence does exist to suggest
that structural and pragmatic language impairments aggregate
within families (Bernier, Gerdts, Munson, Dawson, & Estes,
2012; Bolton et al., 1994; Gerdts, Bernier, Dawson, & Estes,
2013; Landa et al., 1992; Pickles, St Clair, & Conti-Ramsden,
2013; Piven et al., 1997; Taylor et al., 2015; Whitehouse,
Barry, & Bishop, 2007). In addition, the results of early twin
(Dworzynski et al., 2007, 2008) and family (Bailey, Palferman,
Heavey, & Le Couteur, 1998; Folstein et al., 1999; Ruser et al.,
2007; Tomblin, Hafeman, & O’Brien, 2003) studies have
revealed overlaps in the language characteristics among parents
and siblings of children with ASD and those with SLI. For
example, there is an elevated rate of language and literacy
impairments in parents and siblings of ASD probands, and
some of these family members also demonstrate poor perfor-
mance on tests of non-word and sentence repetition, heritable
markers for SLI (Bailey et al., 1998; Folstein et al., 1999; Lindg-
ren, Folstein, Tomblin, & Tager-Flusberg, 2009; Ruser et al.,
2007). Results of more recent studies indicate that the heritable
phenotypes of ASD and SLI breed true in these families (Bolton
et al., 1994; Folstein & Rosen-Sheidley, 2001; Landa et al.,
1992; Lindgren et al., 2009; Pickles et al., 2013; Whitehouse
et al., 2007; Whitehouse, Coon, Miller, Salisbury, & Bishop,
2010). The results of a prospective, longitudinal study of infant
siblings of children with ASD also indicate that at 36 months,
high-risk siblings had worse pragmatic language skills than
low-risk siblings, with 35% of the high-risk group identified as
having PLI, relative to only 10% of the low-risk group (Miller
et al., 2014). However, this study was limited due to the indi-
rect measures of pragmatic language (Language Use Inventory;
O’Neill, 2009) and the sample bias that may result in inflated
rates of pragmatic impairments in the high-risk siblings, who
may be vulnerable to social communication deficits due to the
family history of ASD. Nevertheless, these findings indicate that
pragmatic language impairments are highly heritable in ASD
and may also highlight possible relationships between ASD and
SPCD among families.
© 2016 The Australian Psychological Society
L.J. Taylor and A.J.O. Whitehouse
The results of several studies have also revealed overlaps in
genes that may confer susceptibility to ASD, SLI, and social
communication deficits. A specific gene located on 7q35, Con-
tactin Associated Protein-Like 2 (CNTNAP2), has attracted par-
ticular interest as polymorphisms in this region have been
identified in multiple-incidence ASD families (Alarcón et al.,
2008; Arking et al., 2008; Bakkaloglu et al., 2008). Vernes
et al. (2008) also found significant associations between poly-
morphisms on CNTNAP2 and impaired non-word repetition, a
heritable marker for SLI. Recent evidence also indicates that
there may be associations between common genetic variants
related to ASD and semantic-pragmatic skills (St Pourcain
et al., 2013; Steer, Golding, & Bolton, 2010). These findings
indicate that there may be shared genetic influences on ASD
and social communication skills.
Psycholinguistic Markers of SLI
Putative behavioural markers for SLI include impaired non-
word repetition, poor oromotor skills (Barry, Yasin, & Bishop,
2007), and deficits in the acquisition and use of tense-marking
morphemes (Rice & Wexler, 1996; Tager-Flusberg & Joseph,
2003). Considerable research in this area has focused on non-
word repetition tasks, which are purported to test phonological
short-term memory. In this task, children hear nonsense words
of increasing length and complexity and repeat them verbatim.
Extensive evidence indicates that children with SLI demon-
strate poor performance on non-word repetition tasks, thought
to index phonological short-term memory, a core cognitive def-
icit in this population (Gathercole & Baddeley, 1990). Extensive
evidence indicates that a subgroup of children with ASD who
have comorbid language impairments demonstrate non-word
repetition performance that resembles children with SLI
(Kjelgaard & Tager-Flusberg, 2001; Lindgren et al., 2009; Lou-
cas et al., 2010; Riches, Loucas, Baird, Charman, & Simonoff,
2011; Tager-Flusberg, 1996, 2006; Whitehouse, Barry, &
Bishop, 2008), highlighting overlaps in the language pheno-
types of these two groups. However, the groups can be distin-
guished based on the error patterns as children with SLI make
more errors than children with ASD on long (four-syllable) rel-
ative to short (two-syllable) non-words (Riches et al., 2011;
Whitehouse et al., 2008). These findings indicate that the cog-
nitive origin of the non-word repetition deficits may differ
between the two conditions.
Findings regarding children with PLI have been less conclu-
sive. Botting and Conti-Ramsden (2003a, 2003b) explored
whether performance on non-word repetition, sentence repeti-
tion, and past tense-marking tasks could be used to distinguish
ASD, PLI, and SLI. While the scores for the ASD and SLI groups
were uniform, scores for the PLI group were highly variable.
Therefore, the author divided this group into two subgroups:
“PLI pure,” that is, children with pragmatic impairments only,
and “PLI plus,” those with pragmatic impairments as well as
restricted social behaviour and/or interests. This division
resulted in significant differences across the four groups. While
the SLI groups could be distinguished from the ASD, PLI Pure,
and PLI Plus groups based on poor non-word repetition perfor-
mance, the latter three groups could not be differentiated on
Australian Psychologist (2016)
