Research in Autism Spectrum Disorders 1 (2007) 85–100

http://ees.elsevier.com/RASD/default.asp

Linguistic abilities in children with autism

spectrum disorder
Fiona M. Lewis *, Bruce E. Murdoch, Gail C. Woodyatt
University of Queensland, Australia
Received 4 August 2006; accepted 29 August 2006

Abstract

Background: Two broad approaches have been used to examine linguistic skills in Asperger
syndrome (AS) and high functioning autism (HFA). One approach has aimed at determining the
external validity of each diagnosis by investigating whether developmental language history, which
differentiates AS from HFA, is relevant in long-term linguistic outcomes. An alternative approach,
viewing AS and HFA as presentations on an autism spectrum (ASD), has investigated subgroups
within the spectrum based on linguistic performance. Neither approach, however, has provided an in-
depth description of the linguistic difficulties experienced in ASD necessary for therapy planning.
Purpose: To provide clinically applicable research findings to extend the clinical understanding of
the linguistic difficulties in ASD by: (1) comparing the linguistic skills in ASD with those of normally
developing controls; (2) comparing the linguistic skills of children with ASD re-classified as AS and
HFA using DSM-IV language criterion; (3) documenting the heterogeneity within a group of children
with ASD by investigating within-group differences.
Methods and procedures: Twenty children (aged 9; 0–17; 1 years) with a diagnosis of ASD were
assessed using the Clinical Evaluation of Language Fundamentals—Fourth Edition (CELF-4) and the
Test of Nonverbal Intelligence—Second Edition (TONI-2). Performance by ASD participants was
compared to typically developing peers. Re-classification of individuals with ASD as AS or HFA was
undertaken using DSM-IV language criterion to determine between-group differences on linguistic
measures. Hierarchical cluster analysis was undertaken using the ASD performance on the CELF-4 to
examine within-group differences based on linguistic abilities.
Outcomes and results: There were significant differences between the ASD children and normally
developing peers on a range of linguistic measures. There were no significant differences between the

* Corresponding author at: Division of Speech Pathology, School of Health and Rehabilitation Sciences,
University of Queensland, Queensland 4072, Australia. Tel.: +61 7 3365 1877; fax: +61 7 3365 4754.
E-mail address: f.lewis@uq.edu.au (F.M. Lewis).

1750-9467/$ – see front matter # 2006 Elsevier Ltd. All rights reserved.
doi:10.1016/j.rasd.2006.08.001
86 F.M. Lewis et al. / Research in Autism Spectrum Disorders 1 (2007) 85–100

children re-classified as AS and HFA on the comprehensive linguistic assessment. Subgroups within
ASD, based on linguistic performance, could be identified.
Conclusions and implications: Collectively, the children with ASD in the study had a range of
compromised linguistic skills relative to their peers. Children re-classified as AS could not be
differentiated from children re-classified as HFA on current linguistic performance. An examination
of subgroups of ASD participants revealed the heterogeneous nature of the linguistic skills associated
with ASD, where linguistic proficiency ranged from above average performance to severe difficulties.
The results of the study are discussed in terms of the clinical applicability of the findings.
# 2006 Elsevier Ltd. All rights reserved.

Keywords: Autism spectrum disorder; Clinical Evaluation of Language Fundamentals—Fourth Edition; DSM-
IV; Developmental language history

1. Introduction

The Diagnostic and Statistical Manual of Mental Disorders—Fourth Edition [DSM-IV]

