J Autism Dev Disord
DOI 10.1007/s10803-006-0237-4
ORIGINAL PAPER
Social Communication Profiles of Children with Autism
Spectrum Disorders Late in the Second Year of Life
Amy M. Wetherby Æ Nola Watt Æ Lindee Morgan Æ
Stacy Shumway

Springer Science+Business Media, LLC 2006
Abstract This study examined social communication
profiles from behavior samples videotaped between 18
and 24 months of age in three groups of children: 50
with autism spectrum disorders (ASD), 23 with
developmental delays (DD), and 50 with typical
development (TD). The ASD group scored signifi-
cantly lower than the DD group on 5 social commu-
nication measures and the TD group on all 14
measures, indicating distinct profiles late in the second
year. Understanding was the strongest predictor of
developmental level and behavior regulation and
inventory of gestures were the strongest predictors of
autism symptoms at 3 years of age. The predictive
relations suggest five pivotal skills late in the second
year that have a cascading effect on outcomes of
children with ASD.
Keywords Autism Æ ASD Æ Social communication Æ
Early identification Æ Joint attention
A. M. Wetherby (&) Æ N. Watt Æ L. Morgan Æ S. Shumway
Department of Communication Disorders, Florida State
University, RRC 107, Tallahassee, FL 32306-7814, USA
e-mail: awetherb@fsu.edu
Present Address:
N. Watt
Discipline of Speech Pathology and Audiology, School of
Human and Community Development, University of the
Witwatersrand, Johannesburg, South Africa
Present Address:
S. Shumway
Pediatrics and Developmental Neuropsychiatry Branch,
National Institute of Mental Health, National Institutes of
Health, Bethesda, MD, USA
Introduction
Research has consistently documented social commu-
nication deficits as core features of autism spectrum
disorders (ASD; Volkmar, Lord, Bailey, Schultz, &
Klin, 2004). Social communication skills include a
broad array of verbal and nonverbal behaviors used in
reciprocal social interaction. Weaknesses in social
communication are universal in children with ASD
across ages and ability level, in spite of heterogeneity
of language abilities (Tager-Flusberg, Joseph, &
Folstein, 2001). Although impairments in social com-
munication are a hallmark of ASD, relatively little is
known about these deficits in very young children due
to the usual age of diagnosis. While most children with
ASD are not diagnosed until at least 3 years of age, a
diagnosis can be made reliably by experienced clini-
cians at 2 years of age and this diagnosis has been
found to persist a year later in 90% of children studied
(Lord, 1995; Stone et al., 1999). Impairments in social
communication were found to be prominent by 2 years
of age but restricted and repetitive activities and
interests were not evident in some children until closer
to 3 years. Research on social communication deficits
in children under 2 has important implications for
improving early identification and informing genetic,
biological, and intervention research.
A deficit is considered to be core if it distinguishes
children with ASD from children with other develop-
mental delays (DD) and typical development (TD;
Sigman, Dijamco, Gratier, & Rozga, 2004). A large
body of research has identified core deficits in joint
attention and symbolic aspects of communication and
play in children with ASD from 2 to 5 years of age
based on observational studies (Charman et al., 1997;
123

Dawson et al., 2004; Lord, 1995; Mundy Sigman, &
Kasari, 1990; Sigman, Mundy, Sherman, & Ungerer,
1986; Stone, Ousley, Yoder, Hogan, & Hepburn, 1997;
Wetherby, Prizant, & Hutchinson, 1998). Many longi-
tudinal studies have documented a relationship be-
tween responding to and/or initiating gestural joint
attention in 2- to 3-year old children with ASD and
language outcomes 6 months (McDuffie, Yoder, &
Stone, 2005), 1 year (Mundy et al., 1990), and many
years later (Sigman & Ruskin, 1999).
It is possible that joint attention deficits underlie or
contribute to symbolic deficits in children with ASD in
that difficulties establishing a joint attentional focus
may interfere with learning conventional meanings in
language. Dawson et al. (2004) investigated social
attention impairments in relation to language ability in
3- to 4-year old children with ASD, compared to
mental age-matched children with DD and TD. They
found that impairments in social orienting and joint
attention best distinguished the children with ASD
from the comparison groups. Joint attention was the
best predictor of concurrent language ability but social
orienting and attention to distress were correlated with
joint attention, and therefore, may indirectly impact
language ability through their relationship with joint
attention. Research on core social communication
deficits in younger children with ASD may help
elucidate the nature of this relationship.
Social Communication Deficits of Children
with ASD in the Second Year of Life
Preliminary research on the social communication
deficits of children with ASD under 2 years of age is
emerging from three different sources: (a) retrospec-
tive analyses of home videotapes of children later
diagnosed with ASD; (b) parent report of social com-
munication deficits; and (c) prospective systematic
observational studies, and is briefly reviewed below.
Retrospective Analysis of Home Videotapes
The largest cohort of retrospective analyses is from
home videotapes of first birthday parties of children
later diagnosed with ASD. Osterling and Dawson
(1994) found that at 12 months of age, 4 behaviors
distinguished 11 children with ASD from typically
developing children: lack of pointing, showing, looking
at the face of another, and orienting to name. In a
follow-up study, Osterling, Dawson, and Munson
(2002) compared first birthday videotapes of 20 chil-
dren with ASD, 14 with DD, and 20 with TD. They
found that lack of looking at the face of another and
123
J Autism Dev Disord
orienting to name distinguished children with ASD
from those with DD and TD. Pointing and showing
were too infrequent in all three groups for meaningful
analyses. Decreased use of gestures and increased use
of repetitive behaviors distinguished children with
ASD and TD but not children with ASD and DD. No
significant group differences were found in use of
vocalizations.
Werner and Dawson (2005) recently compared first
and second birthday videotapes of 36 children with
ASD, 21 with early onset of symptoms and 15 with
reported regression, and 18 with TD. The early-onset
ASD group differed significantly from the groups with
regression and TD at 12 months on measures of com-
plex babble or words and declarative pointing but no
differences were found on gaze to people, orienting to
name, imperative pointing, affect, or repetitive motor
behavior. By 24 months, both ASD groups differed
from the TD group on complex babble, single words
and phrases, declarative pointing, gaze to people, and
orienting to name. No differences were found on
imperative pointing, affect, appropriate toy play, or
repetitive motor behavior. These findings suggest that
the social communication deficits of children with ASD
based on analysis of home videotapes at 12 and
24 months are not as prominent as those found in re-
search of 2–5 year olds with ASD. The lack of a DD
control group limits knowing whether these patterns
are specific to ASD.
These retrospective studies of home videotapes
demonstrate that impairments in social communication
are evident in children with ASD at 12 and 24 months
and suggest that a broader array of deficits is evident at
24 months than 12 months; however, the findings are
inconsistent across samples. For example, lack of
looking at people and orienting to name distinguished
ASD and TD at 12 months in the Osterling and col-
leagues (1994, 2002) samples but not the Werner and
Dawson (2005) sample. Limited sample sizes may mask
group differences. Furthermore, the sampling contexts
of home videotapes may not have provided sufficient
opportunity for social communicative behaviors, which
also may mask group differences.
Parent Report
Most children with ASD are reported by their parents
to demonstrate symptoms within the first 2 years of
life, based on retrospective accounts (Werner, Dawson,
Munson, & Osterling, 2005; Wimpory, Hobson,
Williams & Nash, 2000). Furthermore, most families
initially express concern to their pediatrician by the
time their child is 18 months old (Howlin & Moore,
J Autism Dev Disord
1997; Siegel, Pliner, Eschler, & Elliot, 1988). Werner
and colleagues (2005) administered an in-depth retro-
spective interview to parents of 72 children with ASD
when the children were 3- to 4-years of age, and
mental-age matched children with DD and TD, to
examine variations in the course of development of
ASD across the first 2 years of life. They found sig-
nificant differences among all three groups in social
symptoms at 13–15 months, repetitive behaviors at
16–18 months, and communication symptoms at 19–
21 months. Based on parent report with the ADI-R at
20 months of age, Cox et al. (1999) found three
behaviors that distinguished 21 children with ASD
from children with language delay—range of facial
expression, use of conventional gesture, and pointing
to indicate interest.
These parent report studies support the findings
from retrospective home videotape analyses that
impairments in social communication skills may be the
earliest indicators of ASD and are evident in the sec-
ond year of life. In addition, findings from parent re-
port suggest that parents of children with ASD may
notice or recall impairments that are not as readily
apparent on home videotapes. It is important to con-
firm and extend these findings with observational data.
Prospective Systematic Observational Studies
Prospective longitudinal designs with general popula-
tion samples screened to identify very young children
with ASD have been used to distinguish these children
from matched samples of children with DD and TD.
Studies of two cohorts identified in the second year of life
have been published. The first cohort consists of children
identified prospectively using the Checklist for Autism
in Toddlers (CHAT; Baron-Cohen et al., 1996). Char-
man et al. (1997) found that 10 children who failed the
CHAT and were diagnosed with ASD at 20 months used
less social gaze in response to distress displayed by the
adult, fewer gaze shifts in response to activation of
mechanical toys, and less imitation of modeled actions
than both the TD and DD groups. Swettenham et al.
(1998) found that during free play these children with
ASD spent less time looking at people and displayed
fewer gaze shifts between people and objects than DD or
TD controls. These findings indicate that deficits in as-
pects of joint attention are evident in children with ASD
at 20 months of age. Charman et al. (2003) found that
measures of joint attention of 18 children with ASD at
20 months of age predicted language at 42 months of
age. In a group of 26 children with ASD with a mean age
of 24.5 months, Charman et al. (2005) found that rate
of communicating during a systematic sample was
significantly associated with language, social, and com-
munication outcome at 7 years of age, while standard
measures of cognitive and language ability at age 2 did
not predict outcome.
The second major prospective cohort was identified
from a general population screen using the Communi-
cation and Symbolic Behavior Scales Developmental
Profile (CSBS; Wetherby & Prizant, 2002) and later
diagnosed with ASD at age 3. Wetherby et al. (2004)
conducted a prospective, longitudinal study to identify
red flags for ASD from videotapes collected during the
second year of life. Three groups of 18 children were
identified, one with ASD with a mean age of
21.0 months, one with DD in which ASD was ruled out
matched on developmental level and age, and one with
TD matched on age. Children with ASD showed sig-
nificant differences from both the DD and TD groups
on nine red flags: (1) lack of appropriate gaze; (2) lack
of warm, joyful expressions with gaze; (3) lack of
sharing enjoyment or interest; (4) lack of response to
name; (5) lack of coordination of gaze, facial expres-
sion, gesture, and sound; (6) lack of showing; (7) unu-
sual prosody; (8) repetitive movements of the body; and
(9) repetitive movements with objects. Children with
ASD showed significant differences from the TD group
but not the DD group on four additional red flags: (1)
lack of response to contextual cues; (2) lack of pointing;
(3) lack of vocalizations with consonants; and (4) lack of
playing with toys conventionally. These differences
correctly classified 94.4% of the sample. These findings
indicate that children with ASD can be identified in the
second year and distinguished from those with DD and
TD based on a combination of lack of typical and
presence of atypical behaviors, and underscore the
importance of social communication along with repet-
itive behaviors in earlier identification of ASD.
These observational studies suggest that by
20 months of age children with ASD have a distinct
profile of social communication; however, they are
based on small sample sizes. Further research utilizing
systematic sampling is needed to provide more precise
measures of core social communication deficits during
the second year of life. This study is part of an ongoing
longitudinal, prospective investigation of the FIRST
WORDS Project to examine social communication
profiles of children with ASD in the second year of life
using systematic observational methods in relation to
later outcomes. Although Wetherby et al. (2004)
studied samples collected across the second year, the
focus of this study was on the second half of the second
year of life because the largest cohort of children
participated in the Project at this age and social com-
munication features are likely to be prominent at this
123

