Name: Muhammad Hamza Qureshi

Reg no: EN120172101

Section: B
BS 6th
Psycholinguistics

SEMANTIC PRAGMATIC
IMPAIRMENTS

More than a decade has passed since Rapin and Allen (1983) included in their
nosological framework of developmental language disorders that of "semantic-
pragmatic syndrome". The term "semantic-pragmatic language disorder" has
achieved considerable popularity amongst speech and language therapists in
Britain during the last ten years or so but its use as a diagnostic concept is now
being increasingly questioned (Gagnon et al, 1997). It is perhaps time to
examine the evolution of this term and to consider whether it may represent a
case of mis-diagnosis, rather than a category of developmental language
disorder.

The evolution of the term “semantic-pragmatic

disorder”
Rapin and Allen (1983) were the first to use the term "semantic-pragmatic
syndrome" when classifying developmental language disorders from a 'medical'
framework, describing various 'syndromes'. These included: verbal auditory
agnosia; semantic-pragmatic disorder deficit; verbal dyspraxia; phonological-
syntactic disorder; and lexical-syntactic deficit. Rapin and Allen did not
consider their syndromes to be exhaustive. Despite their initial use of a medical
framework, they grouped their subjects according to the most salient feature of
their expressive language, interactive behaviour, and apparent comprehension.
Their syndromes were then defined by determining which language features
were impaired, intact, or variable within the sub-groups.
Bishop and Rosenbloom (1987) took Rapin and Allen's term but modified it to
'semantic-pragmatic disorder', avoiding the term 'syndrome' since they
considered these specific problems with language use and content to be a set of
loosely associated behaviours which shaded into autism at one extreme and
normality at the other. They described the history and symptoms of the
condition from their own experience but cautioned that the literature at the time
was limited to clinical description and that research was needed to identify
objective defining criteria. Bishop and Rosenbloom felt that most children of
this type would never be called autistic, but that their ability to cope in normal
school depended heavily on the extent of the associated social abnormality.
They acknowledged that Wing (1981) had described a similar pattern of
disorder in her account of Asperger's syndrome, concluding that, while the
social and linguistic deficits tended to co-occur, they could be dissociated. Also
in 1987, Rapin reported a study of children with autism or developmental
language disorders which categorised the participants firstly by the type of
language impairment observed and secondly by whether the child met the
criteria for a diagnosis of autism. In an article discussing the boundaries
between autism, Asperger's syndrome and semantic-pragmatic disorder, Bishop
(1989) quoted Rapin's findings in support of the view that autism and
developmental language disorder were not mutually exclusive and that the best
approach was that of a continuum. Bishop's proposed continuum model had two
dimensions: firstly that of meaningful verbal communication and secondly that
of interests and social relationships. In avoiding a single continuum of severity
Bishop was able to contrast the pattern of symptoms between the disorders.
Thus children with relatively normal communication but abnormal social
relationships would have Asperger's syndrome; children with relatively normal
social relationships but abnormal verbal communication would have semantic-
pragmatic disorder; and those with abnormal abilities for each criteria would be
children with autism. Happé (1994) commended Bishop's approach but
cautioned that it presupposed there to be no necessary relationship between
social and communicative competence, whereas there was in fact good reason to
believe that social and communicative abilities might rely on the same cognitive
mechanisms.

Early Debate concerning the validiy of “semantic

pragmatic Disorder”
Aarons and Gittens (1990; 1991; 1993), two speech and language therapists
who were familiar with current understanding of disorders of the autistic
spectrum, protested from the early 90s that children displaying the
communication deficiencies described as "semantic-pragmatic disorder" were
not merely language disordered but also had the underlying cognitive deficit
ascribed to autism by Frith (1989). They argued in favour of diagnosing the
condition as autism, since the social impairments were the most important
diagnostic indicator of the true nature of the difficulties of "semantic-pragmatic
disorder" and since the core cognitive deficit would remain. Aarons and Gittens
recommended using the term "semantic and pragmatic difficulties"
descriptively, but not as a diagnostic label, since such difficulties might occur
for a variety of reasons and it was essential to identify the underlying cause in
order to plan effective management. They concluded that the group of children
who had been labelled as having a "semantic-pragmatic language disorder" was
in fact to be found at the upper end of the autistic continuum and should be
diagnosed appropriately.