(American Psychiatric Association [APA], 1994) established a categorical diagnostic
distinction between Asperger syndrome (AS) and Autistic Disorder (AD) (including high
functioning autism (HFA)), with differential diagnosis related to reported developmental
language history. Individuals with autistic symptomatology (i.e., abnormal communica-
tion, impaired social interaction and relationships, and rigid and limited imagination and
play) (Rutter, 1978; Tantam, 1991; Wing, 1989) and delayed onset or lack of language
development are diagnosed as having AD. In contrast, individuals with autistic features
combined with language onset prior to the age of 2 years are diagnosed as having AS.
Linguistic skills associated with the diagnostic categories of AS and HFA have been the
focus of much research (e.g., Howlin, 2003; Mayes & Calhoun, 2001; Prior et al., 1998;
Shields, Varley, Broks, & Simpson, 1996; Szatmari, Archer, Fisman, Streiner, & Wilson,
1995). Such studies can be characterised by two differing approaches. One approach has
been validation studies which have aimed to determine if AS and HFA are similar
presentations, and whether a separate diagnostic entry of AS in the DSM-IV (APA, 1994) is
warranted. The other approach has pre-empted conclusive findings from validation studies
by viewing AS and HFA as similar disorders on an autism spectrum (ASD).
The provision of a diagnosis of AS or HFA allows access to intervention (Bishop, 2006).
Beyond diagnosis however, detailed knowledge of the linguistic competencies in ASD is
necessary for the formulation of goals for intervention from educational and vocational
support services. Clinically applicable research findings are therefore needed to increase
the clinical understanding of the autistic presentation by accurately defining the areas of
difficulty. It may be, however, that previous findings of the linguistic skills in AS and HFA
may not be an accurate reflection of the difficulties in ASD, as the theoretical perspective
supporting the studies to date may have restricted the clinical application of findings.

1.1. Validation studies

The inclusion of AS as a categorically distinct disorder in DSM-IV (APA, 1994) has

resulted in ongoing debate regarding the external validity of the diagnosis of AS from the
 F.M. Lewis et al. / Research in Autism Spectrum Disorders 1 (2007) 85–100 87

diagnosis of HFA (e.g., Frith, 2003; Klin, Pauls, Schultz, & Volkmar, 2005; Klin &
Volkmar, 2003; Leekam, Libby, Wing, Gould, & Gillberg, 2000; Macintosh &
Dissanayake, 2004; Mayes, Calhoun, & Crites, 2001; Rutter, 1978). Numerous studies
have examined linguistic outcomes in AS and HFA (Ghaziuddin et al., 2000; Howlin, 2003;
Klin, Volkmar, Sparrow, Cicchetti, & Rourke, 1995; Mayes & Calhoun, 2001; Szatmari
et al., 1995; Szatmari, Tuff, Finlayson, & Bartolucci, 1990). Mayes and Calhoun (2001),
for instance, examined the outcomes of children with a history of early speech/language
delay (autism) and children with a history of normal language onset and development (AS),
but with similar full scale IQ, nonverbal, and performance IQ. Data from clinical
observations of the child, parent interviews, teacher reports, and previous evaluations were
combined to complete The Checklist for Autism in Young Children (Mayes & Calhoun,
1999). No significant differences were noted on any of the expressive language measures
between the two groups. Mayes and Calhoun’s (2001) results supported Szatmari et al.’s
(1990) earlier findings. Szatmari and colleagues administered a neurocognitive test battery
that included The Token Test for Children (Di Simoni, 1977) to children diagnosed as AS
or HFA, and found no differences between AS and HFA on the language measure.
In contrast, Klin et al. (1995) described distinct linguistic profiles for the two disorders.
Klin and colleagues assigned their child participants the diagnostic label of AS or HFA
using a modified version of ICD-10 (World Health Organization [WHO], 1992). The
authors determined that, despite a similar full scale IQ, neuropsychological profiles
differentiated individuals with AS from HFA. Using measures of clinical observation rather
than normed assessments, Klin et al. described qualitative differences between the two
disorders on articulation, verbal output, vocabulary, and verbal memory.
Szatmari et al. (1995), however, argued that quantitative differences alone differentiated
AS and HFA on linguistic outcomes. They administered the Word Knowledge Test, Part 2,
of the Oral Vocabulary Section of the McCarthy Scales of Children’s Abilities (McCarthy,
1972), the Verbal Comprehension Scale A of the Reynell Developmental Scales (Reynell
& Huntley, 1987), and the Grammatical Completion Test from the Test of Language
Development-2 (Newcomer & Hammill, 1988) to children with AS and HFA. The children
diagnosed as HFA on the basis of their developmental language histories consistently
performed two standard deviations below the mean on the range of language tests, while
the group diagnosed AS on the basis of onset of language performed just below or within
one standard deviation from the mean. Unlike the methodologies employed by Mayes and
Calhoun (2001) and Klin et al. (1995), however, Szatmari et al. did not match their
participants on nonverbal ability.