age. Three groups of children were selected for this
study, one group with communication delays who were
later diagnosed with ASD, one group with communi-
cation delays in which ASD was ruled out, and one
group with TD. The first objective of this study was to
compare social communication measured late in the
second year of life across groups. The second objective
was to determine whether social communication mea-
sured late in the second year in the ASD group pre-
dicted nonverbal and verbal developmental level and
severity of autism symptoms at 3 years of age.
Method
Participant Recruitment
There were 123 participants in this study, 50 with a
clinical diagnosis of ASD, 23 with DD in which ASD
had been ruled out, and 50 with TD. Children were
recruited from the ongoing longitudinal, prospective
study of the FIRST WORDS Project, which conducts
screening on a general population sample recruited
from healthcare and childcare agencies to identify
children with communication delays under 24 months
of age (see Wetherby et al., 2004 for details on the
recruitment steps) using the CSBS (Wetherby &
Prizant, 2002). The CSBS includes two measures: (a) a
one-page, 24-item Infant-Toddler Checklist for
screening that can be completed quickly by a parent at
a physician’s office or childcare center, and (b) a
Behavior Sample, which is a face-to-face evaluation of
the child interacting with a parent and clinician that is
videotaped for later analysis. Children participating in
this study met the following selection criteria: (a) the
CSBS Infant-Toddler Checklist was completed by the
family when the child was under 24 months of age; (b)
a CSBS Behavior Sample was videotaped when the
child was over 18 months of age; and (c) the Mullen
Scales of Early Learning (MSEL, Mullen, 1995) was
completed when the child was over 2 years of age.
These 123 participants included the 54 children
reported by Wetherby et al. (2004) using samples
collected over 18 months of age.
Children in the ASD and DD groups were drawn
from a pool of children with a communication delay
during the second year of life based on performance
in the bottom 10th percentile on one or more com-
posites of the Behavior Sample. The children with a
communication delay were divided into two groups,
ASD and DD, based on a follow-up evaluation
completed when the child was at least 30 months
of age to make a best estimate diagnosis, described
123
J Autism Dev Disord
below. Children in the TD group were drawn from a
pool of children who displayed performance above
the 25th percentile on all three composites of the
Behavior Sample during the second year and within
normal limits on the MSEL. Additionally, none of the
TD children were suspected of having ASD by the
parent or clinician when the MSEL was completed.
The DD group was matched group-wise to the ASD
group on the symbolic composite of the CSBS in the
second year. Thus, the DD group formed a compar-
ison group at the same age and developmental level
as the children with ASD. It is important to note that
the DD group included a mixture of children with
global developmental delay and with specific lan-
guage, speech, and/or motor delay, in order to match
the variation in cognitive level of the ASD group. The
TD group was matched individually to the ASD
group on sex and chronological age at the time of the
Behavior Sample.
Best Estimate Diagnosis
A diagnostic evaluation was completed for all chil-
dren with a communication delay when they were at
least 30 months of age by an interdisciplinary team
consisting of a licensed speech–language pathologist
and psychologist. A clinical diagnosis by an experi-
enced clinician is the most stable and reliable method
for diagnosis of ASD in children under 4 years of
age, based on consideration of the child’s history,
developmental level, adaptive functioning, verbal and
nonverbal communication, and level of social
engagement and imagination (Chawarska & Volk-
mar, 2005). The team made a best estimate diagnosis
based on the following measures: (a) the MSEL to
determine nonverbal and verbal developmental level;
(b) the Vineland Adaptive Behavior Scales (VABS;
Survey Interview Form; Sparrow, Balla, & Cicchetti,
1984) to provide an index of adaptive behavior; (c) a
developmental history; (d) the Autism Diagnostic
Observation Schedule (ADOS; Lord, Rutter, DiLa-
vore, & Risi, 1999) to provide a standardized
assessment of communication, social interaction, and
play or imaginative use of materials for the diagnosis
of ASD; and (e) the Social Communication Ques-
tionnaire (SCQ; Lifetime Version; Rutter, Bailey,
Berument, Lord, & Pickles, 2001) to provide parent
report of symptoms of ASD.
The team made a best estimate diagnosis of Autistic
Disorder, Pervasive Developmental Disorder-Not
Otherwise Specified (PDD-NOS), or non-spectrum
based on the DSM-IV diagnostic criteria (APA, 1994).
The term best estimate diagnosis is used because the
J Autism Dev Disord

