Pragmatic Language Disorder in Children

What is Pragmatic Language in Childhood?

Pragmatic language in childhood is social language. 

These skills include polite greetings and sharing information. These skills also include asking questions and engaging others in conversation. 

In typical child development, children learn to communicate with others somewhat naturally. Children learn to chat back and forth about a topic. They show delight in each other’s ideas with facial expressions and body language. They share information, ask questions of one another, and read nonverbal communication cues from peers. 

These skills do not develop naturally for children with a pragmatic language disorder. Skill development can also be affected by language impairment. The social rules for daily interactions can be harder for these kids to understand. 

Theory of mind is the idea that a child understands what another person may be thinking or seeing. Theory of mind includes taking another person’s perspective and understanding their social context. This ability tends to be weaker in a child with pragmatic language trouble.

Social events can be more stressful. Children can have a harder time interpreting the nonverbal cues of others. Figurative language, compared to literal language, can be harder to understand as well.

When these skills are less automatic, pragmatic language therapy may be essential. This type of therapy can help a child develop these skills.

Top Pragmatic Language Skills

1. Social skills: Know how to offer a social greeting or say goodbye in a polite manner
2. Flowing conversations: Have a back-and-forth conversation with comments, responses, and questions
3. Appropriate comments: Use tone, volume, and subject matter that is appropriate for a given setting
4. Nonverbal skills: Communicate using nonverbal skills like eye contact, gestures, and facial expressions
5. Nonverbal comprehension: Understand the nonverbal communication of others, including body language
6. Engaging stories: Tell stories in a way that keeps others engaged and offers the right amount of information
7. New topics: Introducing conversation topics and keeping those going in conversation
8. Meaningful comments: Contributing to conversations started by another person in a meaningful way
9. Deeper understanding: Understand humor, metaphors, or comments stated in a nonliteral, ambiguous manner
10. Social cues: Know if a conversation partner is interested in continuing to chat or not
11. Context awareness: Changing tone of voice and content based on a peer group and situation
12. Helpfulness: Offering help to others, using manners in a way that is fitting the situation
13. Personal space: Understanding personal space cues and keeping appropriate distance while talking
14. Polite acceptance: Accepting offers of help from others politely and smoothly
15. Polite replies: Asking for clarification or disagreeing with another person inoffensively

Phases of Pragmatic Language Development in Childhood

Regarding pragmatic language development, ensuring that your child’s skills are on track with peers their age is important. A typical trajectory for pragmatic development would look as follows (Linder & Peterson-Smith, 2008, p.264-269) [1]:

Pragmatic skill progression in infants, toddlers, and preschool children

• 2 months: eye contact
• 3 months: social smile
• 4 months: vocalizes to initiate socializing, social laugh
• 5 months: shows a preference for familiar faces
• 6 months: refuses objects or toys they don’t want
• 7 months: plays simple games like peek-a-boo
• 8 months: follows the pointing and eye gaze of the caregiver
• 9 months: makes requests and initiates interactions
• 10 months: initiates games, points to desired objects
• 11 months: uses gestures and simple words to get another’s attention
• 12 months: shared enjoyment, takes turns
• 15 months: shared joint attention, follows directions to look at something
• 18 months: responds to simple requests for clarification such as, ‘what?’ or ‘huh’?
• 24 months: takes one or two turns in a conversation
• 36 months: uses words to communicate in play, engages in some parallel play but may also interact with peers by sharing toys or commenting on their play

If your baby, toddler, or preschooler’s skills are not developing as shown in the list above, there may be concerns about pragmatic language skills. Keep in mind that pragmatic language skills build on each other over time. As you will see below, communication gets more complex as the child matures.

Pragmatic skill progression in older children 

Kindergarten social skills require play skills and language abilities. Once children reach elementary school, their skills should evolve. You would want your kindergarten child to play games with peers, such as a card game like Uno or a board game like Jenga. You would expect them to play tag on the playground using some back-and-forth social language to establish the rules. Children this age read one another’s emotions on their faces and know when and how to enter games and join other children.

From 1st grade to 2nd grade, social skills get more advanced. As children move up in elementary school, we expect them to understand jokes and sarcasm. They can now discern whether or not they should take statements literally. For example, we would expect a 2nd grader to know that ‘button your lip’ means being quiet, not actually buttoning your lip. 