1.2. Spectrum approach

Szatmari et al.’s (1995) findings of quantitative linguistic differences accord with an

alternative approach to defining linguistic skills in AS and/or HFA; that is the
conceptualisation of AS and HFA as disorders on an autism spectrum (Wing, 1981).
Numerous studies have adopted this approach to examining the communication skills
associated with ASD (e.g., Mandell, Walrath, Manteuffel, Sgro, & Pinto-Martin, 2005;
Paul, Augustyn, Klin, & Volkmar, 2005; Prior et al., 1998; Seltzer et al., 2003; Sperry &
Mesibov, 2005; Warreyn, Roeyers, & De Groote, 2005), but to date few have focused on
88 F.M. Lewis et al. / Research in Autism Spectrum Disorders 1 (2007) 85–100

linguistic skills. Prior et al. (1998) adopted a spectrum approach in their study by including
diagnoses of AS, HFA and/or pervasive developmental disorder. To address the reported
heterogeneous presentation of the autistic presentation (e.g., Emerich, Creaghead, Grether,
Murray, & Grasha, 2003; Griswold, Barnhill, Myles, Hagiwara, & Simpson, 2002), these
authors also examined within-group differences. Based on performance on the British
Picture Vocabulary Test (Dunn, Dunn, Whetton, & Pintillie, 1982) or the Peabody Picture
Vocabulary Test-Revised (Dunn & Dunn, 1981), Prior et al. described a number of
subgroups differing on verbal skills, but due to incomplete data, were not able to examine
the relationship between IQ and subgroup membership in their study.
Research findings gain relevance when they are applied in clinical practice, thus
providing an evidence base for treatment and support (Rutter, 2005). The clinical
applicability of findings from validation studies and the spectrum approach taken by Prior
et al. (1998) may be restricted, however, due to the theoretical perspective adopted in both
approaches. Linguistic testing for both the validation studies and the spectrum study was
restricted to basic linguistic skills only, such as expressive and receptive vocabulary and
syntax. Theoretically, this position aligns with DSM-IV’s (APA, 1994) focus on early
semantic and syntactic development, which has diagnostic relevance only. Knowledge of
an individual’s diagnosis, whether it be AS or HFA, however, offers little information for
planning effective support programmes (Griswold et al., 2002). The subsequent
development of communicative competence, which encompasses broader aspects of
language development such as morphological and syntactic content, meaning, and
structure (Semel, Wiig, & Secord, 2003) does not have diagnostic relevance, yet these
aspects are highly relevant in terms of the provision of clinical support.
The current study investigated the linguistic skills in ASD in order to provide research
findings that have clinical application in the determination of the type and level of language
intervention and support needed following diagnosis. To extend previous findings,
linguistic skills beyond those central to the diagnostic process were included in the
linguistic assessment. The first aim was to administer a comprehensive assessment of
semantic, morphological, and syntactic content, meaning, and language structure to
children with a diagnosis of ASD, with group performance being compared to a typically
developing control group. The second aim was to examine whether current linguistic
performance differentiated AS from HFA. Based on the methodology applied in the
validation studies, the ASD children were re-classified as AS or HFA according to DSM-IV
(APA, 1994) language criterion. Between-group differences were then examined. Finally,
incorporating aspects of the methodology used by Prior et al. (1998), hierarchical cluster
analysis of the ASD participants’ performance on the language measures was undertaken
to examine heterogeneity through within-group differences.
Based on previous findings of linguistic deficits in both AS and HFA, it was hypothesised
the ASD group would present with significantly different linguistic skills when compared to
normally developing peers. Although previous studies have proposed that linguistic
outcomes fail to differentiate individuals with AS and HFA, no hypothesis was made for the
current study as previous conclusions have been based on restricted semantic/grammatical
assessments only. Finally, as previous investigations of within-group analyses have
identified subgroups reflecting the heterogeneous presentation within ASD, it was
hypothesised that subgroups, based on current language status, would be evident.
 F.M. Lewis et al. / Research in Autism Spectrum Disorders 1 (2007) 85–100 89

