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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

Differential characteristics in social, imaginative,


communicative and repetitive behaviour domains

SUZANNE BARRETT University of Melbourne, Australia

MARGOT PRIOR University of Melbourne, Australia

JANINE MANJIVIONA Royal Children’s Hospital, Melbourne, Australia

A B S T R AC T A sample of 37 children aged 4–7 years who all showed K E Y WO R D S


some autistic features was investigated. Children with a primary diag- autism;
nosis of autism were compared with those diagnosed with a language diagnostic
disorder, on behaviours within four domains; social behaviour, imagin- discrimin-
ative activities, repetitive behaviour and communication. The aim was ation;
to identify potentially differentiating features of the two groups using language
observational ratings and questionnaire measures provided by parents
and teachers. Information on participants’ intelligence and language
disorders
skills was also collected. The children with autism showed greater
deficits in joint attention, functional play and pragmatic language, and
engaged in more repetitive behaviours, than the language disordered
children. However, the groups did not differ significantly on formally
assessed language skills. A cluster analysis produced three groups of
children varying in level of functioning and parent-rated behaviours.
The results are informative for clinicians dealing with the challenge of
differential diagnosis.
ADDRESS Correspondence should be addressed to: P R O F E S S O R M A R G O T
P R I O R , Department of Psychology, University of Melbourne, Parkville, Victoria, Aus-
tralia. e-mail: priorm@unimelb.edu.au

The recent conceptualization of autism as a continuum varying in the level


of severity of impairments in social interaction, communication and rigid,
repetitive patterns of behaviour allows for considerable clinical hetero-
geneity (Prior et al., 1998; Wing and Gould, 1979). It implies not only a
lack of clear boundaries between ‘classic autism’ and other lesser manifes-
tations of the triad, but also a lack of boundaries separating the autistic
spectrum from other syndromes. This creates difficulties and ambiguity in

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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).

Autistic features seen in children with language disorders


The overlap between autism and language disorders is most obvious in the
impairments related to communication. According to DSM-IV, the features
diagnostically differentiating autistic disorder from expressive language
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disorder and mixed receptive–expressive language disorder are a marked
impairment in social interaction, and the presence of restricted, repetitive
and stereotyped patterns of behaviour, interests and activities. Wing (1997)
highlighted deficits in imaginative activities, in social relationships, and in
non-verbal communication as criteria distinguishing autism from language
disorders, but there is evidence that the overlap between these conditions
extends to the social and behavioural features of autism. Bishop (2000a)
noted that a substantial minority of the children diagnosed with a language
disorder have abnormalities in the use of non-verbal as well as verbal com-
munication, and some have restricted or peculiar interests. Studies by Bartak
et al. (1975), Cantwell et al. (1989) and Howlin et al. (2000) have con-
firmed that there are children who are extremely difficult to categorize
unambiguously as cases of autism or of a language disorder.
Children with LDs also experience some social difficulties (Botting and
Conti-Ramsden, 2000; Brinton and Fujiki, 1999), and show higher levels
of withdrawal behaviour and lower levels of impulse control and prosocial
behaviour compared with normal children (Fujiki et al., 1999b). They are
less well accepted by peers, have fewer reciprocal friendships, and initiate
fewer interactions when playing with their parents (Fujiki et al., 1999a;
Willemsen-Swinkels et al., 1997). Additionally, they are less responsive to
adult solicitations and use fewer non-verbal responses (Bishop et al., 2000).
Communication difficulties may distort social experiences and create a
history of difficult interactions, thus influencing subsequent social develop-
ment (Bishop, 1997, cited in Farmer, 2000; Fujiki et al., 1999b). Alterna-
tively, language impairment and difficulties in social functioning may be
linked by a common underlying deficit, e.g. in social cognition or in
working memory and processing capacity (Bishop, 1997, cited in Farmer,
2000). Either way, it is most likely that a complex, interdependent and
interactive relationship exists between the two domains.