From 3rd grade to 5th grade, relationships become more complex. In the later years of elementary school, kids have established deeper and longer-lasting friendships. Those relationships require lots of social communication. Conversations now include telling inside jokes, engaging in gentle teasing, sharing and keeping secrets, and telling stories. 

In middle school and high school, intimate relationships develop. Teens and pre-teens have even higher expectations in terms of pragmatic social skills. They need to learn how to ‘read the room’ to know if their voice should be loud or soft. Teens are expected to understand how different people like to communicate. Some friends joke around, while others might be more serious. 

They also need to pick up on non-verbal communication skills, such as another child in their midst suddenly becoming quiet. This quiet demeanor may indicate that the peer has hurt feelings or is confused. A teenager with good social communication skills can pick up and respond to these subtle social cues in conversations.

As shown here, pragmatic language skills build on each other throughout childhood. It is a good idea to see if your child’s skills are coming along typically. If there are concerns, this article can provide some ideas and next steps to advance your child’s skills.

Symptoms of Pragmatic Language Issues in Children

Some children may speak very well but seem unable to talk to friends. They may enjoy facts and details and love books about insects or outer space, but they may express little interest in socializing. They may not seem to read facial expressions or nonverbal cues and struggle to make inferences from what friends share. Instead, they may only take information verbatim or in a concrete manner.

Here are some common signs and symptoms of pragmatic language issues.

• Social difficulties: child does not understand how to interact with peers in conversation, read communicative intent, or follow along in conversation
• Vulnerable to teasing: child has difficulty understanding the motives of peers; may be taken advantage of often, or be overly sensitive to sarcasm or jokes
• Often confused: child seems confused when talking with peers; does not follow back-and-forth conversations
• Quiet around peers: child has trouble joining peers in conversation. They may speak to adults just fine but seem very shy around peers.
• Formal vocabulary: child may sound too mature for their age. They may use big words like “it’s preposterous,” “I’m confounded,” or “propagating the species” 
• Non-verbal communication issues: child misses important feedback from peers in terms of body language and eye contact; may talk too long on a topic without noticing others are bored
• Monologues: child talks on and on without allowing others to get a word in; conversations lack the back-and-forth quality
• Restricted interests: child gets stuck talking about a topic without bringing you into the conversation or considering if you are interested in what they are sharing

Recognizing pragmatic language challenges

A child psychologist’s clinical evaluation or a speech-language pathologist’s speech evaluation may lead to the discovery of pragmatic language challenges. It is helpful to discover this information early because so much can be done through language therapy and practice at home. 

The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) by the APA includes two diagnoses that specifically include difficulty with social communication or pragmatic language. These are Autism Spectrum Disorder and Social Pragmatic Communication Disorder.

Most researchers believe these diagnoses fall under an umbrella category of autism. Children with ADHD or social anxiety may have some social communication challenges secondary to attention or anxiety issues, but pragmatic language is not a part of those diagnoses.

Listed below are some signs you may notice of pragmatic language issues.

…You hear  “I don’t know” or “I don’t remember” a lot. When you ask your child to tell you about their day, you may see a blank stare. You may also notice that your child has challenges telling you how they feel about things. This difficulty relates to insight,’ which is the ability to recognize and talk about one’s emotions. 

…Your child may do much better on structured tasks. For example, your child may enjoy the organization and consistency of the school day. They may thrive on seated schoolwork activities. However, they may sit alone during recess. They may struggle with free play, creative social interaction, and social problem-solving. You may even see behavior problems in these unstructured times because your child is unsure how to act and react socially. 

…You hear your child report that the other kids are mean. Although it is certainly possible that the other kids are being unkind to your child, keep an eye on statements like these. It could be that your child is really having trouble connecting with other kids.

All of the above are signs that your child may be struggling with pragmatic skills. Below are some pragmatic language milestones we expect kids to reach at various ages. If concerns are noted, there are suggestions in this article to help your child work on these critical skills. 

Top 10 Causes of Pragmatic Language Issues in Children

Clinically, social communication is called pragmatic language. Pragmatic language refers to the social aspects of speech, such as conversation, reading nonverbal cues, and maintaining a back-and-forth flow of information. 