© 2016 The Australian Psychological Society
Autism, SLI, and social communication disorder
this task. In contrast, the SLI, PLI Pure, and ASD groups were
all impaired on the past tense-marking and sentence repetition
tasks and could not be distinguished on either of these mea-
sures. The PLI Plus group had significantly higher scores than
the SLI, PLI Pure, and ASD groups on the tense-marking task
and the SLI and PLI Pure groups on the sentence repetition
task. Sensitivity and specificity analysis revealed that the sen-
tence repetition task was the most accurate marker, distin-
guishing all but the PLI Plus group from typically developing
peers. Therefore, while psycholinguistic markers can accurately
distinguish children with communication disorders from their
typically developing peers, these markers alone cannot reliably
discriminate ASD from SLI or from PLI.
ASD Symptomatology
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, Tager-
Flusberg, 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 stand-
ard” measures of ASD in addition to showing a structural lan-
guage 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 difficul-
ties 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 Com-
munication 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 PDD-
NOS 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 Recip-
rocal 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
3
Autism, SLI, and social communication disorder
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 beha-
vioural 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 clini-
cal 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 differen-
tiating 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 demon-
strating 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 repeti-
tive 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 pat-
tern, usually impaired social communication, without display-
ing 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 ADOS-
G 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 impair-
ments 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 strin-
gent diagnostic criteria for SPCD.
4 Australian Psychologist (2016)
L.J. Taylor and A.J.O. Whitehouse
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 dis-
orders are also unstable over time. Conti-Ramsden, Crutchley,
and Botting (1997) classified children attending specialist lan-
guage 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 pro-
files 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 psycho-
social 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 difficul-
ties, 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 abil-
ities) for those with SLI but not for those with PLI. In adult-
hood, the individuals with ASD continued to present with
substantial pragmatic difficulties in addition to social impair-
ments 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 evi-
dence indicating that there is a group of children with ongoing
communication difficulties, who have a language and beha-
vioural 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
© 2016 The Australian Psychological Society
L.J. Taylor and A.J.O. Whitehouse
pragmatic and structural language deficits falling along a con-
tinuum 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 psychi-
atric 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 communica-
tion impairment in SLI from the pragmatic language impair-
ments and ASD symptomatology that characterise SPCD and
ASD, respectively. Measures such as the CCC-2 can reliably dis-
criminate children with communication difficulties from their
typically developing peers and can identify children with prag-
matic and social deficits disproportionate to their structural lan-
guage 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 standardised 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 dis-
criminating children with SLI, ASD, and PLI from their typically
developing peers. While these three groups also cannot be dis-
tinguished 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 stand-
ard” 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
Australian Psychologist (2016)
© 2016 The Australian Psychological Society
Autism, SLI, and social communication disorder
presenting with language or communication difficulties.
Figure 1 presents a pathway for the assessment and diagnosis
of children presenting with significant language and communi-
cation 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 identi-
fies 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 use-
ful 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 present-
ing with structural and pragmatic difficulties may have co-
occurring diagnoses of SLI and SPCD, if repetitive behaviour is
also present, ASD with a language impairment specifier should
be considered (American Psychiatric Association, 2013). Chil-
dren with pragmatic difficulties and RRBI may meet diagnostic
thresholds for ASD on “gold-standard” measures of ASD symp-
tomatology, 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 effec-
tiveness 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 impair-
ment (Ebbels, 2014).
Children with pragmatic language impairments also benefit
from individualised intervention tailored to their specific com-
munication needs (Adams et al., 2012). In a randomised con-
trolled 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 interven-
tion 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 treat-
ment effects were observed for conversational competence and
5
Autism, SLI, and social communication disorder L.J. Taylor and A.J.O. Whitehouse