clinicians were allowed to make a judgment using the
information gathered from the diagnostic evaluation to
make a diagnosis. A diagnosis of Asperger Disorder
was not made or ruled out due to the young age of
these children. Children were assigned to the ASD
group if they received a diagnosis of Autistic Disorder
or PDD-NOS and their communication and social
interaction total on the ADOS fell at or above the cut-
off for autism spectrum; otherwise they were assigned
to the DD group. There was only one child whose
ADOS scores fell above the autism spectrum cut-off
but did not receive a PDD-NOS diagnosis because the
team felt that his heightened scores were due to the
severity of his developmental delay. The ADOS could
not be completed for two children because they lived at
a distance and families could not return for the eval-
uation. Both of these children received a diagnosis of
ASD at 30 months of age or older by a pediatric neu-
rologist, and therefore, were assigned to the ASD
group. Of the 73 children with a communication delay,
50 were assigned to the ASD group and 23 to the DD
group.
In an effort to rule out ASD, families in the TD
group were mailed the SCQ (Rutter et al., 2001), which
is a 40-item parent report tool for diagnostic screening
of ASD appropriate for young children (Corsello,
Cook, & Leventhal, 2003). The SCQ total score of 0
indicates no risk for ASD and 15 or higher indicates
risk for ASD. If the families did not return the SCQ
within 3 weeks, they were sent another copy of the
questionnaire. The SCQ was returned by 26 families,
which is 52% of the children in the TD group. These
children received an average score of 6.1, with a range
from 0 to 12, and all had scores below the cutoff
for ASD.
Participant Demographic and Developmental
Characteristics
A summary of participant demographics is presented
in Table 1. Mervis and Klein-Tasman (2004) recom-
mended a p-value > .50 on tests of group differences to
indicate that groups are well-matched on a variable
and a p-value < .20 to indicate that groups are not
matched on the variable. Using these criteria, all three
groups were well-matched on mother’s and father’s
education and mother’s age, suggesting that the groups
were comparable on socioeconomic status. The ASD
group had slightly more children who were Hispanic
and Asian than the TD group and the DD group had
slightly more children who were African American
than both the ASD and TD groups. Thus, the groups
were fairly similar with regard to most aspects of
demographics.
A summary of participant developmental charac-
teristics for the CSBS Behavior Sample gathered in the
second year and the follow-up diagnostic evaluation
for the three groups is presented in Table 2. The chil-
dren ranged in age from 18.24 to 26.86 months at the
Behavior Sample. The ASD group was well-matched
on age with the TD group using the Mervis and Klein-
Tasman (2004) criterion and minimally-matched with
the DD group. The ASD group was significantly dif-
ferent than the TD group on all three CSBS compos-
ites and the total. The ASD group was well-matched
with the DD group on the symbolic composite only,

Table 1 Summary of participant demographics

Demographic ASD (n = 50) DD (n = 23) TD (n = 50) F-value Pairwise p-value
DD-ASD TD-ASD

Parent’s education in years completed

Mother (M, SD) 15.48a 2.08 15.36a 2.42 15.15a 2.29 0.27 .996 .841
Father (M, SD) 15.73a 2.52 15.40a 2.42 15.44a 2.69 0.21 .938 .923
Parent’s age at child’s birth in years
Mother (M, SD) 31.19a 4.93 32.15a 6.32 31.60a 5.83 0.22 .892 .973
Father (M, SD) 32.99a 6.82 35.72a 5.66 34.18a 6.45 1.53 .232 .766
Males (%) 86.0 82.6 86.0
First born (%) 39.5 39.1 37.5
Ethnicity (%)
Caucasian 70.0 65.2 86.0
African American 16.0 21.7 12.0
Hispanic 10.0 8.7 2.0
Asian 4.0 4.3 0.0
Note: Means in the same row with different subscripts differ significantly at p < .05 on the post-hoc Dunnet T3 comparison
F-values are Welch corrected when necessary for violation of homogeneity of variance as assessed by Levene’s test

123
 J Autism Dev Disord

Table 2 Summary of developmental characteristics

Characteristic ASD (n = 50) DD (n = 23) TD (n = 50) F-value Pairwise p-value
M SD M SD M SD DD-ASD TD-ASD

CSBS DP behavior sampled

Age in months 21.36a 1.90 20.71a 1.58 21.14a 1.72 1.17 .342 .896
Social composite 4.96a 2.37 7.83b 3.33 11.34c 2.39 88.82*** .002 .000
Speech composite 5.84a 2.63 7.30a 2.75 10.38b 2.48 40.08*** .109 .000
Symbolic composite 5.84a 3.07 6.48a 2.39 11.30b 2.58 55.74*** .707 .000
Total 73.86a 12.63 81.78a 12.05 103.50b 11.43 79.39*** .040 .000
Mullen scales of early learninge
Age in months 37.74a 9.61 36.37a 6.01 35.98a 5.11 0.64 .843 .593
Nonverbal DQ 76.73a 25.19 86.16a 21.41 115.25b 16.90 45.51*** .282 .000
Verbal DQ 67.38a 31.12 79.43a 21.84 109.88b 16.78 43.83*** .177 .000
Vineland adaptive behavior scalesf
Age in months 42.13a 13.41 44.58a 10.93 0.66 .422
Communication 74.60a 17.50 81.30a 16.52 2.41 .128
Daily living 72.84a 13.28 81.48a 20.28 3.42 .074
Social 74.16a 16.20 85.70b 17.97 6.70* .013
Motor 78.56a 14.09 76.43a 24.36 0.15 .702
Adaptive behavior 70.27a 13.67 78.04a 19.95 2.82 .103
Note: Means in the same row with different subscripts differ significantly at p < .05 on the post-hoc Dunnet T3 comparison
F-values are Welch corrected when necessary for violation of homogeneity of variance as assessed by Levene’s test
d
Standard Scores based on a M of 10 and SD of 3 for the Composite and M of 100 and SD of 15 for the Total
e
Developmental Quotients (DQ) based on age equivalent divided by chronological age multiplied by 100
f
Standard Scores based on a M of 100 and SD of 15
* p < .05, ** p < .01, *** p < .001

indicating they were matched on development level in
the second year.
A DQ based on age equivalent divided by chrono-
logical age multiplied by 100, was used to more fully
characterize individual variation. A nonverbal DQ was
calculated from the average of the fine motor and visual
reception scales, and a verbal DQ was calculated from
the average of the receptive and expressive language
scales. The MSEL scores presented in Table 2 indicate
that the ASD and DD groups show a wide range of
cognitive functioning. As expected, the ASD group was
significantly different than the TD group on nonverbal
and verbal DQ. The ASD group was not significantly
different than the DD group on nonverbal DQ. The
mean verbal DQ for the ASD group was slightly but not
significantly lower than that for the DD group, however,
the large variance for the ASD group may limit the
ability to detect group differences. On the VABS, also
presented in Table 2, the ASD group was not signifi-
cantly different than the DD group on only the motor
domain, with small non-significant differences on the
communication and daily living domains and significant
differences on the social domain. This sample represents
the diversity of verbal and nonverbal skills found in this
population, with more than half of the sample being
relatively higher functioning (nonverbal DQ > 70); 38%
had a nonverbal DQ below 70. The DD group was
comprised of 39% who had a nonverbal DQ below 70,
26% with specific language delay, and 35% with speech
and/or fine motor delay.
The mean age at the time of the ADOS was
44.18 months (SD = 14.09) for the ASD group and
44.76 months (SD = 10.11) for the DD group, which was
not significantly different, F = 0.04, p = .845. There
were 27 children in the ASD group (54%) who received
a best estimate diagnosis of autistic disorder and 23
(46%) who received a diagnosis of PDD-NOS. The
mean ADOS communication and social total algorithm
score was 13.94 (SD = 4.25) for the ASD group and 3.91
(SD = 3.29) for the DD group, which was significantly
different, F = 114.59, p = .000. Based on performance at
the time of the diagnostic evaluation, 40 children in the
ASD group (80%) and 21 in the DD group (91%) used at
least five words regularly with communicative intent; 25
children in the ASD group (50%) and 17 in the DD
group (74%) used flexible word combinations.
Social Communication Measures from the Second
Year of Life
The CSBS Behavior Sample was collected using
the standard sampling procedures and materials