2. Method

2.1. Participants

A total of 20 children (16 male; 4 female; M age: 11; 6 years; SD: 2; 2 years; range: 9; 0–
17; 1 years; M years of schooling: 6.1; range: 3–11) with a diagnosis of AS and/or HFA
were recruited through the Asperger Syndrome Support Network of Queensland, Autism
Queensland, and newspaper articles. Recruitment articles specified children and
adolescents with a diagnosis of AS, HFA, or autism with average intelligence. Table 1
displays the demographic details of participants. In addition to a diagnosis of AS/HFA/
autism with average intelligence, inclusion criteria for the study were: aged 9 years or
older, English as a first language, no neurological disease or trauma, no other co-morbid
condition, and normal vision and hearing.
Documentation of diagnosis was requested before the commencement of testing.
Diagnoses made by psychiatrists, paediatricians, and psychologists were accepted for
inclusion into the study. A range of diagnostic criteria have been proposed for AS (e.g.,
APA, 1994; Gillberg & Gillberg, 1989; Szatmari, Bremner, & Nagy, 1989; WHO, 1992)
and the criteria used by the various professionals for diagnosis of participants were not

Table 1
ASD participant demographics
ID Sex Age in Handedness Dev Lge Given Diag Re-classified diagnosis using
years; months Hist (source) DSM-IV language criterion
1 M 9; 4 Right Normal AS (paed) AS
2 M 11; 11 Right Normal ASD (paed) AS
3 M 14; 0 Right Normal AS (psych) AS
4 M 11; 0 Right Normal ASD (paed) AS
5 M 12; 1 Right Normal AS (paed) AS
6 M 12; 6 Right Normal AS (psychiat) AS
7 Fe 13; 6 Right Delayed AS (psychiat) HFA
8 M 17; 1 Right Normal AS (paed) AS
9 M 15; 1 Right Normal AS (paed) AS
10 Fe 9; 7 Right Delayed AS (paed) HFA
11 M 13; 7 Right Delayed AS (paed) HFA
12 M 9; 5 Right Unsure AS (paed) Unsure
13 M 11; 6 Right Delayed AS (psychiat) HFA
14 M 10; 5 Right Delayed AS/ASD (paed) HFA
15 M 10; 10 Right Normal AS (psych) AS
16 Fe 13; 3 Right Delayed AS/ASD (paed) HFA
17 M 9; 8 Right Delayed ASD (paed) HFA
18 M 9; 0 Right Delayed ASD (paed) HFA
19 Fe 9; 0 Right Unsure ASD (paed) Unsure
20 M 10; 5 Right Normal ASD (paed) AS
ASD = Autism spectrum disorder. AS = Asperger syndrome. HFA = High functioning autism. Dev Lge Hist =
Developmental language history. Normal = Language onset prior to age 2 years. Delayed = Language onset after
age 2 years. Given Diag = Independently given diagnosis. Source = Source of diagnosis. M = Male. Fe = Female.
Psych = Psychologist. Paed = Paediatrician. Psychiat = Psychiatrist. Re-classified diagnosis = Based on devel-
opmental language histories provided, participants were re-classified as AS or HFA using the DSM-IV language
criterion.
90 F.M. Lewis et al. / Research in Autism Spectrum Disorders 1 (2007) 85–100

known. It is acknowledged that some of the diagnoses may not adequately reflect DSM-IV
criteria (APA, 1994) in regards to developmental language histories. Appendix A and
Appendix B show DSM-IV criteria for AD and AS, respectively.
A total of 18 children/adolescents (14 males; 4 females; M age: 11; 5 years; SD: 1; 8
years; range: 9; 1–14; 8 years; M years of schooling: 6.2; range: 4–9) with non-significant
developmental histories were recruited as control participants. A Student t-test indicated
there was no significant difference in age between the ASD and control group. Recruitment
of controls was through newspaper articles in local papers, local sporting clubs, and
schools in the south-east corner of Queensland. To be included in the control group,
participants were required to be aged 9 years or older, have English as a first language, no
history of neurological trauma or disease, no history of drug and/or alcohol abuse, and
normal hearing and vision. To avoid the issues of co-morbidity with autism and/or
language difficulties, no family history of autism, no developmental history of language
delays or difficulties, and no family history of language delays or difficulties were also
required for control participant inclusion.