If your child is struggling, here are some potential causes of these challenges. The top 4 challenges noted are clinical diagnoses, while the following 6 are characteristics that may lead to pragmatic language challenges.

Cause #1: Autism Spectrum Disorder (ASD)

Autism includes challenges in social communication and restricted and repetitive patterns of behavior or interests. Social communication challenges in autism often include difficulty with social communication, back-and-forth conversation, and reciprocity. 

Many individuals with autism speak very well and have a huge vocabulary. They may use formal language, recall detailed information, and converse frequently with peers. Conversations that veer off-topic or miss the point are common for autism. 

For example, if a peer is sharing an emotional story about her dog dying, an autistic child may ask, “What breed was it?” or say, “Oh, that’s the life cycle” instead of saying, “I’m so sorry, that is sad.” This example shows how social language and perspective-taking may be challenging for some autistic individuals.

Cause #2: Social Pragmatic Communication Disorder (SPCD)

Social Pragmatic Communication Disorder (SPCD), sometimes known as Social Communication Disorder (SCD), is a communication disorder. Someone diagnosed with SPCD does not naturally have the pragmatic language skills noted above. It is a new diagnosis in the most recent diagnostic manual (DSM-5) version. SPCD is meant to capture the social communication challenges of autism for those individuals who do not meet the criteria for an autism diagnosis (Flax et al., 2019). 

Specifically, according to the DSM-5, a diagnosis of SPCD includes difficulty communicating socially, difficulty modulating language and tone for various settings, and trouble following rules in conversation and storytelling. The diagnosis also includes trouble understanding inferences, metaphors, and other non-literal language. These challenges must impact communication, begin in childhood, and not be better explained by autism.

Cause #3: Attention Deficit Hyperactivity Disorder (ADHD) 

ADHD can cause pragmatic language challenges because of the interplay of inattention, impulsivity, and hyperactivity. People with ADHD are often ‘disinhibited,’ which means it is hard to resist doing the first thing that pops into their heads. 

A child with ADHD may cut a peer off, invade personal space, forget what is being discussed, or talk on and on without listening. All of these behaviors could have an impact on social interactions. However, many individuals with ADHD do not have any social challenges. Social skills issues are not diagnostic for ADHD, but sometimes ADHD symptoms can interfere with social interactions.

Cause #4: Social anxiety 

A child with social anxiety may have issues with pragmatics. Your child’s anxiety could make it hard to think of what to say, leading to short answers, extreme shyness, and social avoidance. Anxiety could cause challenges with planning or working memory. It can be hard for children to read social cues if they are not thinking clearly. 

Cause #5: Poor perspective-taking

Perspective-taking is understanding and relating to another person’s thoughts, interests, and ideas. It requires noticing when a peer is disinterested by reading nonverbal cues. Signs of disinterest might include shifting eye contact, appearing squirmy, or drifting off during a conversation. 

To have quality reciprocal conversations, an individual must be able to do the following: 

• think of relevant things to share
• draw on experiences
• pay attention
• take turns
• formulate questions
• know when and how to end the conversation politely

Cause #6: Immature social development

Social communication is much more complex than vocabulary. Even very bright individuals can have difficulties with pragmatic communication. In that case, speech therapy is often required to get along with peers, do well in school, and support long-term success and happiness.

The primary reason your child may struggle with social communication is that these skills simply don’t come naturally. For most individuals, social development follows a typical course from the early childhood play skills to the BFFs in 3rd grade, and on into high school and adulthood, where relationships deepen. 

For some children, this ‘natural’ progression does not happen. Instead, the child struggles to make friends and socialize with peers. There are many reasons why this can occur, and it can certainly be the case in supportive, loving homes. Parents, listen closely! It is not your fault! Some kids simply socialize naturally, and some kids simply don’t. For those who don’t, there is a lot of help available. 

Cause #7: Social cognition problems

Social ‘cognition’ refers to understanding social relationships and social interactions. This skill includes picking up on social cues and comprehending social language, such as idioms, sarcasm, and humor. 

If your child is struggling with the cognition of these important and nuanced social skills, interpersonal interactions will likely feel confusing and frustrating. Direct teaching of these skills can often help a child with challenges in social cognition learn to pick up social cues and interact with others more effectively.