123
J Autism Dev Disord
(Wetherby & Prizant, 2002). A child’s caregiver was
present and instructed to respond naturally, but not
to direct the child’s behavior, in order to encourage
spontaneous communication and play. The evaluation
session began with a warm-up of about 10 min and
lasted 30–40 min. The Behavior Sample uses a stan-
dard set of systematic procedures designed to
encourage spontaneous behavior that range in degree
of structure. The child is first presented with com-
municative temptations to entice spontaneous com-
munication using a windup toy, balloon, bubbles, jar
with food, bag with toys, and picture books, and then
presented with a feeding toy set and stuffed animal
to play symbolically and blocks to play construc-
tively. The sample is divided into six activities during
which the child’s social communication skills are
rated and includes probes of gaze/point follow and
comprehension of object names, person names, and
body parts. The Behavior Sample was videotaped
and scored using the standard procedures by one of
four trained examiners who were blind to the child’s
diagnosis.
Information about the reliability and validity of
the CSBS has been reported in Wetherby, Allen,
Cleary, Kublin, and Goldstein (2002), Wetherby,
Goldstein, Cleary, Allen, and Kublin (2003), and
Wetherby and Prizant (2002). The CSBS was found
to have high internal consistency (a coefficients
ranging from .86 to .92) and good test–retest reli-
ability over a 4-month interval. Construct and con-
current validity have been supported by the
developmental progression of scores from 12 to
24 months of age, inter-correlations among cluster
and composite scores, and correlations between the
parent report measures and the Behavior Sample.
The three composites of the Checklist and Behavior
Sample were a significant predictor of receptive and
expressive language outcomes at 2 and 3 years of age
and the Behavior Sample explained a significant
amount of unique variance in language outcomes
beyond the Checklist. Thus, the CSBS Checklist and
Behavior Sample are appropriate evaluation tools for
children with developmental delays from 12 to
24 months of age.
For this study, the raw scores were used for 14 items
of the CSBS Behavior Sample that form the social,
speech, and symbolic composites. Following are
descriptions of each.
Gaze Shifts
The number of activities out of 6 during which the child
displays a gaze shift to measure social referencing of
objects with alternating gaze and must be a 3-point
gaze shift (i.e., person–object–person or object–
person–object).
Shared Positive Affect
The number of activities out of 6 during which the child
displays shared positive affect to measure social ref-
erencing of positive affect defined as a clear facial
expression of pleasure or excitement that is directed
with gaze to another person.
Gaze/Point Follow
The number of times that the child looks where the
clinician is pointing and looking out of 2 trials, one to
the side of the child and one behind the child, to
measure the ability to follow the regard of another
person’s gaze and point at a distance and is also
referred to as responding to joint attention.
Rate of Communicating
The number of communicative acts used with a maxi-
mum of 3 per activity out of 18 to measure the rate of
vocal or gestural communicative signals that serve a
communicative function.
Acts for Behavior Regulation
The number of activities out of 6 during which the child
communicates for behavior regulation to measure the
use of vocal or gestural communicative acts to regulate
the behavior of another person to request or protest an
object or action.
Acts for Social Interaction
The number of activities out of 6 during which the child
communicates for social interaction to measure the use
of vocal or gestural communicative acts to draw
attention to oneself to get the other person to look at,
notice, or comfort him/her.
Acts for Joint Attention
The number of activities out of 6 during which the child
communicates for joint attention to measure the use of
vocal or gestural communicative acts to direct atten-
tion to an object to get the other person to look at or
notice something of interest.
123

Inventory of Gestures
The number of different conventional gestures dis-
played with a maximum of 8 (i.e., give, push away,
reach, show, point, wave, head shake, head nod).
Inventory of Consonants
The number of different consonants produced with a
maximum of 10 (e.g., b, d, g, m, n).
Inventory of Words
The number of different words (i.e., forms that are
used referentially and that approximate conventional
words, spoken or signed) produced with a maximum of
16.
Understanding
The sum of the number of object names out of 3 pos-
sible, person names out of 2 possible, plus body parts
out of 3 possible with a maximum of 8 to measure
understanding single words without gestural cues.
Inventory of Actions
The number of different functional actions used with
objects during play with a maximum of 12.
Pretend Play Actions
The number of pretend actions with objects toward
other (i.e., adult or stuffed animal) used during play
with a maximum of 6.
Stacking Blocks
The number of blocks stacked to measure the ability
to use one object in combination with another to
construct in play with a maximum of 5.
Inter-rater Reliability
Inter-rater reliability for the CSBS Behavior Sample
was calculated using generalizability (g) coefficients for
pairs of four independent raters on randomly selected
videotapes for at least 20% of the samples scored by
each rater. G coefficients that are at least .60 are
considered acceptable for demonstrating inter-rater
reliability (Mitchell, 1979). Rater one scored the larg-
est number of samples and therefore was considered
the expert to which the other raters were compared.
123
J Autism Dev Disord
The g coefficients for the social communication mea-
sures ranged from .76 to 1.00, with an average of .91,
indicating that the raters exhibited high inter-rater
reliability.
Results
Group Differences in Social Communication
Measures
The mean scores on each of the social communication
measures from the CSBS Behavior Sample are pre-
sented in Table 3. A series of one-way analyses of
variance (ANOVA) were conducted to evaluate group
differences using a Welch correction for lack of
homogeneous variances. Significant group differences
were found for all 14 social communication measures.
Post-hoc tests were conducted using Dunnet T3
method to evaluate pairwise differences among means.
There were significant differences between the ASD
and TD groups with large effect sizes on all 14 mea-
sures. There were significant differences between the
ASD and DD groups with large effect sizes on gaze
shifts, gaze/point follow, rate of communicating, and
acts for joint attention and a significant difference with
a medium effect size on inventory of conventional
gestures. There were non-significant differences be-
tween the ASD and DD groups with medium effect
sizes on shared positive affect, acts for social interac-
tion, and pretend play actions and with small or minimal
effect sizes on acts for behavior regulation, inventory
of consonants, inventory of words, understanding,
inventory of play actions, and stacking blocks.
Intercorrelations among the Social Communication
Measures for the ASD Group
To examine concurrent relations among the social
communication measures, Pearson product-moment
correlation coefficients controlling for the effects of
age were computed for the ASD group and are pre-
sented in Table 4. As expected, moderate to large
correlations were observed among most of the social
communication measures. Large correlations were
observed between gaze shifts and shared positive affect
but small correlations were found between each of
these measures and measures in the speech and sym-
bolic composite. Small to moderate correlations were
observed between acts for social interaction and all
other measures, except understanding, for which a
large correlation was found. Additionally, small
J Autism Dev Disord

Table 3 Group differences in social communication measures

Social communication ASD DD (n = 23) TD (n = 50) F-value Pairwise group differences
measures (n = 50)
DD-ASD TD-ASD
d
M SD M SD M SD p value Effect size p value Effect sized

Social composite
Gaze shifts 4.02a 2.06 5.48b 0.85 5.88b 0.33 21.55*** .000 1.00 .000 1.56
Shared positive affect 2.24a 1.73 3.13ab 1.82 4.20b 1.51 18.10*** .154 0.50 .000 1.21
Gaze/point follow 0.66a 0.82 1.39b 0.78 1.92c 0.27 54.81*** .002 0.91 .000 2.31
Rate of communicating 10.60a 5.34 14.65b 4.42 17.46c 1.52 40.58*** .004 0.83 .000 2.00
Acts for behavior regulation 4.50a 1.58 4.91a 1.20 5.68b 0.59 14.86*** .529 0.29 .000 1.09
Acts for social interaction 0.86a 1.31 1.83ab 1.64 2.70b 1.81 17.16*** .052 0.66 .000 1.18
Acts for joint attention 1.30a 1.73 3.35b 2.17 4.52b 1.36 52.95*** .001 1.05 .000 2.08
Inventory of gestures 2.64a 1.47 3.70b 1.71 5.24c 1.15 48.99*** .044 0.67 .000 1.98
Speech composite
Inventory of consonants 1.84a 2.17 2.74a 2.47 5.30b 2.23 31.47*** .363 0.39 .000 1.57
Inventory of words 1.42a 3.25 2.13a 2.58 7.50b 5.69 21.99*** .681 0.24 .000 1.36
Symbolic composite
Understanding 1.68a 2.49 1.96a 2.21 5.76b 2.48 39.01*** .950 0.12 .000 1.65
Inventory of play actions 4.30a 2.59 5.30a 2.16 7.42b 1.28 33.67*** .243 0.42 .000 1.61
Pretend play actions 1.24a 1.52 2.00a 1.48 3.44b 1.13 35.32*** .138 0.51 .000 1.66
Stacking blocks 3.10a 1.80 2.61a 1.53 4.54b 1.15 20.68*** .546 –0.29 .000 0.98