2.2. Measures

The Clinical Evaluation of Language Fundamentals—Fourth Edition (CELF-4) (Semel

et al., 2003) and the Test of Nonverbal Intelligence—Second Edition (TONI-2) (Brown,
Sherbenou, & Johnsen, 1990) were administered to all participants.
The CELF-4 (Semel et al., 2003) is a standardised test for the paediatric population, and
assesses the basic foundations of mature language use. The test assesses language
competence through an examination of semantic content, morphological and syntactic
content, meaning, and structure (Semel et al., 2003). Depending on the child’s age, a
number of subtests were administered. Subtests administered included Concepts and
Following Directions, Recalling Sentences, Formulated Sentences, Word Classes,
Expressive Vocabulary, Word Definitions, Understanding Spoken Paragraphs, Sentence
Assembly, and Semantic Relationships. CELF-4 provides Index Scores using the scores of
subtests that measure similar language features (Semel et al., 2003). The five indices
computed for the present study were Core Language, Receptive Language, Expressive
Language, Language Content, and Language Memory.
The TONI-2 (Brown et al., 1990) was administered to determine if differences in verbal
results were due to nonverbal cognitive abilities rather than linguistic factors only.

2.3. Procedure

In addition to the formal assessments, all participants completed a questionnaire prior to

the commencement of testing. As well as providing identifying data, the ASD
questionnaire requested a retrospective history of language development. Questions
regarding the participant’s developmental history were worded in a way to avoid parents/
caregivers making decisions regarding the appropriateness of the timing of language onset.
Aspects from the questionnaire relating to language history are shown in Appendix C.
Judgments regarding language onset were made by an experienced speech pathologist
(author FL). Inter-rater reliability of 100% agreement on decisions was provided by a
 F.M. Lewis et al. / Research in Autism Spectrum Disorders 1 (2007) 85–100 91

second experienced speech pathologist (GW). Judgment for classifying language onset was
based on DSM-IV’s language criterion (APA, 1994) (i.e., onset of single words prior to age
2 years = normal onset = AS; onset of single words after age 2 years = delayed
onset = HFA). Where language history could not be provided, this was documented as
unsure. Developmental language history was not available for two children. For one child,
the parents were not able to recall developmental milestones, and for the other,
developmental history was not available as the child did not live with his family of origin.
Children with a diagnosis of ASD were re-classified as AS and HFA based on their
reported developmental language history. Using DSM-IV’s (APA, 1994) language
criterion, the re-classification of children resulted in three groups: onset of first words prior
to 2 years of age (AS: n = 10), onset after 2 years of age (HFA: n = 8), and those with unsure
developmental language history (n = 2) (refer to Table 1). The Unsure group data were
excluded from the re-classification analyses.
All testing was undertaken at the University of Queensland, at the participant’s school,
or in the home of the participant. Each assessment was administered in a distraction-free
environment in a standardised manner according to the instruction manual. No time limits
were placed on participant responses.

