Professional Documents
Culture Documents
autism © 2004
Children on the borderlands SAGE Publications
and The National
Autistic Society
of autism Vol 8(1) 61–87; 040640
1362-3613(200403)8:1
www.sagepublications.com 61
DOI: 10.1177/1362361304040640
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the diagnosis of cases at the borderlands of autism. Developmental language
disorders are one group of conditions that seem to overlap with the autistic
spectrum (Allen and Rapin, 1992). (The term ‘language disorders’ or LDs
will be used to refer to developmental language disorders, dysphasias and
specific language impairments in this article.) In most children with
autism, an impairment in language is apparent by the second year of life
(Lord and Paul, 1997), and this impairment is almost always the present-
ing complaint of parents (Howlin and Rutter, 1987; Rapin, 1996a). A quali-
tative impairment in communication that affects both verbal and
non-verbal skills (American Psychiatric Association, 1994; Wing, 1996) is
a major feature of autism, and varies from failure to develop language at all
to a range of language abnormalities, including echolalia, odd intonation
patterns, confusions with pronoun distinctions, and poor comprehension
(Bishop and Rosenbloom, 1987; Lord and Paul, 1997; Tager-Flusberg,
2001). However, the most common and severe impairment in speaking
children is in the pragmatic aspects of language, that is, the communicative
or conversational aspects (Rapin, 1996b; 1997; Tager-Flusberg, 1999;
2001; Wing, 1996).
The same manifestations of the communication impairment, including
the characteristic ‘autistic language features’ (e.g. unintelligible jargon,
immediate echolalia and pronominal errors), are also seen in children with
LDs without autism (Allen and Rapin, 1992; Rapin, 1996a). These mani-
festations vary widely, with the common feature being a significant
problem in mastering language or communication, for no clearly specified
reason (Bishop, 1998). There is still no consensus over the classification of
developmental language disorders into qualitatively distinct syndromes
(Bishop, 1998; Rapin, 1996b). Semantic-pragmatic disorder (SPD)
(recently termed pragmatic impairment) has been of particular interest
because the characteristic deficits in understanding verbal messages,
particularly questions and non-literal communications, poor conversational
skills, repeated questioning and perseveration (Bishop and Rosenbloom,
1987; Lister-Brook and Bowler, 1992) are similar in kind to those seen in
autism (Bishop, 1998; Botting and Conti-Ramsden, 1999). There continues
to be considerable controversy regarding the diagnostic criteria for PI and
its putative relationship to autism (Boucher, 1998; Gagnon et al., 1997;
Lister-Brook and Bowler, 1992).
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children at the milder end of the autistic continuum. Differential diagnosis
may also be a particular problem in very young children. Clearer guidelines
for the differentiation between autism and LDs are important both in regard
to intervention and for research. For example, children with LDs are often
used as controls in experimental work on autism (e.g. research into theory
of mind), based on the assumption that these two groups of children are
behaviourally different. This assumption needs testing.
The aims of this exploratory study were (1) to investigate a specific
group of young children who all showed some autistic features, in order
to compare those diagnosed as autistic with those diagnosed as language
disordered; and (2) to investigate whether there were features that differ-
entiated between the two groups, by comparing them on behaviours within
four domains, i.e. social behaviour, imaginative activities, repetitive behav-
iours and communication. That is, the focus was on assessing children at
the borders of diagnostic categories to see if behavioural markers relevant
to clinical diagnosis could be found. It was hypothesized that, compared
with the group with language disorders, the group with autism would
have: (1) greater impairments in social behaviour; (2) greater impairments
in imagination; (3) greater tendencies to engage in repetitive behaviours;
and (4) greater impairments in pragmatic language. In addition, it was
hypothesized that relationships would be found between behaviours across
the different domains, such that participants with greater impairment in
one domain (e.g. social behaviour) would tend to have greater impairments
in other domains (e.g. pragmatic language and repetitive behaviours). A
positive relationship between parents’ and teachers’ ratings of participants’
behaviours was also expected.
The children in this study, all of whom showed some autistic behav-
iours, had received a diagnosis either of autism spectrum disorder (ASD)
or of LD, and were assessed with a range of behavioural, cognitive and
language measures, including observations of play. Cluster analyses were
used to explore whether the participants were best represented as distinct
diagnostic groups of children with LD or with ASD, or were more appro-
priately divided into different subgroups on the basis of behavioural, com-
municative and cognitive features. We also compared and contrasted the
empirically derived clusters of cases with the groups produced by clinical
diagnosis.