Note: Means in the same row with different subscripts differ significantly at p < .05 on the post-hoc Dunnet T3 corrected comparison
F-values are Welch corrected when necessary for violation of homogeneity of variance as assessed by Levene’s test
d
Effect size based on Cohen’s d ‡ .20 is small, .50 is medium, and .80 is large
* p < .05, ** p < .01, *** p < .001

Table 4 Intercorrelations among the social communication measures for the ASD group (n = 50)
Social communication measures 1 2 3 4 5 6 7 8 9 10 11 12 13

Social composite
1. Gaze shifts
2. Shared positive affect .71***
3. Gaze/point follow .29* .18
4. Rate of communicating .47** .51*** .36*
5. Acts for behavior regulation .37** .35* .36* .87***
6. Acts for social interaction .28 .28* .21 .45** .18
7. Acts for joint attention .51*** .45** .37** .74*** .58*** .44**
8. Inventory of gestures .45** .37** .50*** .66*** .66*** .32* .67***
Speech composite
9. Inventory of consonants .34* .28* .48*** .65*** .54*** .42** .60*** .61***
10. Inventory of words .16 .11 .48** .48** .32* .46** .54*** .46** .86***
Symbolic composite
11. Understanding .13 .18 .61*** .54*** .38** .55*** .61*** .58*** .52*** .59***
12. Inventory of play actions .26 .32* .52*** .68*** .68*** .28* .55*** .62*** .60*** .44** .51***
13. Pretend play actions .29* .34* .40** .69** .58*** .33* .71*** .64*** .60*** .54*** .60*** .75***
14. Stacking blocks .18 .21 .21 .44** .45** .09 .35* .41** .46* .21 .28* .45** .38**

Note: Intercorrelations are Pearson partial correlation coefficients controlling for age
* p < .05, ** p < .01, *** p < .001

correlations were observed between stacking blocks
and gaze/point follow, inventory of words, and
understanding.
Predictive Relations with Developmental Outcome
To examine predictive relations between early social
communication measures and developmental outcome
at 3 years, bivariate correlations between the social
communication measures gathered in the second year
of life and nonverbal and verbal DQ were computed
for children in the ASD group who had a MSEL
completed at 36 months of age or older (n = 42).
Pearson correlation coefficients controlling for the ef-
fects of age are presented in the left two columns of
Table 5. Individual variation on all of the social

123
 J Autism Dev Disord

Table 5 Correlations among

Social communication measures Controlling for age Controlling for age
the social communication
and understanding
measures in the second year
and nonverbal and verbal DQ Nonverbal DQ Verbal DQ Nonverbal DQ Verbal DQ
at 3 years of age for children
with autism spectrum Social composite
disorder (n = 42) Gaze shifts .10 .08 .11 .08
Shared positive affect .03 .01 –.00 –.03
Gaze/point follow .41* .40* .15 .09
Rate of communicating .56** .53*** .37* .31
Acts for behavior regulation .56*** .44** .50** .35*
Acts for social interaction .29 .39* –.13 –.02
Acts for joint attention .48** .48** .19 .17
Inventory of gestures .62*** .42** .46** .14
Note: Nonverbal and Verbal
Speech composite
Developmental Quotients
Inventory of consonants .58*** .57*** .39* .35*
(DQ) are based on age
Inventory of words .44** .53*** .08 .18
equivalent divided by
Symbolic composite
chronological age multiplied
Understanding .62*** .67***
by 100 on the Mullen Scales
Inventory of play actions .52** .45** .36* .24
of Early Learning
Pretend play actions .45** .51** .18 .25
* p < .05, ** p < .01, Stacking blocks .51** .32* .45** .20
*** p < .001

communication measures except gaze shifts, shared
positive affect, and acts for social interaction was found
to correlate significantly with nonverbal DQ at 3 years
of age. Similar patterns of effect size and level of
significance were found for verbal DQ except that a
moderate significant relation was observed between
verbal DQ and acts for social interaction. Additionally,
inventory of conventional gestures showed a larger
correlation with nonverbal DQ and inventory of words
with verbal DQ.
The large, significant correlation observed between
understanding and both nonverbal and verbal DQ
suggests that this is the best indicator of develop-
mental level measured in the second year. Therefore,
the relationship between the other social communi-
cation measures and DQ while controlling for
understanding and age was explored and the partial
correlations are presented in the right two columns
of Table 5. When controlling for age and under-
standing, nonverbal DQ was predicted by rate of
communicating, acts for behavior regulation, inven-
tory of gestures, inventory of consonants, inventory
of play actions, and stacking blocks; verbal DQ was
predicted by acts for behavior regulation and inven-
tory of consonants.
Predictive Relations with Severity of Autism
Symptoms
To examine predictive relations between early social
communication abilities and autism symptoms at
3 years, bivariate correlations between the social
communication measures gathered in the second year
of life and severity of autism symptoms based on the
ADOS algorithm totals for the communication and
social interaction domains were examined. It should
be noted that higher ADOS scores indicate more
severe symptoms of autism. Correlations were com-
puted for the ASD (n = 48) and DD (n = 22) groups
combined to examine the relations between early
social communication measures in children with
communication delays and severity of autism symp-
toms at 3 years of age and are presented in the left
two columns of Table 6. Significant negative corre-
lations were observed between all of the early social
communication measures and the communication
and/or social interaction ADOS algorithm totals at
3 years of age with the exceptions of inventory of
words, understanding, and stacking blocks. Correla-
tions were also computed for the ASD group only
and are presented in the right two columns of Ta-
ble 6. Significant negative correlations were observed
between the following six early social communication
measures and the communication total on the
ADOS—rate of communicating, acts for behavior
regulation, inventory of gestures, inventory of con-
sonants, inventory of play actions, and pretend play
actions. Only acts for behavior regulation and
inventory of gestures were significantly related to the
social interaction total on the ADOS. The smaller
correlations with the ASD group only are expected
given the more limited variance both in the early
social communication measures and the ADOS
scores within this group than the combined groups.

123
J Autism Dev Disord

Table 6 Correlations among

CSBS DP ADOS algorithm totals
the social communication
measures in the second year ASD and DD groups ASD group only
and autism symptoms at
3 years of age for children Social communication Communication Social Communication Social
with ASD (n = 42) and DD measures interaction interaction
(n = 22)
Social composite
Gaze shifts –.32** –.32** –.17 –.08
Shared positive affect –.28* –.17 –.19 .03
Gaze/point follow –.35** –.41*** –.11 –.12
Rate of communicating –.45*** –.39** –.35* –.22
Acts for behavior regulation –.34** –.28* –.40** –.34*
Acts for social interaction –.29* –.21 –.02 .12
Acts for joint attention –.39** –.39** –.14 –.05
Inventory of gestures –.39** –.39** –.36* –.32*
Speech composite
Inventory of consonants –.40** –.30* –.34* –.18
Inventory of words –.20 –.19 –.10 –.10
Symbolic composite
Understanding –.08 –.08 –.02 –.09
Inventory of play actions –.42*** –.32** –.38* –.26
Pretend play actions –.43*** –.34** –.38* –.26
* p < .05, ** p < .01,
Stacking blocks –.02 –.04 –.05 .03
*** p < .001