Aims of the present study


Previous studies have compared children with autism with children with
LDs who are clearly not autistic, on a variety of linguistic, behavioural and
social indices (Allen and Rapin, 1992; Bartak et al., 1975; Cantwell et al.,
1978; Rapin, 1996a; Shields et al., 1996a; 1996b; Tuchman et al., 1991).
Social behaviour, imaginative activities, repetitive or stereotyped behav-
iours, and communication variables can differentiate between autism and
LDs at their extremes, where they are most easily distinguishable. However,
confusion remains regarding the diagnosis of children who lie nearer to an
as yet undefined ‘boundary’ between autism and LDs. This includes
language disordered children with autistic behavioural features and
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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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Method

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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a jar (containing magnetic numbers) with a lid that was too tight for a child
to open, and hence he/she needed to elicit help. Toys were chosen because
they were considered fun or interesting by children in the participating age
range, as determined by pilot sessions with normally developing children,
and discussions with professionals on the autism assessment team.
The videotaped play session behaviours listed in Table 1 were rated by
the researcher. Behaviours were event-coded to provide frequency ratings.
In order to obtain inter-rater reliability coefficients, a postgraduate psy-
chology student was trained in analysing and rating the play sessions. This
second rater was unaware of the identities or diagnoses of the participants,
and of the hypotheses being investigated. Nine play sessions were randomly
chosen and rated independently of the ratings provided by the principal
investigator. Inter-rater reliability was established by calculating the
Pearson’s correlation coefficient to indicate the degree of relationship

Table 1 Behaviours observed in the play session

Social behaviours domain


Social interaction initiate Eye contact, acts or gestures to obtain attention to self or
to initiate interactive play
Social interaction respond Participating in interactive games initiated by researcher;
responses to researcher in turn-taking games (e.g. eye
contact, gestures to continue game)
Joint attention initiate Pointing, showing or giving objects to researcher;
alternating eye contact between researcher and toy
Joint attention respond Looking towards objects shown by researcher (who said
‘look’ and either held up or pointed to the object)
Behaviour regulation initiate Eye contact, acts or gestures to request objects or help
with objects (e.g. removing jar lid)
Behaviour regulation respond Compliance with simple requests (e.g. to give an object)

Imaginative activities domain


Functional play Demonstrating conventional use of objects or associations
between objects without pretence (e.g. making doll talk,
brushing doll’s hair)
Pretend play Demonstrating pretence (i.e. referring to something not
present), including inventing imaginary objects,
pretending an object is a different object, or attributing
pretend properties (e.g. pretending a doll is dirty)

Repetitive behaviours domain


Repetitive bodily movements (e.g. rocking, finger twisting,
hand flapping); object preoccupations, or repetitive
action involving an object, such that child only attends to
that object; other repetitive actions (e.g. repetitive
sensations, or repetitive self-injury)

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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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involving an object), and other repetitive actions (e.g. repetitive sensations
or self-injury). An object preoccupation was rated if the child would attend
only to that object and would not play with any others (including the
several sets of toys presented after it).

Assessment of intellectual abilities and language


The Wechsler Preschool and Primary Scale of Intelligence–Revised
(WPPSI–R) (N = 30) or the Wechsler Intelligence Scale for Children Third
Edition (WISC–III) (N = 3) was administered to 33 children. Five of the
children completing the WPPSI–R were given a short version including
block design, mazes, comprehension, arithmetic and vocabulary. IQ esti-
mates could not be obtained for four participants (all ASD) owing to non-
compliance or inability to cope with testing procedures. The vocabulary
and comprehension subtests of the WPPSI–R (or, for three participants, the
WISC–III) were used as measures of language capacities in the analysis of
results.

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).