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Participants
The participants were 37 children referred to the Royal Children’s Hospital
(Melbourne) Autism Assessment Program. Diagnoses are made by expert
multidisciplinary autism assessment teams (paediatrician, psychologist and
speech pathologist) according to DSM-IV criteria. Diagnoses of LD are made
on the basis of evidence of communication impairments, the exclusion of
other diagnoses, and speech pathologists’ formal and informal assessment
of the child’s receptive language abilities, language structure, and use of
language in conversations.
The five girls and 32 boys were aged between 4 years 0 months and 7
years 11 months (mean 5.5 years). The group had a mean full-scale IQ of
84 (SD = 14.2), mean verbal IQ of 79 (SD = 14.9) and mean non-verbal
IQ of 94 (SD = 14.8). All participants spoke in short phrases or sentences,
except for one boy aged 4.5 years (the group comparison analyses were
run with and without this participant, and no differences were found in
the results). Participants came predominantly from families from the
middle to lower end of the SES distribution.
Twenty-two children were diagnosed with autism (ASD) and 15 were
diagnosed with LD. Of the 22 participants in the ASD group, 20 were diag-
nosed with autistic disorder and two with Asperger’s disorder. (This latter
diagnosis was made using modified DSM-IV criteria, i.e. non-delayed
language was not required for diagnosis.) Of the 15 participants in the LD
group, 10 were diagnosed with mixed receptive–expressive language
disorder, four with communication disorder not otherwise specified, and
one with expressive language disorder. Three of the participants with mixed
receptive–expressive language disorder were also diagnosed with another
disorder, including developmental coordination disorder, phonological
disorder and mild intellectual disability. This pattern reflects common
comorbidities in children with language impairments.
Questionnaire data were obtained from parents of 35 participants, and
from 34 teachers or other professionals who were familiar with the child’s
behaviour in a group environment. No questionnaire data were obtained
for one child from each group, owing to loss of contact with their parents.
The teacher-rated questionnaires for another participant in the ASD group
were not received. The ‘teachers’ category of respondents included 18
preschool or kindergarten teachers, 11 primary school teachers, three
teachers of special education or intervention groups, and two speech
pathologists involved in group work with the children. On average, the
teachers had known the children for 12 months (SD = 8 months). The
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researcher (SB) was blind to the diagnoses of the children until all data had
been collected.
Procedure
The children participated in a play session at the Royal Children’s Hospital,
the majority on the day of their diagnostic assessment. Overall, all children
were observed in a play session within a year of diagnosis, with three-
quarters assessed within 6 months.
Parents and teachers independently completed the questionnaires and
returned them by post. The questionnaires included the Children’s Com-
munication Checklist (CCC: Bishop, 1998), the Autism Screening Ques-
tionnaire (ASQ: Berument et al., 1999), and the Repetitive Behaviours
Questionnaire (RBQ: Turner, 1995).
Each participating child was videotaped in a structured play session
with the principal researcher (SB), who is experienced in working with
children with autism or communication difficulties. The session was
planned to last 25 minutes, although in some cases it was shorter owing to
the child’s lack of responsiveness or non-compliance. Each participant was
presented with the same five sets of toys, placed on the table in a standard
way, with one set presented at a time. A new set was presented following
an interval of approximately 4 minutes, unless the child failed to play with
a particular toy set for over 1 minute, or when a child was unwilling to
continue playing with a toy set. During the final 5 minutes of the play
session, the children were invited to play with a toy of their choice. If they
did not make a selection, the researcher showed them the toy set that they
appeared to have most enjoyed playing with.
Five times during the play session, the researcher made a bid for joint
attention using speech and gesture, by saying ‘look’ while looking at and
pointing to one of the colourful posters on the walls, or holding up a toy
for the child to see. When this was unsuccessful in directing the child’s
attention to the object, she repeated the procedure once. On another five
occasions, the researcher made simple requests of the child using speech
and gesture, such as requests to pass a toy, pack up toys, or sit down. When
unsuccessful, they were repeated twice. The researcher attempted to engage
the child in turn-taking games or interactive play at least twice during the
play session. Once engaged in the games, the researcher paused when it
was her turn and waited for the child’s response.
The toys used covered a broad range of developmental levels including
some that are known to elicit imaginative play in typical children (e.g. a
farm set and dolls with feeding accessories). Other toys were included in
an attempt to engage the child in turn-taking games or interactive play (e.g.
‘push-and-go’ moving cars, or sliding Pokemon creatures). There was also
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between the two sets of ratings. The inter-rater reliability coefficients
ranged from 0.88 to 1.00.