Discussion
This prospective, longitudinal study examined social
communication measures of children with ASD late in
the second year of life with a mean age of 21.36 months
(SD = 1.90) in comparison to children with DD and
TD and in relation to outcomes at 3 years of age. This
discussion highlights the core social communication
deficits in these children with ASD and predictive
relations of social communication in the second year
with developmental level and severity of autism
symptoms at 3 years of age. Implications for improving
early identification and understanding early social
communication development in ASD are discussed.
Core Social Communication Deficits in Children
with ASD Late in the Second Year
The children with ASD scored significantly lower than
the age-matched children in the TD group on all social
communication measures. These results are based on a
larger sample than previous research and confirm pre-
vious findings that social communication deficits are
evident in children with ASD between 18 and 24 months
of age. These findings demonstrate that deficits in social
communication in children with ASD under 2 years of
age can be detected on standardized measures of social
communication using systematic observation, such as
the CSBS, which has important implications for
improving early identification. This is a particularly
important finding given that more than half of the ASD
group in this study was high functioning.
Compared to children with DD matched on age and
developmental level, children with ASD performed
significantly lower on five social communication
measures—gaze shifts, gaze/point follow, rate of com-
municating, acts for joint attention, and inventory of
conventional gestures. All of these skills have been
found to distinguish older preschool children with ASD
from children with DD and TD (Mundy et al., 1990;
Stone et al., 1997; Wetherby et al., 1998; Dawson et al.,
2004). These findings suggest that these five social
communication skills are core deficits of ASD in the
second year of life and should be evident by 18–
24 months of age. The findings of Wetherby et al.
(2004) and Werner et al. (2005) suggest that repetitive
behaviors and restricted interests are also likely to be
evident at this age or earlier. Future research should
examine more precise measures of social communica-
tion and repetitive behaviors and restricted interests in
the second year to better understand the ontogeny of
core deficits across domains.
It is important to consider limitations of this study in
interpreting findings. One limitation is that this sample
was heterogeneous in developmental level and the
social communication profile identified may not be the
same in subgroups. It would be informative to examine
social communication profiles in children with low
versus high developmental levels separately. Second,
the sampling procedures of the CSBS provide sup-
port to structure interactions that may limit group

123

differences. The children with ASD may have used
more or higher-level social communication skills dur-
ing the sample than in unstructured natural environ-
ments. Additionally, the CSBS sampling opportunities
and restricted range of scores may limit group differ-
ences. For example, children in all three groups used
more acts for behavior regulation and joint attention
than social interaction, and therefore, there may have
been insufficient opportunities to detect differences
between the ASD and DD groups on acts for social
interaction. Finally, matching the ASD and DD groups
on the symbolic composite may have limited group dif-
ferences on items within this composite. Wetherby et al.
(1998) matched groups on expressive language and
found significant differences in symbolic play between
slightly older children with ASD and DD, in addition
to the core deficits identified in the present study.
These findings support the use of a multilevel
screening and evaluation process to sift out children
with ASD from a general pediatric population. It can
be very challenging to inform a family that their young
child has ASD, whether they recognize that their child
is delayed or not. The CSBS maximizes the role of the
family by having parents complete the Infant-Toddler
Checklist and participate in the Behavior Sample. The
CSBS can be used with a general pediatric population
to inform the family that their child has a social com-
munication delay, which puts their child at risk for
ASD. For children who show the collection of core
deficits identified in this study, the next step should be
a systematic rating of red flags of ASD (see Wetherby
et al., 2004) and/or referral for a diagnostic evaluation.
It may be the combination of social communication
deficits with repetitive behaviors and restricted inter-
ests that should alert professionals to consider a diag-
nosis of ASD. Building consensus with the family on
the child’s social communication profile may be an
important initial step to get a family ready to consider
a diagnosis of ASD and enter early intervention.
Predicting Outcomes at 3 Years from Social
Communication Late in the Second Year
The heterogeneity of developmental functioning in
children with ASD was reflected in this sample at
outcome and found to be related to individual varia-
tion in many social communication skills in the second
year of life. Understanding was the strongest predictor
of both nonverbal and verbal developmental outcome;
however, the other social communication measures
showed moderate to large correlations with develop-
mental outcome with only two exceptions. Gaze shifts
and shared positive affect were not related to devel-
123
J Autism Dev Disord
opmental outcome. For the children with ASD
between 18 and 24 months, the best predictors of
nonverbal skills at 3 years were understanding, rate of
communicating, acts for behavior regulation, inventory
of conventional gestures, inventory of consonants,
inventory of conventional actions in play, and stacking
blocks. The best predictors of verbal skills at 3 years
were understanding, acts for behavior regulation, and
inventory of consonants.
For the combined group of children with commu-
nication delays (i.e., ASD and DD groups combined),
all of the social communication measures from the
second year predicted severity of autism symptoms at
3 years with three exceptions. Inventory of words,
understanding, and stacking blocks in the second year
were not related to the ADOS totals at 3 years. For the
children with ASD between 18 and 24 months, the best
predictors of autism symptoms in the social interaction
domain at 3 years were acts for behavior regulation
and inventory of conventional gestures. There was a
larger set of significant predictors of autism symptoms
in the communication domain which included acts for
behavior regulation and inventory of conventional
gestures, but also rate of communicating, inventory of
consonants, inventory of conventional actions in play,
and pretend play actions.
The Social Communication Phenotype of ASD
Late in the Second Year
These findings contribute to a better understanding of
the social communication phenotype of children with
ASD late in the second year of life and relationships
with developmental level and severity of autism
symptoms at 3 years. The results suggest that social
communication deficits of young children with ASD
are multifaceted, with some components shared with
children with DD and others unique to ASD. We will
examine the following components of social commu-
nication and suggest that these are pivotal skills that
through a transactional process have a cascading effect
on outcomes: communicative intentions, conventional
behaviors, representation, social referencing, and rate
of communicating.
Communicative Intentions
Typical children communicate for behavior regulation,
social interaction, and joint attention by the end of the
first year before the emergence of words (Bruner, 1981;
Wetherby & Prizant, 1993). Wetherby (1986) sug-
gested that the easiest and first emerging communica-
tive intention for children with autism is behavior
J Autism Dev Disord
regulation and the most difficult is joint attention,
presumably because of the differing social underpin-
nings. This ontogeny has been supported by Stone and
Caro-Martinez (1990) in children with ASD ranging
from 4 to 13 years of age and by Wetherby et al. (1998)
in 2–4 year old children. The present study extends
those findings down to 18–24 months. Compared to the
children with DD, these children with ASD were
comparable on acts for behavior regulation, slightly
lower on acts for social interaction, and significantly
lower on acts for joint attention.
The predictive relations between acts for behavior
regulation and both nonverbal and verbal develop-
mental outcomes as well as severity of autism symp-
toms in both the communication and social
interaction domains suggest that this is a pivotal skill
that has a cascading effect on cognitive, social, and
language development in very young children with
ASD. The relative strengths that children with ASD
may have in communicating for behavior regulation at
18–24 months may be used to bootstrap other skills.
Furthermore, communicating for social interaction to
draw attention to self may be inherently easier than
communicating for joint attention for children with
ASD because it does not require the triadic coordi-
nation of attention between another person and an
object. Dyadic coordination of shared attention may
be the next step after children with ASD can com-
municate for behavior regulation and may be another
bootstrapping mechanism to learn social contingen-
cies. As suggested by Dawson et al. (2004), engaging
more in early successful exchanges, even if only to
meet environmental needs, could help children
attend to the social cues of their caregivers and learn
the inherent value of communicating with people,
thus enhancing communication for other intentions
later.
Conventional Behaviors
The capacity to acquire conventional behaviors is
triggered by children using active learning strategies
that involve exploring objects, observing others, and
learning in social exchange through imitation (Bates,
1979; McLean & Snyder-McLean, 1999; Meltzoff,
2004). For both inventory of conventional gestures and
play actions, the ASD group had large deficits com-
pared to the TD group and moderate deficits compared
to the DD group. The predictive relations between
these early conventional behaviors and both nonverbal
DQ and autism symptoms suggest that these are
pivotal skills that may impact cognitive and social
development in young children with ASD. This may
reflect a transactional process in that caregivers are
better able to be responsive to children who initiate
with conventional behaviors. Group differences in
inventory of conventional gestures were greater than
group differences in inventory of play actions. This is
consistent with studies of imitation in children with
ASD that have documented greater difficulty imitating
actions without objects than with objects (McDuffie,
Yoder, & Stone, 2005; Williams, Whiten, & Singh,
2004). Thus, difficulty imitating actions without objects
may hinder learning conventional gestures and objects
may provide a scaffold for learning conventional actions
in play.
Representation
Like children with DD, children with ASD are delayed
at 18–24 months in symbolic skills or the capacity for
representation across domains. The combination of
understanding, inventory of play actions, and stacking
blocks was the best predictor of nonverbal represen-
tation, which suggests that boosting these early repre-
sentational skills would have a positive impact on
developmental outcome. However, it is noteworthy
that understanding, stacking blocks, and inventory of
words were independent of autism symptoms. Thus, it
appears that the conventional aspect of play, not the
representational aspect, is a significant predictor of
autism symptoms.
Both gaze/point follow and initiating joint attention
were core deficits in these children with ASD at 18–
24 months and showed moderate relations with non-
verbal and verbal DQ at 3 years, consistent with pre-
vious research. However, after controlling for
understanding, gaze/point follow and acts for joint
attention were no longer significant predictors, sug-
gesting that it is the representational aspect of these
skills that is predictive of developmental outcome. This
is noteworthy considering the important role of gaze/
point follow as a predictor of later joint attention and
language outcome for older children with ASD
(Sigman & Ruskin, 1999) and as a potential moderator
of the effects of intervention on language outcomes
(Bono, Daley, & Sigman, 2004). Joint attention deficits
may not have been unique predictors of outcome at
this young age because so many of the children with
ASD were so deficient on these skills in the second
year of life. It is not until children with ASD are a little
older that individual variation in joint attention skills is
a unique predictor of language and other develop-
mental outcomes.
123