Questionnaire measures analyses


Where there was no response given for an item, the total score for that
subscale or composite was pro-rataed. However, if more than one-fifth of
the items in a scale had missing scores, then that scale score was treated as
a missing value. For the CCC, higher scores indicated lesser impairment.
For the ASQ and RBQ, higher scores indicated a greater number, frequency
or severity of repetitive behaviours. Within each domain, one questionnaire
measure was chosen to be used in the group comparison analyses, based
on the strength of correlations between the measures, and the compre-
hensiveness or demonstrated reliability and validity of the measures (see
below). (The description ‘strong’ is used for correlations greater than 0.50,
‘moderate’ for correlations between 0.30 and 0.50, and ‘small’ for correla-
tions less than 0.30.) The measures used in further analyses included: (1)
the social interactions scale of the ASQ; (2) the total repetitive behaviours
score from the RBQ; (3) the pragmatic language scale of the CCC.
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Table 2 Group means and standard deviations for age, IQ, and verbal test
measures

Variable AD group LD group


Mean (SD) Mean (SD)

Age (years) (N = 22) (N = 15)


5.46 (1.01) 5.56 (1.18)

Verbal IQ (N = 17) (N = 15)


78.83 (17.50) 78.60 (11.63)
Performance IQ 91.67 (15.93) 95.87 (13.59)
Overall IQ 83.33 (16.44) 84.87 (11.46)

Comprehension 5.00 (3.67) 5.47 (2.75)


Vocabulary 7.35 (4.43) 5.73 (2.09)

There were no significant group differences on any variables.

Significant correlations were found between social interaction (ASQ)


and social relationships (CCC) where the two scales were completed by the
same informant (r(27)= –0.55, p < 0.01 for parents; and r(22) = –0.51,
p < 0.01 for teachers). Hence only the social interactions scale (ASQ) was
included in further analyses as the questionnaire measure of social behav-
iours. It is a more comprehensive measure of social behaviours than the
social relationships scale (CCC), which has fewer items and a narrower
focus.
There were six questionnaire measures within the domain of repetitive
behaviours: repetitive movements, sameness behaviours, repetitive
language, total repetitive behaviours (RBQ measures), repetitive behaviours
(ASQ) and interests (CCC). Within informants, these measures were gener-
ally strongly correlated with each other in the expected direction. Total
repetitive behaviours (RBQ total) was strongly related to the other
measures, with correlation coefficients greater than 0.80, and as this was
also the most broad-ranging measure of repetitive behaviours it was used
in further analyses of repetitive behaviours. A moderate to strong corre-
lation was found in the expected direction between the pragmatic com-
posite score (CCC) and language/communication (ASQ) for parents (r(29)
= –0.69, p < 0.001) and for teachers (r(20) = –0.48, p < 0.05). Only the
pragmatic composite (CCC) was used in further analyses, since it has the
greatest demonstrated reliability and validity of the two measures.
Significant relationships were found between behaviours from different domains
within each group of informants (Table 3). Participants with greater impairments
in social interaction or pragmatic language tended to engage in more repeti-
tive behaviours than participants with lesser impairments. The moderate
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Table 3 Correlations between questionnaire measures

Social Repetitive Pragmatic Social Repetitive Pragmatic


interaction: behaviours: language: interaction: behaviours: language:
parent1 parent1 parent1 teacher1 teacher1 teacher1
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Repetitive behaviours: parent 0.47**


Pragmatic language: parent –0.47** –0.58***
Social interaction: teacher 0.20 0.05 0.17
Repetitive behaviours: teacher 0.43 0.52** –0.18 0.56**
Pragmatic language: teacher 0.04 –0.32 0.41* –0.28 –0.51**

Verbal IQ –0.04 –0.23 0.24 –0.43* –0.22 0.16


Performance IQ –0.12 –0.27 0.47** –0.62** –0.41* 0.66***
1Higher scores indicate greater impairment in social interaction, more repetitive behaviours, and greater pragmatic language abilities.
N ranged from 23 to 35.
*p < 0.05. **p < 0.01. ***p < 0.001.
Age of child was not significantly related to any questionnaire 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).