3. Results

3.1. Linguistic skills in ASD

Group means and standard deviations for all ASD participants and controls are shown in
Table 2. For determination of statistical significance, a conservative level of p  0.01 was
utilised. This significance level was chosen to account for possible Type I errors resulting
from the multiplicity of tests, while not increasing Type II error rates. There were no

Table 2
Descriptive statistics of the participants
ASD (n = 20) Controls (n = 18) t Significance (two-tailed)
M SD M SD
Age 11; 6 2; 2 11; 5 1; 8 0.223 0.825
TONI-2 100 18 113 16 2.258 0.473
CELF-4
Core Lge 84 20 106 12 3.800 0.001***
Rec Lge 88 19 98 10 2.169 0.037
Exp Lge 86 20 107 12 3.943 0.001***
Lge Cont 84 17 102 14 3.729 0.001***
Lge Mem 84 21 102 12 3.428 0.002**
ASD = Autism spectrum disorder. TONI-2 = Test of Nonverbal Intelligence—Second Edition. CELF-4 = Clinical
Evaluation of Language Fundamentals—Fourth Edition. Core Lge = Core Language Index from CELF-4. Rec
Lge = Receptive Language Index. Exp Lge = Expressive Language Index. Lge Cont = Language Content Index.
Lge Mem = Language Memory Index.
**
p  0.01.
***
p  0.001.
92 F.M. Lewis et al. / Research in Autism Spectrum Disorders 1 (2007) 85–100

significant differences between the two groups on age ( p  0.01) or nonverbal intelligence
( p  0.01). For each measure, a Levene’s test was carried out, and where necessary,
appropriate corrections for non-homogeneity were undertaken.
Student t-tests indicated the children with ASD performed significantly less well than
the normally developing children on Core Language ( p  0.001), Expressive Language
( p  0.001), Language Content ( p  0.001), and Language Memory ( p  0.01). Receptive
Language was not significantly different to that of normally developing children ( p  0.01).

3.2. ASD grouping based on developmental language history

Comparative analyses of the children re-classified as AS and HFA were undertaken

using Mann–Whitney U tests. No significant differences were detected between the two

Table 3
Subgroups of ASD children as determined by CELF-4 indices showing standard deviations from the control group
means
ID number Given Diag Lge hist Core Lge Rec Lge Exp Lge Lge Cont Lge Mem
Subgroup 1 (n = 7), mean age: 11; 1 years, SD: 2; 4 years
16 AS/ASD Delayed 3.0 2.5 3.0 2.5 3.0
17 ASD Delayed 3.5 2.5 3.5 2.5 3.5
9 AS Normal 2.5 2.5 3.5 2.5 2.5
19 ASD Unsure 2.5 1.5 3.5 2.0 2.5
1 AS Normal 2.5 2.0 2.0 2.5 2.0
12 AS Unsure 2.0 2.0 1.5 2.0 1.0
5 AS Normal 2.5 2.0 2.0 2.0 4.5
Subgroup 2 (n = 6), mean age: 12; 2 years, SD: 2; 8 years
11 AS Delayed 1.5 1.5 1.5 1.5 0.5
14 AS/ASD Delayed 1.0 0.5 1.0 1.5 1.5
6 AS Normal 1.5 1.5 1.0 0.5 1.5
15 AS Normal 2.0 1.5 1.5 0.5 2.0
18 ASD Delayed 2.0 1.5 2.0 1.0 2.0
8 AS Normal 2.0 0.0 2.5 0.5 1.5
Subgroup 3 (n = 3), mean age: 11; 1 years, SD: 2; 0 years
7 AS Delayed 4.5 4.0 4.0 3.5 4.0
10 AS Delayed 5.0 5.0 4.5 4.0 4.5
20 ASD Normal 4.0 3.5 4.0 2.0 3.5
Subgroup 4 (n = 4), mean age: 12; 1 years, SD: 1; 3 years
4 AS Normal +0.5 +2.0 +1.0 +0.5 +1.0
13 AS Delayed +0.5 +1.5 +0.5 0.0 +1.0
2 ASD Normal +0.5 +1.5 +1.5 +1.0 +1.5
3 AS Normal +1.0 +2.5 +1.5 +0.5 +2.0
ASD = Autism spectrum disorder. CELF-4 = Clinical Evaluation of Language Fundamentals—Fourth Edition.
Given Diag = Independently determined diagnosis. AS = Asperger syndrome. Lge hist = Developmental lan-
guage history. Normal = Language onset prior to age 2 years. Delayed = Language onset after age 2 years. Core
Lge = Core Language Index from CELF-4. Rec Lge = Receptive Language Index. Exp Lge = Expressive
Language Index. Lge Cont = Language Content Index. Lge Mem = Language Memory Index. Scores are entered
as within standard deviations above or below the control means. + = above the control mean. = below the
control mean. Scores entered as 0.0 indicate no deviation from the control mean.
 F.M. Lewis et al. / Research in Autism Spectrum Disorders 1 (2007) 85–100 93

groups on age (Z = 1.022; p = 0.307), nonverbal intelligence (Z = 0.800; p = 0.423),