Social behaviours were grouped into three categories: social interaction,
joint attention and behaviour regulation (following Mundy et al., 1986)
(Table 1). The categories were then subdivided into ratings of the child as
the initiator and the responder. Each child received a frequency rating for
behaviours within each of the six categories. The social interaction category
included behaviours used to elicit or maintain face-to-face interaction. As
initiator, this included behaviours such as eye contact, actions or gestures
used by children to elicit the researcher’s attention to self, or to initiate
interactive play. As responder, this included participating in interactive play
initiated by the researcher and appropriate responses to pauses in turn-
taking games (e.g. eye contact and gestures used by the child to continue
the game). In the joint attention category the children were rated on behav-
iours used to initiate joint attention, such as alternating eye contact between
the researcher and a toy, or pointing, showing or giving objects to the
researcher, and on responding to attempts to direct their attention to posters
or toys.
The behaviour regulation category included behaviours used to request
aid in obtaining objects or events. Initiating behaviours included the use of
eye contact, acts or gestures to request out-of-reach objects or assistance
with objects (e.g. in removing the jar lid). Responding behaviours included
compliance with simple requests made by the researcher.
Imaginative activities were grouped into pretend play and functional
play. The definition of pretend play followed the fundamental forms of
pretence outlined by Leslie (1987). All behaviours in this category demon-
strated a reference to something that was not present (see Table 1). In
particular, this included object substitution (e.g. pretending a bed is a tele-
vision); attributions of pretend properties to an object or situation (e.g. a
doll is wet); and inventing an imaginary object. Behaviours that appeared
to involve pretence, but could not be definitely placed in the pretend play
category because the child’s actions and intentions were ambiguous, were
not scored. Examples were putting an empty spoon to a doll’s mouth
without reference to any food on it, or to the doll actually eating (in which
case it is unclear whether the child is imagining food on the spoon or just
imitating the conventional association between a toy spoon and a doll’s
mouth without any pretence). The functional play category included behav-
iours that demonstrated the conventional use of objects or the conventional
association between objects, e.g. putting a doll in a toy bed.
Repetitive behaviours included repetitive bodily movements (e.g.
rocking, hand twisting, or whole body movements), object preoccupations
(including preoccupations with parts of objects, or with repetitive actions
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Results
Given the limitations imposed by small sample sizes in this study, effect
sizes were calculated in addition to the statistical significance tests. Effect
sizes were calculated using Cohen’s (1988, p. 284) formula ES = [2/(1
– 2)];‘small’ effect size is 0.10,‘medium’ is 0.25, and ‘large’ is 0.40. There
were no significant differences between the clinically diagnosed groups on
age (t(35) = –0.27, p > 0.05); verbal IQ (t(31) = –0.04, p > 0.05) or
performance IQ (t(31) = –0.81, p > 0.05) (see Table 2).
AU T I S M 8(1)
Table 2 Group means and standard deviations for age, IQ, and verbal test
measures
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relationship found between parent-rated social interaction and pragmatic
language (r(32) = –0.47, p < 0.01) suggested that impairment in social
interaction may be related to pragmatic language impairment. However, this
relationship was not significant for the teacher-rated scales (r(23) = –0.28,
p > 0.05).
There was a moderate level of agreement between parents and teachers across
domains, including the pragmatic composite (r(29) = 0.41, p < 0.05) and
the repetitive behaviours scale (r(28) = 0.52, p < 0.05). However, the corre-
lation between informants on the social interaction scale was non-signifi-
cant.
Group comparisons
Overall, the clinically diagnosed groups did not differ significantly on the
parent questionnaire measures. However, there was a significant univariate
difference on repetitive behaviours (medium ES 0.37), with the children
diagnosed with ASD showing more of these than the children with LDs.
Scores on all tests for the groups are provided in Tables 2, 4a and 4b. After
deletion of cases with missing values, the group comparison analyses were
performed on teacher questionnaire measures for 19 of the participants. An
overall MANCOVA showed that the groups differed significantly on the
teacher ratings (F(3, 14) = 6.99, p < 0.01). Significant differences were
found in group means on teacher-rated repetitive behaviours (large ES
1.15) and pragmatic language (large ES 0.64, see Table 4b). The group
differences were in the expected direction, with the ASD group showing
more impairment. For both parent and teacher ratings of pragmatic
language, both group means were below the cutoff of 132, suggesting that
participants in both groups tended to have particular difficulties in this area.
Table 4 shows effect sizes for the group comparisons in the last column.
Although differences in the group means were in the expected direction,
with the ASD group showing more impairment, the effect sizes were all
very small, except for teacher ratings on pragmatic language (moderate
effect size) and repetitive behaviours (large effect size, see Table 4b).