Play session results


The play session variables were frequency scores indicating the number of
times that the child engaged in each type of behaviour during the play
session. For the imaginative activities (functional play and pretend play),
repetitive behaviours, and social behaviours initiated by the child (social
interaction initiate, joint attention initiate and behaviour regulation
initiate), the frequency scores could potentially have been any value greater
than (or equal to) zero. However, there were maximum possible scores for
the variables reflecting the child’s response to social behaviours. Joint
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Table 4 Group means and standard deviations, and statistics regarding group
differences
(a) Parent-rated questionnaire measures

Variable AD group LD group Univariate Significance Effect size


(N = 22) (N = 14) F-test level
Mean (SD) Mean (SD) (F (1, 34)) (p-value)

Social interaction 5.49 (3.68) 4.43 (3.90) 0.69 0.41 0.14


Repetitive behaviours 17.97 (11.99) 10.08 (8.18) 4.65 0.04 0.37
Pragmatic language 126.55 (14.67) 131.79 (12.31) 1.23 0.28 0.18

(b) Teacher-rated measures

Variable AD group LD group Univariate Significance Effect size


(N = 11) (N = 8) F-test level
Mean (SD) Mean (SD) (F (1, 16)) (p-value)

Social interaction 5.58 (4.06) 5.39 (1.85) 0.07 0.79 0.00


Repetitive behaviours 10.67 (6.81) 2.71 (2.35) 20.83 0.00 1.15
Pragmatic language 116.36 (9.36) 124.25 (9.63) 6.43 0.02 0.64

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.

attention respond and behaviour regulation respond each had a maximum


frequency score of 5. The maximum score for social interaction respond
was 4, because each child was given at least four opportunities to respond
to social interactions initiated by the researcher.
The frequency of children engaging in any types of repetitive behav-
iours during the play session was extremely low (one behaviour observed
in each of three ASD children). Hence this variable was not included in any
further analyses. Two other variables, joint attention respond and behaviour
regulation respond, were also excluded from further analyses because the
majority of participants in each group achieved the maximum score.

Correlations between play variables


The significant correlations between the play variables are shown in Table
5. A moderate positive correlation was found between functional play and
pretend play, and both functional play and pretend play were positively cor-
related with several of the social behaviour variables. Specifically, medium
to strong correlations were found for social interaction initiate with func-
tional and pretend play; and for social interaction respond with both func-
tional and pretend play. Moderate relationships were also found with joint
attention initiate for functional play and for pretend play. Thus, participants
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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 5 Correlations between the play session variables

Functional Pretend Interaction Interaction Attention


play play initiate respond initiate

Pretend play 0.49**


Interaction initiate 0.35* 0.63***
Interaction respond 0.64*** 0.43** 0.48**
Attention initiate 0.49** 0.44** 0.42** 0.39*
Behaviour regulation initiate 0.02 0.20 0.19 –0.02 0.12

‘Interaction’ refers to social interaction; ‘attention’ refers to joint attention.


N = 37.
*p < 0.05. **p < 0.01. ***p < 0.001.

Table 6 Group medians and ranges, and statistical values for group
comparisons on play session variables

Variable AD group LD group Mann–Whitney Significance


(N = 22) (N = 15) test (U-value) level
Median Range Median Range (p-value)

Functional play 5.0 0–12 7.0 5–19 81.0 0.01


Pretend play 2.0 0–7 3.0 0–12 116.0 0.09
Social interaction 2.0 0–7 3.0 0–9 120.5 0.11
initiate
Social interaction 4.0 0–4 4.0 1–4 146.0 0.38
respond
Joint attention 3.0 0–7 6.0 0–15 104.0 0.04
initiate
Behaviour regulation 1.0 0–4 1.0 0–6 131.5 0.21
initiate