Core Language (Z = 1.200; p = 0.230), Receptive Language (Z = 1.112; p = 0.266),
Expressive Language (Z = 1.068; p = 0.285), Language Content (Z = 1.605;
p = 0.108), or Language Memory (Z = 1.156; p = 0.248).

3.3. Subgroups based on ASD linguistic performance

Current language status of all ASD participants, based on the performance on language
tasks that reflect basic linguistic skills, formed the basis for the potential clustering. All five
language indices provided by the CELF-4 (Semel et al., 2003) were included for the cluster
analysis. In order to obtain an optimal classification of ASD children, an agglomerative
hierarchical cluster analysis was undertaken. The hierarchical clustering of the ASD child
participants is shown in Fig. 1.
Four subgroups can be identified from the analysis. The resultant subgroups are
descriptive only. Table 3 displays the membership of the subgroups. Each participant’s
score is defined as within a number of standard deviations from the control group’s mean.
Subgroup 1 was characterised by mild to moderate difficulties on Receptive Language and

Fig. 1. Agglomerative hierarchical cluster analysis of the 20 ASD children using the CELF-4 scores. When a
horizontal line joins two vertical portions, it indicates fusion between two clusters of participants. Subgroup
membership is shown in Table 3.
94 F.M. Lewis et al. / Research in Autism Spectrum Disorders 1 (2007) 85–100

Language Content, and moderate-severe difficulties on Core Language, Expressive

Language, and Language Memory. Subgroup 2 presented with generally mild difficulties
on Receptive Language and Language Content and mild to moderate difficulties on Core
Language, Expressive Language, and Language Memory. Subgroup 3 presented with
severe deficits across all five CELF-4 indices, and subgroup 4’s performance was average-
to-above average on all five CELF-4 indices.
Non-parametric tests (Kruskal–Wallis) established there was no significant difference
between the four ASD subgroups on the TONI-2 (x2 = 10.317; p = 0.016) or age
(x2 = 1.426; p = 0.700). Significant differences were noted between the subgroups on Core
Language (x2 = 16.664; p = 0.001), Receptive Language (x2 = 16.527; p = 0.001),
Expressive Language (x2 = 16.092; p = 0.001), Language Content (x2 = 16.316;
p = 0.001), and Language Memory (x2 = 15.748; p = 0.001).

4. Discussion

Children with a diagnosis of ASD presented with linguistic deficits relative to typically
developing peers. Re-classifying participants as AS and HFA using DSM-IV’s (APA,
1994) language criteria failed to detect significant differences between the resultant groups
on linguistic measures. A more accurate presentation of the range of linguistic skills
associated with ASD was revealed when within-group analyses were undertaken, which
indicated the heterogeneous nature of the children’s linguistic skills.

4.1. Linguistic skills in ASD

Compared to typically developing peers, children with ASD had difficulties on a wide
range of linguistic parameters. Children with ASD presented with intact receptive language
skills, but deficits in core language, expressive language, language content, and language
memory. The linguistic deficits identified in the ASD participants relative to normally
developing peers in the current study cannot be attributed to nonverbal cognitive deficits, as
the two groups could not be differentiated on nonverbal ability. The identification of
linguistic deficits beyond merely semantic knowledge, such as language memory and
content, suggests that children with ASD may require a range of supports in the educational
setting.

