Some practical solutions to the complex language problems of children with semantic pragmatic disorder
Semantic pragmatic language disorder was first described by psychologists Rapin & Allen in 1983. Although there has been some controversy about using the label, it does clearly describe a group of children and young people who have difficulties with language at an abstract and conversational level. Now the diagnostic criteria for autistic spectrum disorders (ASD) have broadened to include more young people with pervasive developmental difficulties, some people with semantic pragmatic disorder (SPD) may also fit into the outer spectrum of ASD.
Speech and language therapists (SLTs) usually diagnose SPD in young people through a process of observation in more than one setting, using formal language tests and by the use of questionnaires. Dorothy Bishop’s Communication Checklist is particularly helpful because it highlights the pragmatic difficulties young people experience which are not picked up on other SLT tests. For older children, the recently developed Communication Self Report can be used to help with diagnosis, to understand the young person’s insight and help them own their diagnosis when this is shared with them.
Initially, young people with SPD may be slow to speak but, with help at pre-school, they usually become superficially articulate. Therefore, the pervasive nature and complexity of their language difficulties may well be disguised and may not be recognised in school. Characteristics include:
- slow processing of language, so they miss general instructions
- literal understanding, so, unless instructions are explicit, they fail to make sense of what people mean
- one sided conversational skills with repetitive questioning and preferred topics.
Early diagnosis is important because it encourages the teaching of language skills at the optimum time for children. Once identified, children with SPD can be taught social communication skills, which come naturally to others, through a positive reward and rule based approach, and many programmes are available to support teachers in this area. Advice from specialist SLTs and teachers can also help schools develop specific strategies for the delivery of the school curriculum.
Of course, young people with SPD all have their own individual personalities. Some are shy and withdrawn while others may be active and “in your face”. Many children with SPD see their role as the class clown, as they desperately try to seek approval. The more lively children tend to be referred for help more routinely because of the impact of their behaviour on classroom management, while more passive individuals are less easy to identify. It is often the parents of the quieter children who draw attention to their children’s problems. These parents often describe quite different behaviour at home, involving lack of compliance and emotional outbursts.
The signs can be difficult for teachers to spot. As a general rule, children who have a history of speech and language delay, and have few close friends either inside or outside school should be screened. They may exhibit behaviour problems which have not responded to normal sanctioning and their verbal skills may not match their written language skills. A referral to an SLT and an educational psychologist is usually necessary for confirmation of a diagnosis and to profile their strengths and difficulties. In some cases, intervention from Child and Adolescent Mental Health Services (CAMHS) may be necessary.
Those with a history of significant language delay may have been diagnosed early by an SLT, while more verbally able children may not be detected until adolescence. This is obviously a difficult time in life and a young person’s growing awareness of their difference, if not treated, can result in significant mental health problems.
In order to provide appropriate support, teachers need to have a thorough understanding of the nature of the disorder. They also need multi-disciplinary training which looks at classroom management, differentiated delivery of language and structure with visual supports.
Children who have spoken language difficulties which persist beyond the age of five are likely to have literacy difficulties. This certainly applies to children with SPD. Most have difficulty with phonological awareness skills. Some appear to read superficially well and are more often labelled hyperlexic. They have specific problems with comprehending text at an abstract and inferential level. The majority have difficulty with open-ended writing or narrative skills, rarely writing enough unless additional help with planning and structuring is provided. Most have subtle fine motor difficulties which can make writing a chore. Many young people with SPD may have particular strengths in other subject areas, and the discrepancies between their strengths and weaknesses can lead to assumptions by some that they need to listen more or make more of an effort.
Most children with SPD suffer from high levels of anxiety. They struggle to make sense of a complex social and academic world by relying on routine and predictability. This complexity increases dramatically at Year 7 when young people move to secondary school. Not only do they have to cope with managing different subjects while finding their way around, they can also be at the mercy of subtle bullying as their vulnerability is exposed in unstructured situations. Many schools now have sophisticated transition programmes and these can help to minimise problems.
Parents are often the best judges of how well their child is coping with school life. Many young people with SPD do not have the abstract vocabulary or social communication skills to ask for clarification or explain how they are feeling. Boys can often be physically aggressive, while girls may tend to internalise their anxiety, which may be expressed through self harming. A recent audit of four inpatient CAMHS wards in Birmingham, where there is a specialist language assessment facility, found that more than 70 per cent of the young people admitted had a previously undiagnosed language and social communication disorder. Clearly, the failure to identify and tackle problems early on can lead to more serious issues in the future. Strategies to consider are:
- referral to an SLT
- programme of language and social communication targets to be embedded in the school day
- whole school training, so all staff, including dinner ladies and secretaries, are aware of how to communicate with young people with SPD and avoid confrontation
- whole school policy of positive behaviour programmes
- visual timetables to provide structure and certainty
- cards to signal the need for work breaks
- delivery of a modified curriculum with visual support
- opportunities for one to one and small group teaching
- social use of language programmes
- provision for young people to access small group special interest clubs at lunch times
- close liaison with parents
- statementing, particularly where the child is unlikely to fit into the complex social environment of a large secondary school
- provision of a mentor, to help with problems with relationships.
The road to success is a rocky one. Young people need to be supported by a process of close collaboration between schools, families and SLTs. They also need individual help in school to organise their work and resolve conflicts with friends and teachers. This will allow them to reach their potential and make a safe transition to further education and employment.
Margo Sharp is a trustee of Afasic. For more information about SPD and useful resources, visit the charity’s website:
This article was first published in issue 47 (July/August 2010) of SEN Magazine.