Dr. Bishop et al. Reply

In “The Need for a Clinically Useful Schema of Social Communication,” Blank et al. present an observation and coding method (The Initiating, Responding, Expectancy Violations [IREV] schema) for identifying “expectancy violations (EVs),” which may signal clinically significant departures from normal social communication behavior (eg, in individuals with autism spectrum disorder [ASD]).¹ The authors point out that “historically, observation of a patient's (social communication) has not been part of the routine psychiatric mental status examination,” and argue that this is an important missed opportunity for clinicians. Several direct observation methods exist for identifying and/or monitoring changes in social communication deficits associated with ASD.² Despite their established diagnostic validity, it remains true that these measures used in isolation will result in a relatively high rate of “false positives”—usually comprising children who are better described with other diagnoses (eg, intellectual disability, language disorder, attention-deficit/hyperactivity disorder [ADHD]).² This underscores the critical importance of context when interpreting observed social communication deficits.