Developmental History Core difficulties with

Standardised assessments of structural language
phonology, morphology,
Comprehensive Language
semantics, syntax, pragmatics SLI
Assessment
Language Sample
Identify structural
Parent/Teacher report
language difficulties
Direct observation

Screening Difficulties with structural

Hearing test
Parent/teacher report, e.g. CCC-2,
SRS-2
Child presents with significant Assess Language and
language or communication
difficulties or ASD symptoms Identify structural and
pragmatic language
difficulties
and pragmatic language
Developmental history
Standardised assessments of 'SLI plus'
language and ASD
symptomatology
ASD symptoms Naturalistic observation
Language Sample
ASD + LI
Parent/Teacher report
Difficulties with pragmatic
and structural language
plus RRBI

Developmenal History
Standardised assessment Pragmatic difficulties and RRBI
of ASD symptoms
Identify pragmatic
Parent interview
language difficulties Comprehensive ASD ASD
assessment Naturalistic observation
Rule out other developmental
disorders associated with
pragmatic difficulties, e.g. ADHD
Assess repetitive behaviour SPCD

Core difficulties with pragmatic

language

Figure 1 Proposed Pathway for the Assessment and Diagnosis of SLI, PLI, and ASD.

parent-reported social communication, social behaviour, and Notes

language skills. Children in the social communication interven-
tion had significantly higher scores on these measures than the
TAU group, and these gains were retained at 6-month follow-
up. Therefore, the results of this study indicate that children
with social communication deficits derive benefit from indivi-
dualised, tailored interventions.
Concluding Remarks
Undoubtedly, some children with marked language difficulties
will fall between the boundaries of conventional diagnostic cri-
teria 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 lan-
guage profiles of children with communication disorders high-
lights 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 diagnos-
tic evaluation. These assessments may help in discerning
whether the child’s difficulties relate primarily to structural lan-
guage 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 diffi-
culties that interfere with academic and social functioning
require individualised intervention that is tailored to their
unique cognitive and linguistic profile.
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 through-
out the review.
2 Researchers and clinicians have historically used the terms
social communication and pragmatic language interchangeably,
with descriptions of social communication and pragmatic lan-
guage encompassing the same behaviours (Norbury, 2014).
Therefore, in this paper, we use the terms Pragmatic Language
Impairment (PLI) and Social (Pragmatic) Communication Dis-
order (SPCD) synonymously.
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