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Cluster analysis results
In order to assess whether distinct diagnostic subgroups would emerge (in
particular ASD versus LD children), exploratory cluster analyses were per-
formed to determine whether children could be classified on the basis of
verbal IQ, performance IQ, parent-rated questionnaire measures, and the
six play variables. The teacher-rated questionnaire measures and formally
assessed language measures were excluded from these analyses because of
the number of missing values on these measures. Sample size was reduced
to N = 29, following deletion of cases with missing values on any variables.
Results of SPSS K-means cluster analyses specifying two, three, four or five
clusters were explored.
The two-cluster analysis resulted in a cluster of 13 participants (cluster
A) and a cluster of 16 participants (cluster B). The two clusters differed in
level of functioning: cluster A had a significantly lower verbal IQ and
performance IQ than cluster B, as well as significantly greater impairment
in social interaction, more repetitive behaviours, and poorer pragmatic
language skills, as rated by parents. There were no significant differences
between the two clusters on any of the play variables. There was no corre-
spondence evident between the clusters and the participants’ clinical diag-
noses. Thus, these results were not useful for discriminating between the
identified diagnostic groups and simply added to the considerable body of
findings illustrating differences between children with autistic behaviours
according to level of functioning.
Results of the three-cluster analysis are reported in more detail because
these were considered to be the most interpretable and useful regarding
potential markers for children on the borderlands of autism. Cluster A con-
sisted of nine participants, cluster B consisted of seven participants, and
cluster C consisted of 13 participants. Cluster group means and standard
deviations for the variables that significantly differentiated the three clusters
are shown in Table 7. There were no significant cluster group differences
on any of the play variables, so they are not included in the table. Tukey’s
HSD (Honestly Significant Difference) comparisons indicated that cluster B
had a significantly higher mean verbal IQ than both cluster A (p < 0.01)
and cluster C (p < 0.001), while the latter two group means were not
significantly different. For performance IQ, clusters A and B did not differ
significantly, but both means were significantly higher than the mean
performance IQ for cluster C (p < 0.001). Thus, participants in cluster B
had the highest levels of verbal and non-verbal intellectual functioning and
may be considered the ‘high-functioning’ subgroup. Cluster C had the
lowest levels of verbal and non-verbal intellectual functioning (the ‘low-
functioning’ subgroup). Cluster A did not differ significantly from the low-
functioning cluster on verbal IQ, nor did it differ significantly from the
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Table 7 Cluster group means and standard deviations, and statistics for
comparisons between clusters on significantly differentiating variables

Variable Cluster A Cluster B Cluster C F-test Significance


Mean (SD) Mean (SD) Mean (SD) (F(2, 26) level
(p-value)

Verbal IQ 79.00 (11.88) 98.00 (11.89) 69.08 (7.99) 18.0 0.00


Performance IQ 102.78 (9.20) 105.14 (9.58) 82.15 (10.86) 16.7 0.00
Social interaction 2.25 (1.90) 4.19 (2.63) 6.41 (3.85) 4.89 0.02
Repetitive 6.33 (5.61) 12.88 (8.62) 20.48 (10.40) 7.04 0.00
behaviours
Pragmatic language 139.89 (8.18) 128.00 (8.76) 117.00 (11.07) 14.77 0.00

N = 9 for cluster A, N = 7 for cluster B, and N = 13 for cluster C.

high-functioning cluster on performance IQ. Cluster A thus showed the dis-


crepancy between verbal and non-verbal skills characteristic of children
with LDs
Table 7 also shows descriptive statistics for the parent-rated question-
naire measures for each cluster. Cluster A had the lowest mean level of
impairment in social interaction, the lowest level of repetitive behaviours,
and the greatest pragmatic language abilities. This is the pattern expected
of children with LDs compared with children with autism. In contrast,
cluster C had the highest rated impairment in social interaction, the most
repetitive behaviours, and the greatest impairment in pragmatic language.
Thus, cluster C, the low-functioning subgroup, was rated by parents as
having the highest level of ‘autistic’ features. Cluster B, the high-functioning
subgroup, was intermediate between the other clusters on each of the ques-
tionnaire measures. Tukey’s HSD comparisons indicated that, for each of
these variables, the mean for cluster A was significantly different from the
mean for cluster C (p < 0.01). The means for cluster B did not differ signifi-
cantly from either of the other two clusters, with the exception of the
significant difference between clusters B and C on pragmatic language (p <
0.05).