Higher social interaction scores indicate greater impairment in social interaction; higher repetitive
behaviours scores indicate more repetitive behaviours; and higher pragmatic language scores indicate
greater pragmatic language abilities.
AU T I S M 8(1)
who frequently engaged in imaginative activities tended more often to
initiate and respond to social interaction and initiate joint attention.
Moderate positive relationships were generally found between the social
behaviour play variables. Initiating social interactions was related to
responding to social interactions, and to initiating joint attention (Table 5).
Initiating joint attention was also related to responding to interactions.
Behaviour regulation initiate was not related to any other social behaviour.
As Table 6 shows, the clinically diagnosed groups differed significantly
using the Mann–Whitney non-parametric test, on functional play and in
joint attention, with the LD children showing more of these behaviours (U
= 81, p < 0.01; and U = 104, p < 0.05, respectively).
Table 6 Group medians and ranges, and statistical values for group
comparisons on play session variables
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Table 7 Cluster group means and standard deviations, and statistics for
comparisons between clusters on significantly differentiating variables
Cluster A 0 0 3 3 6
Cluster B 3 1 1 5 2
Cluster C 1 1 7 10 4
Total 4 2 11 18 12
a ‘Other AD’ refers to children diagnosed with autism, not specified as high functioning.
Discussion
The aim of this study was to discover if young children presenting with
autistic features and clinically diagnosed with autistic spectrum disorder
(ASD) or language disorder (LD) could be discriminated on the basis of
measures of a range of cognitive and behavioural variables identified as
diagnostically significant in previous studies. Beginning with a group of 37
children presenting to an autism assessment centre and diagnosed as having
either LD or ASD, we obtained systematic observational, psychometric and
questionnaire measures on which to base a search for variables that might
discriminate between subgroups. Cluster analyses were used to identify
groups which were then compared with the groups identified via clinical
diagnosis.
Differential diagnosis continues to be a challenge in the field of
developmental disorder and the boundaries between differently labelled
conditions are unclear. Mahoney et al. (1998) noted that there is no ‘gold
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standard’ by which we can differentiate autism from other pervasive
developmental disorders and that a high rate of diagnostic error is likely
with children who show ‘atypical autism’. Moreover, Tager-Flusberg
(2003) has concluded that it is not feasible reliably to discriminate, on the
grounds of language characteristics, between speaking children with
autism and those with developmental language disorders. Such studies
illustrate the need for further research to search for differentiating charac-
teristics of these complex disorders, and further refinement of current
systems of diagnosis and classification. This is important for both clinical
and research purposes.
There were differences between the clinically diagnosed groups in this
study on some behavioural features. The ASD group initiated joint atten-
tion significantly less often during the play session than the LD group. Other
differences on social behaviour variables were in the expected direction,
but were not statistically significant. Group comparisons were not con-
ducted on joint attention or behaviour regulation responses in the play
session, because the majority of participants in both groups responded to
all bids for joint attention and complied with all requests. However, partici-
pants who obtained less than perfect scores on these variables tended to be
from the ASD group rather than the LD group. As predicted, the ASD group
engaged in fewer imaginative activities than the LD group, including less
functional play and less pretend play, though the difference was only signifi-
cant for functional play. These results provided some support for the
hypothesis that the ASD group would have greater impairments in imagin-
ation than the LD group.
Based on the data from the parent-rated and teacher-rated questionnaire
measures, the ASD group were rated as engaging in a greater number, fre-
quency or severity of repetitive behaviours compared with the LD group.
The size of this effect was larger for the teacher-rated measure (ES = 1.152
= 0.57) than the parent-rated measure (ES = 0.372 = 0.12). Only three
participants showed repetitive behaviour during play observations, all from
the ASD group. This group was also rated by both parents and teachers as
having greater difficulties in pragmatic language than the LD group,
although this was statistically significant only for the teacher measure.
There were no significant differences between the groups on the univari-
ate tests for either vocabulary or comprehension, supporting the hypothe-
sis that the groups would not differ in formally assessed vocabulary and
comprehension skills.