The ASD group was comparable to the DD group
on inventory of consonants and words, suggesting that
these deficits are not specific to ASD. Although a very
large correlation was observed between inventory of
consonants and inventory of words, only inventory of
consonants was a significant predictor of nonverbal and
verbal DQ, after controlling for understanding.
Inventory of words was not related to developmental
level or autism severity. Thus, the capacity to produce
well-formed canonical syllables is another pivotal skill
for these young children with ASD. While it may seem
surprising that inventory of consonants would be re-
lated to representational skills and predict nonverbal
DQ, caregivers are more likely to model language in
response to their children’s use of canonical vocaliza-
tions; therefore, children with a larger inventory of
consonants in communicative acts will likely be ex-
posed to more words within a meaningful interaction
(Yoder & Warren, 1999).
Social Referencing
Children with ASD in this sample showed a collection
of core deficits that reflect difficulty with social refer-
encing. By 9 months of age, typical children actively
observe and shift gaze between people and objects to
see if their caregiver is attending to their focus of
interest (Bakeman & Adamson, 1984) and are able to
coordinate gaze with the expression of emotional states
to share affect. In this study, a very large correlation
was found between gaze shifts and shared positive af-
fect in the children with ASD (r = .71). These skills
showed relatively small or negligible correlations with
representational skills and were not significant predic-
tors of either developmental outcome or autism
symptoms. Thus, the core deficit in gaze shifts through
its relationship with shared affect, communicative
intentions, and conventional behavior may have a
cascading effect on developmental outcome and autism
symptoms. These findings are consistent with those of
Dawson et al. (2004) on 3- and 4-year olds with ASD
that impairments in social attention were related to
joint attention but not concurrent measures of lan-
guage.
Rate of Communicating
Rate of communicating was a core deficit of ASD at
18–24 months that reflects the combined repertoire of
social communicative skills. Moderate to large inter-
correlations were found between rate of communicat-
ing and all of the other social communication
measures, which suggests that it is a useful index of
123
J Autism Dev Disord
initiating and responding to social bids. Rate of
communicating showed moderate correlations with
nonverbal and verbal DQ when controlling for
understanding and with autism symptoms in the com-
munication domain, consistent with the predictive
relations reported by Charman et al. (2005) between
rate of communicating and outcome at 7 years. These
predictive relations may reflect a transactional process
in that children with higher rates of communicating are
more likely to impact their social environment by
creating more opportunities for interacting and
engagement.
Building on previous work of Mundy and col-
leagues, Mundy and Burnette (2005) have eloquently
presented a neurodevelopmental model of ASD. They
suggested that an initial neurological deficit in infants
with autism leads to an early impairment in social
orienting and joint attention, which contributes to
subsequent neurodevelopmental pathology by an
attenuation of social input. This transactional process
can lead to a cumulative spiraling that may compro-
mise subsequent neurological and behavioral devel-
opment or possibly be ameliorated through early
intervention. The findings of the present study suggest
that by 18–24 months of age there are five core social
communication deficits of ASD—gaze shifts, gaze/
point follow, rate of communicating, acts for joint
attention, and inventory of gestures. These core defi-
cits may attenuate the quality of the social input that
children with ASD are exposed to very early in life.
Future research should examine social communication
skills in even younger children with ASD and the
relation between social communication skills and
repetitive behavior and restricted interests in the
second year of life to elucidate the ontogeny of aut-
ism symptoms. We have proposed that these core
social communication deficits are related to a set of
pivotal component skills in the second year that im-
pacts the quality of the social environment and
through a transactional process has a cascading effect
on developmental outcome and autism symptoms at
3 years of age. These pivotal skills may be critical
targets to consider in early intervention to enhance
social communication skills that are likely to impact
the social environment, and thus, lead to better
outcomes for children with ASD.
Acknowledgments This research was supported in part by two
grants from the U.S. Department of Education, Office of Special
Education and Rehabilitation Services (H324M010071 and
H324C030112) and a grant from the U.S. Department of Edu-
cation, Institute of Education Sciences (R305T010262). The au-
thors would like to thank the families who gave their time to
participate in this project.
J Autism Dev Disord
References
American Psychiatric Association (1994). Diagnostic and statis-
tical manual of mental disorders (4th ed.). Washington, D.C.:
APA.
Bakeman, R., & Adamson, L. (1984). Coordinating attention to
people and objects in mother–infant and peer–infant inter-
action. Child Development, 55, 1278–1289.
Baron-Cohen, S., Cox, A., Baird, G., Swettenham, J., Nightin-
gale, N., Morgan, K., et al. (1996). Psychological markers in
the detection of autism in infancy in a large population.
British Journal of Psychiatry, 168, 158–163.
Bates, E. (1979). The emergence of symbols: Cognition and
communication in infancy. New York: Academic Press.
Bono, M., Daley, T., & Sigman, M. (2004). Relations among joint
attention, amount of intervention and language gain in
autism. Journal of Autism and Developmental Disorders, 34,
495–505.
Bruner, J. (1981). The social context of language acquisition.
Language and Communication, 1, 155–178.
Charman, T., Baron-Cohen, S., Swettenham, J., Baird, G., Drew,
A., & Cox, A. (2003). Predicting language outcome in
infants with autism and pervasive developmental disorder.
International Journal of Language & Communication
Disorders, 38, 265–285.
Charman, T., Swettenham, J., Baron-Cohen, S., Cox, A., Baird,
G., & Drew, A. (1997). Infants with autism: An investigation
of empathy, pretend play, joint attention, and imitation.
Developmental Psychology, 33, 781–789.
Charman, T., Taylor, E., Drew, A., Cockerill, H., Brown, J., &
Baird, G. (2005). Outcome at 7 years of children diagnosed
with autism at age 2: Predictive validity of assessments
conducted at 2 and 3 years of age and pattern of symptom
change over time. Journal of Child Psychology and Psychi-
atry, 46, 500–513.
Chawarska, K., & Volkmar, F. (2005). Autism in infancy, early
childhood. In F. Volkmar, R. Paul, A. Klin, & D. Cohen
(Eds.), Handbook of autism and pervasive developmental
disorders (3rd ed., pp. 223–246). New York: Wiley.
Corsello, C., Cook, E., & Leventhal, B. (2003, April). A
screening instrument for autistic spectrum disorders. Poster
presentation at the Biennial Conference of the Society for
Research in Child Development, Tampa, FL.
Cox, A., Klein, K., Charman, T., Baird, G., Baron-Cohen, S.,
Swettenham, J., Wheelright, S., & Drew, A. (1999). Autism
spectrum disorders at 20 and 42 months of age: Stability of
clinical and ADI-R diagnosis. Journal of Child Psychology
and Psychiatry, 40, 719–732.
Dawson, G., Toth, K., Abbott, R., Osterling, J., Munson, J.,
Estes, A., & Liaw, J. (2004). Early social attention impair-
ments in autism: Social orienting, joint attention, and
attention to distress. Developmental Psychology, 40,
271–283.
Howlin, P., & Moore, A. (1997). Diagnosis of autism: A survey of
over 1200 patients in the UK. Autism, 1, 135–162.
Lord, C. (1995). Follow-up of two year-olds referred for possible
autism. Journal of Child Psychology and Psychiatry and
Allied Disciplines, 36, 1365–1382.
Lord, C., Rutter, M., DiLavore, P., & Risi, S. (1999). Autism
diagnostic observation schedule-generic. Los Angeles, CA:
Western Psychological Services.
McDuffie, A., Yoder, P., & Stone, W. (2005). Prelinguistic pre-
dictors of vocabulary in young children with autism spec-
trum disorders. Journal of Speech, Language, and Hearing
Research, 48, 1080–1097.
McLean, J., & Snyder-McLean, L. (1999). How children learn
language. San Diego: Singular Publishing.
Meltzoff, A. (2004). The case for developmental cognitive sci-
ence: Theories of people and things. In: G. Bremner, &
A. Slater (Eds.), Theories of infant development (pp. 145–
173). Oxford: Blackwell Publishers.
Mervis, C.B., & Klein-Tasman, B.P. (2004). Methodological
issues in group-matching designs: Alpha levels for control
variable comparisons and measurement characteristics of
control and target variables. Journal of Autism and Devel-
opmental Disorders, 34(1), 7–17.
Mitchell, S.K. (1979). Interobserver agreement, reliability, and
generalizability of data collected in observational studies.
Psychological Bulletin, 86, 376–390.
Mullen, E. (1995). The Mullen scales of early learning. Circle
Pines, MN: American Guidance.
Mundy, P., & Burnette, C. (2005). Joint attention and neurode-
velopmental models of autism. In F. R. Volkmar, R. Paul, A.
Klin, & D. Cohen (Eds.), Handbook of autism and develop-
mental disorders (3rd ed., pp. 650–681). New Jersey: Wiley.
Mundy, P., Sigman, M., & Kasari, C. (1990). A longitudinal study
of joint attention and language development in autistic
children. Journal of Autism and Developmental Disorders,
20, 115–128.
Osterling, J., & Dawson, G. (1994). Early recognition of children
with autism: A study of first birthday home videotapes.
Journal of Autism and Developmental Disorders, 24,
247–257.
Osterling, J., Dawson, G., & Munson, J. (2002). Early recogni-
tion of one year old infants with autism spectrum disorder
versus mental retardation: A study of first birthday party
home videotapes. Development and Psychopathology, 14,
239–252.
Rutter, M., Bailey, A., Berument, S., Lord, C., & Pickles, A.
(2001). Social communication questionnaire research edition.
Los Angeles, CA: Western Psychological Corporation.
Siegel, B., Pliner, C., Eschler, J., & Elliot, G. (1988). How chil-
dren with autism are diagnosed: Difficulties in identification
of children with multiple developmental delays. Develop-
mental and Behavioral Pediatrics, 9, 199–204.
Sigman, M., Dijamco, A., Gratier, M., & Rozga, A. (2004).
Early detection of core deficits in autism. Mental Retar-
dation and Developmental Disabilities Research Reviews,
10, 221–233.
Sigman, M., Mundy, P., Sherman, T., & Ungerer, J. (1986). Social
interactions of autistic, mentally retarded, and normal chil-
dren and their caregivers. Journal of Child Psychology and
Psychiatry, 27, 647–656.
Sigman, M., Ruskin, E., Arbeile, S., Corona, R., Dissanayake, C.,
Espinosa, M., Kim, N., Lopez, A., & Zierhut, C. (1999)
Continuity and change in the social competence of children
with autism, Down syndrome, and developmental delays.
Monographs of the Society for Research in Child Develop-
ment, 64, 1–114.
Sparrow, S. Balla, D., & Cicchetti D. (1984). Vineland adaptive
behavior scales. Circle Pines, MN: American Guidance
Service.
Stone, W. L., & Caro-Martinez, L. M. (1990). Naturalistic
observations of spontaneous communication in autistic
children. Journal of Autism and Developmental Disorders,
20, 437–453.
Stone, W., Lee, E., Ashford, L. Brissie, J., Hepburn, S., Coonrod,
E., & Weiss, B. (1999). Can autism be diagnosed accurately
in children under three years? Journal of Child Psychology
and Psychiatry, 40, 219–226.
123