Cause #8: Developmental delays

Certainly, some typically developing children may struggle socially from time to time. However, if your child has consistent issues with social skills, a developmental disability may be present. It also could be an issue called ‘developmental delay,’ which means what the name implies. That is, the child is simply not meeting developmental milestones as expected. A language delay or a brain injury at an early age or prenatally could lead to developmental delays for a child.

Cause #9: New culture or language 

A child who moves to an unfamiliar place may struggle socially for a while due to cultural and societal norms. This struggle may be especially true if your child is learning a new language. It can be hard to pick up on some social cues, jokes, sarcasm, and other nuances when a child is assimilating into a new culture. This kind of challenge is not at all a sign of a language disorder. Most kids with strong social skills in one culture will eventually make new friends and feel comfortable in a new place. It will be important for family and friends to be supportive and patient with this process.

Cause #10: Quirky kiddo

Some children really can only enjoy certain types of people, prefer being alone a lot, or have mild social anxiety in specific situations. They may avoid big parties, loud concerts, or assemblies. Perhaps you have a quirky kid with peculiar interests and a unique interaction style. If your child is happy and healthy, these social patterns are fine! Research shows that most people do just fine with one good friend and one close relationship at home. No matter how quirky your child is, there has to be one other kid who is just as quirky and needs a friend just as much. Help your child connect with others, and do not stress if your child prefers the company of just one or two friends instead of having several. 

Social pragmatic communication disorder (SPCD) vs autism: What’s the difference

Autism is characterized by social communication differences and characteristics like those discussed above. To diagnose autism, a psychologist or medical doctor must also find Restricted and Repetitive Behaviors (RRBs). The difference between ASD and SPCD comes down to the presence or absence of restricted and repetitive behaviors. Those diagnosed with SPCD must not have any RRBs.

Some more classic or unmistakable RRBs are hand flapping, finger flicking, spinning, and bouncing. Less obvious RRBs are pacing, repeatedly talking about the same topics, and repeating words or phrases in conversation. 

Many professionals have argued that this mild distinction between SPCD and autism means that SPCD is merely a broader autism phenotype (Flax et al., 2021). With DSM-5, the umbrella category of PDD-NOS is no more. Before that change, more mild cases on the Autism Spectrum were diagnosed PDD-NOS.

Children or adults were noted to be “on the spectrum” but not meeting the full criteria. With DSM-5, that diagnosis was no longer available to clinicians. Many believe that those milder ASD cases are now being diagnosed as SPCD.

What to Do About Social Communication Skills in Childhood

There’s good news! Children can be taught social communication skills. To improve pragmatic language, a parent can access a lot of strategies and resources listed below.

First, use and model social and emotional language for your child. Talk about your feelings. Share about your day and how you cope. “Work was stressful for Mom today, so I’m going to take a walk. Would you like to come too?”

Second, get your child enrolled in social activities that are low-risk socially. Lego club, cooking class, robotics club, and music are good options. Find an activity with a team or group that isn’t extremely competitive. Start with something that has a structure but is about individual performance. Pay attention to who the coach or adult sponsor is, and seek those individuals who are accepting, warm, and not competitive.

Third, practice social conversation with your child and provide feedback like, “You could ask Sally what she did this weekend.” Provide a bit of structure to family discussions instead of simply asking, “How was your day?” Instead of asking a broad question, you can help your child think of a better response by asking, “How did it go with that art project you have been working on in class?” Listen carefully, and do not give up when your child can’t think of anything to say. It takes practice, and this practice begins to pay off over time. Social scripts can allow your child to think about things to say in advance and practice some questions or phrases to have on hand in social situations. 

Fourth, provide breaks and downtime. Give your child time to relax after school. Most kids will want time to decompress after school. Perhaps allow your child to play a bit or have some fun at the park before launching into a discussion about the day. When you do start talking, you can give very specific prompts like,  “What did you have for lunch?” or “What game did you play in P.E?”

Fifth, seek out structured social groups. If your child continues to struggle, seek out a social group, social skills therapy, and supports at your child’s school. We have seen children make significant gains in pragmatic language skills with practice.

When to Seek Help for Pragmatic Language Challenges

The biggest sign that it is time to seek help is when your child constantly struggles to make friends. You may notice your child is confused or frustrated frequently during social interactions. It is a good idea to seek help if you see one of these challenges occurring for your child.