Two exploratory cluster analyses using behaviours from all four
domains were reported. The two-group analysis divided the cases into low-
and high-functioning groups. That is, one cluster had lower verbal and
performance IQ, higher levels of repetitive behaviours, and greater
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The results concerned with other social behaviours are inconsistent
with previous research that has found greater impairments in children with
autism than in children with LDs, in social development, social responsiv-
ity, interactive play and peer relationships (Bartak et al., 1975; Fein et al.,
1996; Noterdaeme et al., 2002; Willemsen-Swinkels et al., 1997). Our
results also question the emphasis on broadly defined social interaction
impairments in the DSM-IV and ICD-10 criteria for differential diagnosis
of ASD and LD. While it may be true that social behaviours (other than joint
attention) may not differentiate between children with autism and those
with LDs who have some behavioural difficulties, there are a number of
possible explanations that may account for the pattern of differences in this
study. Children with LDs have been shown to experience social difficulties
compared with normally developing children (Botting and Conti-
Ramsden, 2000; Brinton and Fujiki, 1999; Farmer, 2000; Fujiki et al.,
1999a; 1999b). This is particularly apparent in children with pragmatic
impairments (Bishop, 2000b; Bishop et al., 2000; Botting and Conti-
Ramsden, 1999; Byers et al., 1989; Shields et al., 1996b). The particular LD
group in this study may have been one with more social difficulties than is
typical of children with a language disorder, since their problems were
severe enough for them to be referred to an autism assessment service for
consultation. Social behaviours other than joint attention may not differ-
entiate between children with autism and children with LDs who are near
the boundary between these conditions.
An alternative explanation relates to the nature of the play session,
which was very different from the situations in which children are typi-
cally observed. This was a tightly regulated situation, involving structured
activities, one-to-one adult-to-child attention, and seating arrangements
that encouraged the child to remain seated and directly face the researcher.
Previous research suggests that children with autism are more likely to
initiate social interactions and engage in other appropriate social behaviours
in such conditions (see Tager-Flusberg, 1999; Willemsen-Swinkels et al.,
1997). Thus, the social behaviours elicited by this structured setting may
be optimal behaviours rather than typical (Mundy et al., 1986; Sigman et
al., 1986). The adaptive social behaviours that can be elicited by the struc-
ture and regulation of the play session have important implications for the
management of children with autism: for example, in developing strategies
to elicit adaptive behaviours at home and at school. The highly structured
nature of the play session may also explain the finding that, contrary to
expectations, the majority of children in both groups responded to every
bid for joint attention and complied with every request made by the
researcher. This situation appeared to bring out the best in these children.
The significant difference found in functional play is consistent with
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teachers’ ratings. The discrepancies between parents’ and teachers’ ratings
may be a reflection of the greater challenges, complexity, and unpredict-
ability involved in communications in the school (or kindergarten)
environment compared with the home environment (Tager-Flusberg,
1999). Moreover, pragmatic language difficulties may be less apparent to
parents of ASD children because the familiarity of interactions in their
home environment may support them in communicating effectively. In
addition, parents may have adopted adaptive strategies that assist them in
communicating with their child.
To a large extent, the distinctions drawn between the domains of behav-
iour are artificial. Social interaction and communication are closely linked
and to some extent overlap (Tager-Flusberg, 1999). This overlap is seen in
pragmatic language and joint attention, both of which are social com-
munication skills that were more impaired in the ASD than in the LD group.
Joint attention has strong developmental connections with language
development. Pragmatic language, in particular, builds on developments in
the social domain and hence is closely linked to non-verbal social deficits,
including deficits in joint attention (Tager-Flusberg, 2001).
While this study was designed to explore possible differentiating
features of children with ASDs and those with LDs, it is possible that this
population of children is more appropriately divided into several subgroups
on the basis of differentiating features. Cluster analysis identified three
groups with features consistent with low-functioning autism, high-func-
tioning autism or Asperger’s disorder, and language disorders. Cluster
differences appeared to be strongly related to the intellectual ability vari-
ables, namely verbal IQ and performance IQ. This is consistent with
previous attempts to subclassify participants with autism spectrum dis-
orders (e.g. Prior et al., 1998). The differences in cognitive functioning
seemed to be very powerful variables that could overwhelm any more fine-
grained diagnostic differences, especially since IQ measures were related to
severity of autistic symptoms. Nevertheless the three clusters also differed
in regard to the severity of impairment on social interaction, repetitive
behaviour and pragmatic language measures. The LD cluster showed the
least impairment across all three measures. The differences between the two
autistic clusters related to the severity of impairment and the level of intel-
lectual functioning, rather than distinctive patterns of behaviour (Prior et
al., 1998; Waterhouse et al., 1996).
AU T I S M8(1)
imagination/repetitive behaviours, and with the implication that the bor-
derlines of the autistic spectrum are continuous rather than discrete, and
blend into developmental language disorders.
Acknowledgements
Grateful acknowledgements to Loretta Jones, Speech Pathologist, and the
Autism Assessment Team at Royal Children’s Hospital.
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