Stone, W., Ousley, O., Yoder, P., Hogan, K., & Hepburn, S.
(1997). Nonverbal communication in 2- and 3-year old
children with autism. Journal of Autism and Developmental
Disorders, 27, 677–696.
Swettenham, J., Baron-Cohen, S., Charman, T., Cox, A., Baird,
G., Drew, A., et al. (1998). The frequency and distribution
of spontaneous attention shifts between social and nonsocial
stimuli in autistic, typically developing, and nonautistic
developmentally delayed infants. Journal of Child Psychol-
ogy and Psychiatry, 39, 747–753.
Tager-Flusberg, H., Joseph, R., & Folstein, S. (2001). Current
directions in research on autism. Mental Retardation and
Developmental Disabilities Research Reviews, 7, 21–29.
Volkmar, F., Lord, C., Bailey, A., Schultz, R., & Klin, A. (2004).
Autism and pervasive developmental disorders. Journal of
Child Psychology and Psychiatry, 45, 135–170.
Werner, E., & Dawson, G. (2005). Validation of the phenome-
non of autistic regression using home videotapes. Archives
of General Psychiatry, 62, 889–895.
Werner, E., Dawson, G., Munson, J., & Osterling, J. (2005).
Variation in early developmental course in autism and its
relations with behavioral outcome at 3–4 years of age. Jour-
nal of Autism and Developmental Disorders, 35, 337–350.
Wetherby, A. (1986). The ontogeny of communicative functions
in autism. Journal of Autism and Developmental Disorders,
16, 295–316.
Wetherby, A., Allen, L., Cleary, J., Kublin, K., & Goldstein, H.
(2002). Validity and reliability of the Communication and
Symbolic Behavior Scales Developmental Profile with very
young children. Journal of Speech, Language, & Hearing
Research, 45, 1202–1218.
123
J Autism Dev Disord
Wetherby, A., Goldstein, H., Cleary, J., Allen, L., & Kublin, K.
(2003). Early identification of children with communication
disorders: Concurrent and predictive validity of the CSBS
Developmental Profile. Infants and Young Children, 16(2),
161–174.
Wetherby, A., & Prizant, B. (1993). Communication and sym-
bolic behavior scales—Normed edition. Baltimore, MD: Paul
H. Brookes.
Wetherby, A., & Prizant, B. (2002). Communication and sym-
bolic behavior scales developmental profile—First Normed
edition. Baltimore, MD: Paul H. Brookes.
Wetherby, A. M., Prizant, B.M., & Hutchinson, T. (1998).
Communicative, social-affective, and symbolic profiles of
young children with autism and pervasive developmental
disorder. American Journal of Speech-Language Pathology,
7, 79–91.
Wetherby, A., Woods, J., Allen, L., Cleary, J., Dickinson, H., &
Lord, C. (2004). Early indicators of autism spectrum disor-
ders in the second year of life. Journal of Autism and
Developmental Disorders, 34(5), 473–493.
Williams, J., Whiten, A., & Singh, T. (2004). A systematic review
of action imitation in autism spectrum disorder. Journal of
Autism and Developmental Disorders, 34, 285–299.
Wimpory, D. C., Hobson, R. P., Williams, J. M. G., & Nash, S.
(2000). Are infants with autism socially engaged? A study of
recent retrospective parental reports. Journal of Autism and
Developmental Disorders, 30, 525–536.
Yoder, P., & Warren, S. (1999). Maternal responsivity mediates
the relationship between prelinguistic intentional commu-
nication and later language. Journal of Early Intervention,
22, 126–136.