• Your child may say they have lots of friends but may not be able to tell you much about them
• Your child may know their friends’ heights and eye color but may not recall what they like to do for fun
• Your child may report that everyone in class is mean or that they just don’t like anyone
• Your child may boss other kids around or lecture on a topic without stopping to assess whether anyone is listening
• Your child never asks how others are doing or struggles to carry on a back-and-forth conversation

If any of the above challenges are happening fairly frequently, it would be good to seek help. Many school-based and community-based speech therapists treat pragmatic language, and it is generally readily amenable to intervention.

Further Resources on Pragmatic Language

• Psychologist or neuropsychologist: to consider pragmatic symptoms in a developmental context, a comprehensive evaluation could include social skills and language evaluation, as well as a look at verbal and nonverbal abilities as well as problem-solving skills. A psychologist or neuropsychologist can make an ASD diagnosis, SPCD diagnosis, or ADHD diagnosis. The gold standard measure a clinician will use to make a diagnosis of autism or to rule that out is called the ADOS or Autism Diagnostic Observation System. ADOS scores can help a psychologist determine this diagnosis.
• School psychologist: to test IQ or intelligence, anxiety, social skills and consider the academic impact. Some school psychologists also give an ADOS, though it is not necessarily recommended practice in the school setting
• Speech and language pathologist: to provide language assessment and then therapy. At-school therapy can happen during lunchtime or recess for a natural social environment. This therapy may be in a group, or the therapist may come into the classroom to facilitate social learning
• Social group: to work on social communication. Often facilitated by a social worker, counselor, or psychologist, a group with other children with an emphasis on social and conversation skills can help. Make sure your child is matched by approximate age and children have similar language skills and ideally some peer models as well

Similar Conditions to Pragmatic Language Problems

• Social skills: children with poor pragmatic language are likely to have overall social skill difficulties
• Social anxiety: children with poor pragmatic skills may be very nervous in social situations
• General anxiety: children with poor pragmatic skills may have anxiety
• Expressive language: children with poor pragmatic skills may not be able to express their thoughts and ideas due to a language problem
• Receptive language: children with poor pragmatic skills may have difficulty understanding what others are saying
• Attention problem: children with poor attention skills may have trouble with pragmatic language due to the tendency to miss social cues and not listen during social interactions
• Hyperactivity: children with poor pragmatics who are hyperactive may not be able to communicate socially due to excessive movement
• Conversation: children with poor pragmatic skills are likely to struggle with conversations

References on Pragmatic Language In Childhood

[1] Linder Ed.D., Toni & Petersen-Smith Ph.D., Ann (2008) Administration Guide for TPBA2 & TPBI2 (Play-Based Tpba, Tpbi, Tpbc).

Book Resources on Pragmatic Language In Childhood

American Psychiatric Association. (2013). Autism Spectrum Disorder. In Diagnostic and Statistical Manual of Mental Disorders (5th ed.).

American Psychiatric Association. (2013). Communication disorders. In Diagnostic and Statistical Manual of Mental Disorders (5th ed.).

Amoretti, M. C., Lalumera, E., & Serpico, D. (2021). The DSM-5 introduction of the Social (Pragmatic) Communication Disorder as a new mental disorder: a philosophical review. History and Philosophy of the Life Sciences, 43(4), 108.

Flax, J., Gwin, C., Wilson, S., Fradkin, Y., Buyske, S., & Brzustowicz, L. (2019). Social (pragmatic) communication disorder: Another name for the broad autism phenotype?. Autism, 23(8), 1982-1992.

Jed Baker’s series of books for social skills and behavioral supports. He specializes in ADHD and Autism Spectrum Disorder. Link: www.jedbaker.com

Barton, Erin E & Harn, Beth (2012). Educating Young Children with Autism Spectrum Disorders. Sage.

Kroncke, Willard, & Huckabee (2016). Assessment of autism spectrum disorder: Critical issues in clinical forensic and school settings. Springer, San Francisco.

Philofsky, A., Fidler, D. J., & Hepburn, S. (2007). Pragmatic Language Profiles of School-Age Children With Autism Spectrum Disorders and Williams Syndrome. American Journal of Speech-Language Pathology, 16(4), 368-380. doi:10.1044/1058-0360(2007/040)