Support for the views of Aarons and Gittens came from Brook and Bowler
(1992). Noting that some polarization of views had developed between those
who regarded the language problem as primary and those who regarded the
social impairment as primary Brook and Bowler reviewed the literature of
studies of children with language disorders characterized by semantic and
pragmatic impairments. They classified the descriptions of these children using
Wing and Gould's (1979) criteria for inclusion in the autistic continuum. Brook
and Bowler concluded that some of these semantic and pragmatic impairments
resulted from the same fundamental cognitive and interpersonal difficulties
found in autism. It seemed to them that "semantic-pragmatic disorder" and
"high-level autism" were different perceptions of the same phenomenon and
that research was needed to investigate the social-cognitive abilities of children
labelled as having "semantic-pragmatic disorder".

Research Findings
In a study investigating the brain bases of developmental language disorders,
Shields et al (1996a; 1996b) compared children with "semantic pragmatic
disorder" and children with high functioning autism on batteries of
neuropsychological tests, including tests of social cognition, and found striking
similarities between the two groups. The two groups shared a pattern of results
indicative of right hemisphere functional deficiency and of social-cognitive
dysfunction. This finding supported the opinion that "semantic pragmatic
disorder" is a disorder of the autistic spectrum and that the weaknesses in
communicative competence may result from, or be associated with, an
underlying cognitive deficit which is not primarily linguistic in nature.

Recent Debate
Gagnon et al (1997) reviewed the clinical overlap between "semantic pragmatic
syndrome" and high-functioning autism. They found no differential symptoms
or features present in either disorder to support a distinction between the two
conditions and therefore queried the continuing use of "semantic pragmatic
syndrome" as a diagnostic category, or as a clinical entity. They asked: "If the
semantic pragmatic diagnosis does nothing more than arbitrarily group the
verbal communication deficits present in autism under a separate category, what
use is there in keeping such a confounding diagnosis?" (Gagnon et al, 1997:
page 45).

Boucher (1998) continued this debate, noting a continuing unresolved

controversy concerning diagnostic criteria for "semantic pragmatic disorder".
Boucher reviewed the diagnostic status of the term and its relationship to
autistic spectrum disorder, predicting that "semantic pragmatic disorder" will
prove to be a valid sub-type of autism. In the same journal, in a reply to
Boucher, Rapin and Allen (1998) explained their present position regarding the
use of the term "semantic-pragmatic deficit syndrome". They now consider that
"semantic pragmatic disorder" occurs most often in autism, and much less often
in some non-autistic children with disorders such as hydrocephalus, Williams
syndrome, and other brain conditions. They 'strongly disagree with the practice
of using the term "semantic pragmatic disorder" to avoid having to make the
more unpalatable diagnosis of an autistic spectrum disorder' (Rapin and Allen,
1998: page 86).

The current Position

There is now consensus amongst many professionals working with disorders of
the autistic spectrum, that "semantic pragmatic disorder" should be viewed as
part of the autistic spectrum, rather than as a developmental language disorder.
Clinical experience and follow-up of children given the "semantic pragmatic
disorder" diagnosis during the late 1980s and early 1990s indicates that most
members of this group have continuing social difficulties, even when their
language improves (Shields 1998: personal experience and consultation with
others).

Whilst it may be useful to use the term "semantic and pragmatic difficulties" in
a descriptive way, to indicate the nature of the presenting communication
deficits, the use of the term "semantic pragmatic disorder" as a diagnostic label
can mask the underlying socio-cognitive deficits and restrict the available help
for the child's special educational needs. As Wing comments (1996: page 73):
'Most people in the field of autistic disorders do not consider there is any value
in separating semantic-pragmatic disorder from the autistic spectrum. The
disadvantage of doing so is the failure to recognize the child's whole pattern of
disabilities and therefore a failure to address all their needs. It is also most
misleading for the parents.'