Cluster and clinical diagnosis concordance


Table 8 shows the concordance between the cluster groups and clinical
diagnosis.‘Other AD’ in this table refers to those in the ASD group not diag-
nosed as Asperger’s disorder or high-functioning autism, but simply diag-
nosed with autism. Half of the diagnosed LD group were placed in cluster
A while the others were spread between B and C, and the majority of
children in cluster A were from the LD diagnosed group. This is consistent
with the fact that cluster A showed the lowest level of autistic features and
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Table 8 Cluster and diagnosis concordance

Cluster High-functioning Asperger’s Other Total AD LD


group AD disorder ADa

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.

a pattern of intellectual functioning consistent with LDs (i.e. average non-


verbal skills and below average verbal skills). Three ASD children were also
in this cluster. The majority of cases in the high-functioning cluster B were
ASD children, with three having a diagnosis of high-functioning autism,
one with Asperger’s disorder, and one diagnosed with autism with an IQ
of 120. This cluster represents high-functioning autism. Two children with
LDs were in this cluster and each had above average performance IQ and
low average or average verbal IQ. More than half of the ASD diagnosed
children were in the low-functioning cluster C, the majority of these with
an ASD diagnosis. However, one had a diagnosis of Asperger’s disorder and
one was diagnosed with high-functioning autism but had a borderline IQ
and was disinterested and uncooperative in the play session. Of the four LD
children in this cluster, two had additional diagnoses of intellectual dis-
ability.

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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impairment in social interaction and pragmatic language than the other
cluster. A three-group cluster analysis resulted in clusters differentiated by
verbal IQ, performance IQ and the parent-rated questionnaire measures.
The three clusters appeared roughly to correspond to the categories of ‘low-
functioning autism’, ‘high-functioning autism’ and ‘language disorders’.
The ‘low-functioning autism’ cluster had low scores on both IQ measures,
and showed the highest levels of repetitive behaviours, impairment in social
interaction, and pragmatic language difficulties. The ‘high-functioning
autism’ cluster had the highest scores on both IQ measures and an inter-
mediate level of behavioural difficulties and pragmatic language abilities.
The ‘language disorders’ cluster had relatively high scores on performance
IQ, low scores on verbal IQ, and the least repetitive behaviours, social
impairment and pragmatic language difficulties. Notably, play variables did
not contribute to cluster differentiation in any analyses.
From this pattern of results, some findings stand out as potentially
useful in diagnostic differentiation between children with autism and those
with LDs. Joint attention clearly differentiated between the two groups,
such that the ASD group initiated sharing attention to an object or event
with the researcher less often than the LD group. Initiating joint attention
requires the use of non-verbal communication, such as gestures and eye
contact, to coordinate attention with the other person to share the experi-
ence (Mundy et al., 1994). The group difference found is consistent with
the conclusion drawn by Fein et al. (1996) that children with autism have
greater deficits in joint attention and non-verbal communicating behav-
iours than children with a language disorder. Children with autism have
also been shown to have greater impairments in initiating joint attention
than developmentally matched typical children, intellectually disabled
children, and children with Down syndrome (Baron-Cohen, 1989; Mundy
et al., 1993; 1994; Sigman et al., 1986; Wetherby and Prutting, 1984;
Wetherby et al., 1997). Mundy et al. (1986) and Sigman et al. (1986) also
found that initiating joint attention was the most pronounced character-
istic specific to the autistic group. The joint attention deficit seems to be a
more integral component of the expression of social impairment in autism
than the other social behaviours measured (Mundy et al., 1994), support-
ing related observations that children with autism use ‘protoimperative’
communicative gestures or vocalization to express their needs, but rarely
use ‘protodeclarative’ gestures, which communicate objects of shared
interest and critically involve joint attention (Baron-Cohen, 1989; Tager-
Flusberg, 1996; 1999). Communicative behaviours of children with autism
are heavily skewed toward behaviour regulation or need-based functions
rather than the social goal of sharing experiences (Wetherby and Prutting,
1984; Wetherby et al., 1997).
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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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the hypothesis that children with autism are impaired at producing creative
and imaginative play, rather than having a specific deficit in pretending. It
has been argued that this impairment is due to a general generativity
problem that includes difficulties generating play schemata (Jarrold et al.,
1993; 1996). However, following this argument, the ASD group would be
expected to show deficits relative to the LD group in pretend play as well
as in functional play, but in fact the group differences were not significant.
Nevertheless, pretend play may not be a feature that differentiates between
children at the milder end of the autistic continuum and children with LDs
who have some behavioural difficulties. Some children with an LD, particu-
larly those with pragmatic impairment, have poorly developed imaginative
play (Bishop and Rosenbloom, 1987). Another possible explanation is
based on the developmental level of the participants. Mundy et al. (1993)
suggested that a disturbance in basic representational skill (reflected in
functional play) may be evident in young children with autism before
deficits in more complicated representational processes (as reflected in
pretend play) are apparent. Following this argument, the trend for the ASD
group to engage in less pretend play than the LD group may be reflecting
an emerging group difference among the older children in the sample. This
highlights the importance of considering developmental changes when
researching these disorders (Mundy et al., 1994). Whether or not the
results generalize to children of different ages or developmental levels
remains a question for future research. However, it is at the early age where
differential diagnosis is a particular challenge.
There was a clear difference between the groups in the greater tendency
of children with autism to engage in restricted, repetitive and stereotyped
patterns of behaviour and interests than children with LDs. This difference
on the teacher-rated repetitive behaviours scale had the largest effect size
of any of the research variables. The parent ratings were consistent with the
teacher ratings, although less decisive. These results highlight repetitive
behaviours as a key variable differentiating the two groups (Bartak et al.,
1975; Waterhouse and Allen, 1996). The fact that few repetitive behaviours
were observed during the play session, especially in children with autism,
is likely to be a result of the tightly structured nature of the play session.
The rigidity and routines seen in the behaviour of these children have been
linked to their need for reduced complexity and uncertainty (Tager-
Flusberg, 1999), and the structure of the play session may have reduced
these challenges for the children.
The ratings of pragmatic language abilities suggested that both the ASD
group and the LD group experienced particular difficulties with pragmatic
language. For both sets of raters, greater impairment was found for the ASD
group than the LD group, but the effect was significant only for the
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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).

