SEMANTIC PRAGMATIC
IMPAIRMENTS
INFORMATION
SHEET
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"Semantic Pragmatic Disorder" is a term which has
been used, mostly in the UK and by speech and
language therapists, for the last 10 - 15 years.
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The term was originally used to describe a
developmental language disorder, affecting two aspects
of communication: "semantics" and "pragmatics".
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In recent years, there has been debate about whether or
not "semantic pragmatic disorder" is in fact an
appropriate diagnosis, or merely a descriptive term for
the nature of communication difficulty found in verbal
people with autism.
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Research findings indicate that "semantic pragmatic
disorder" does belong within the autistic spectrum and
has the same underlying triad of socio-cognitive deficits
as high functioning autism.
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Within the NAS, professionals no longer use the term
"semantic pragmatic disorder" as a diagnostic term.
interactive behaviour, and apparent comprehension. Their
syndromes were then defined by determining which language
features were impaired, intact, or variable within the subgroups.
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
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 'semanticpragmatic 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 lexicalsyntactic 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,
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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.
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.
Early debate concerning the validity of
‘Semantic Pragmatic Disorder’
Recent debate
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 "semanticpragmatic 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.
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).
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 "highlevel 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".
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).
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
Whilst it may be useful to use the term "semantic and
pragmatic difficulties" in a descriptive way, to indicate the
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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.'
Rapin, I. 1987: Developmental dysphasia and autism in
preschool children: characteristics and subtypes. Proceedings
of the First International Symposium, specific speech and
language disorders in children. University of Reading,
England.
Rapin, I. and Allen, D.A. 1983: Developmental language
disorders: nosological considerations. In: Kirk, U., editor,
Neuropsychology of language, reading and spelling. New
York: Academic Press.
Rapin, I. and Allen, D.A. 1998: The semantic-pragmatic
deficit disorder: classification issues. International Journal of
Language and Communication Disorders, 33 (1), pp. 82-87.
Dr Jane Shields
July 1998
Shields, J., et al. 1996a: Hemispheric function in
developmental language disorders and high level autism.
Developmental Medicine and Child Neurology, 38, pp. 473486.
References
Aarons, M. and Gittens, T. 1990: What is the true essence of
autism? Speech Therapy in Practice, January 1990, pp. 2-3.
Shields, J., et al. 1996b: Social cognition in developmental
language disorders and high-level autism. Developmental
Medicine and Child Neurology, 38, pp. 487-495.
Aarons, M. and Gittens, T. 1991: Autism as a context. College
of Speech and Language Therapists Bulletin, December 1991,
pp. 6-8.
Wing, L. 1981: Asperger's syndrome: a clinical account.
Psychological Medicine, 11, pp. 115-129.
Aarons, M. and Gittens, T. 1993: Semantic-pragmatic disorder
(or a little bit autistic?) College of Speech and Language
Therapists Bulletin, June 1993, p.18.
Wing, L. 1996: The Autistic Spectrum: a guide for parents
and professionals. London: Constable.
Bishop, D.V.M. 1989: Autism, Asperger's syndrome and
semantic-pragmatic disorder: Where are the boundaries?
British Journal of Disorders of Communication, 24 (2),
pp.107-121.
Wing, L. and Gould, J. 1979: Severe impairments of social
interaction and associated abnormalities in children:
epidemiology and classification. Journal of Autism and
Developmental Disorders, 9, pp.11-30.
Bishop, D.V.M. and Rosenbloom, L. 1987: Childhood
language disorders: Classification and overview. In: Yule, W.
and Rutter, M. editors, Language development and disorders.
London: MacKeith Press.
Boucher, J. 1998: SPD as a distinct diagnostic entity: logical
considerations and directions for future research.
International Journal of Language and Communication
Disorders, 33 (1), pp. 71-108.
Brook, S.L. and Bowler, D. 1992: Autism by another name?
Semantic and pragmatic impairments in children. Journal of
Autism and Developmental Disorders, 22, pp. 61-81.
The National Autistic Society, 393 City Road, London,
EC1V 1NG, UK; tel: + 44 (0) 171 833 2299;
fax: + 44 (0) 171 833 9666; email: nas@nas.org.uk
website: http://www.oneworld.org/autism_uk/
Frith, U. 1989: Autism - explaining the enigma. Oxford: Basil
Blackwell.
Gagnon, L.; Mottron, L. and Joanette, Y. 1997: Questioning
the validity of the semantic pragmatic syndrome diagnosis.
Autism, 1 (1), pp. 37-55.
© The National Autistic Society October 1998
Happé, F.G.E. 1994: Autism: an introduction to psychological
theory. London: UCL Press.
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