Limitations of the study


The small sample size in this study limited statistical power and constrains
the capacity to generalize from the results. This is in part because sampling
was deliberately confined to a particular population of interest – children
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at the borderlands of autism and language disorder (Bishop, 2000a).
Another limitation is the dependence on the accuracy of the diagnoses
given by the autism assessment teams. While the assessment is compre-
hensive and is carried out by experienced clinicians from different disci-
plines who are expert in the differential diagnosis of ASDs, diagnosis is
never infallible. The difficulty is particularly acute with children who may
be on the boundary of overlapping conditions.
The ASD and LD groups were both heterogeneous samples, each com-
prising several subgroups. The LD group consisted of participants with
varying diagnoses within the communication disorders category of DSM-
IV. Grouping subtypes of LDs together may be problematic because different
types of communication disorders appear to be related to different behav-
ioural and social characteristics (Bishop, 2000b; Botting and Conti-
Ramsden, 1999). For example, of all the subtypes of communication
disorders, children with pragmatic impairment are the most likely to have
social and behavioural features characteristic of autism (Bishop and
Rosenbloom, 1987; Gagnon et al., 1997; Lister-Brook and Bowler, 1992).
Although the large majority of children in the ASD group were diag-
nosed with autism, a few had diagnoses of Asperger’s disorder. This
grouping together is justified by recent research suggesting that autism,
Asperger’s disorder and PDD-NOS are all within a spectrum of autistic dis-
orders on which children differ primarily in the severity of their impair-
ments (Mayes and Calhoun, 2001; Prior et al., 1998). In addition, the ASD
and LD groups each consisted of children with varying ages, levels of
development, levels of intellectual functioning, and severity of impair-
ments. Grouping together heterogeneous samples of children may have
reduced the likelihood of detecting differences between the research
groups. However, with a focus especially on young children, sample recruit-
ment limitations prevented comparisons between specific subgroups.
Replication of the research with a larger sample is needed to further
evaluate these findings.

Conclusions and future research directions


This exploratory study of a clinic population of children presenting with
autistic behaviours has helped to illuminate some possible distinctions
between autism and language disorders. However, it may be that no sharp
distinction can be made between these disorders, and that some children
are truly intermediate between the two and cannot be subsumed within
the existing terminology. The results of the study are consistent with
the conceptualization of autism as a continuum varying in the level
of severity of impairments in social interaction, communication, and
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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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