4.2. ASD individuals grouped according to developmental language

The regrouping of individuals with ASD using the reported timing of language onset
was undertaken to determine if subsequent linguistic skills differed significantly between
the groups designated AS and HFA based on DSM-IV language criterion (i.e., onset prior
to age 2 years (AS), or onset after age 2 years (HFA)).
In the current study, linguistic performance failed to differentiate the resultant groups.
This finding is consistent with previous studies (e.g., Howlin, 2003; Mayes & Calhoun,
2001), where the timing of the onset of developmental language was shown to be irrelevant
in subsequent linguistic outcomes. Interpreting the findings from the current study as
 F.M. Lewis et al. / Research in Autism Spectrum Disorders 1 (2007) 85–100 95

supporting previous research is problematic; however, as methodological concerns have

been expressed regarding the validity and reliability of, and the confidence in, the use of
developmental language for diagnostic decision-making, which forms the basis of the
validation studies. Inherent problems undermining the confidence in diagnosis include the
reliance upon retrospective recall of language milestones, the consistency in interpretation
of milestones (Tager-Flusberg, 2003; Woodbury-Smith, Klin, & Volkmar, 2005), and that
the diagnostic distinction between AS and HFA based on DSM-IV (APA, 1994) language
criterion may not consistently be applied in diagnostic and clinical practice (Eisenmajer
et al., 1996; Klin et al., 2005).
These problems were evident in the current study. The developmental histories of two
children were unavailable. Further, there was evidence in the present study of a lack of
adherence to DSM-IV (APA, 1994) language criterion, or possibly inconsistent
interpretation of reported milestones, resulting in unreliable independently given
diagnoses. The findings of the current study suggest diagnosticians such as psychiatrists,
paediatricians, and psychologists may be disregarding developmental language history
when making diagnostic decisions regarding autistic classification.
Using research findings from validation studies to extend the understanding of the
linguistic outcomes in AS and HFA may have limited value in clinical practice. Further, the
debate regarding differences between AS and HFA may remain unresolved while the
reliance upon the timing of the onset of language to differentially distinguish between a
diagnosis of AS and a diagnosis of HFA remains.

4.3. Subgroups within ASD based on current performance on basic language tests

An examination of within-group differences revealed the heterogeneity of linguistic

skills in ASD. Linguistic competence in children with ASD ranged from above average
skills through to severe deficits on all language indices measured. It is possible that the
range of skills demonstrated in the present study represent variations as observed in the
normal population. Normal variation, however, cannot account for the severe deficits
observed in a number of the subgroups. Nonverbal cognition approached significance in the
subgroup formation, suggesting the possibility that cognitive skill may influence linguistic
competence. The exact nature of the relationship between cognition and language is yet to
be clarified (see e.g., Howlin, 2003; Klin et al., 1995; Mayes & Calhoun, 2001; Szatmari
et al., 1995). It may be that cognitive skill, rather than the timing of the onset of language, is
a marker that differentiates individuals with ASD.
The description of subgroups based on performance on a comprehensive linguistic
assessment extends the findings by Prior et al. (1998) who described subgroups within ASD
based on performance on expressive semantics. The utility of examining within-group
differences in the ASD group is highlighted by the identification of receptive language
difficulties in three of the four subgroups, despite receptive language skills not being
significantly different to controls in the between-group analysis.
The range of competencies identified in the majority of the participants suggests that
language difficulties may interfere with success in home and school life for children with
ASD. The Expressive and Receptive Language indices from the CELF-4 (Semel et al.,
2003) reflect basic language proficiency. Expressive language difficulties may reduce the
96 F.M. Lewis et al. / Research in Autism Spectrum Disorders 1 (2007) 85–100

effectiveness in oral and written expression through poor use of grammar and restricted
word use. Reduced receptive language skill as noted in some individuals, may result in
difficulties following directions, understanding verbal concepts, and understanding spoken
and written paragraphs. Deficient language memory skills may result in poor recall of
complex spoken directions. Language content encompasses more complex skills such as
category formulation, comprehending relationships between words, and interpreting
inferential and factual information. Specific individual intervention plans would be
required to optimise success in these language areas to reduce the negative academic,
social, and emotional outcomes in children with ASD.
There are limitations to the current study, such as the sample size. Replication of the
study with a much larger sample is advised before the results can be generalised to the
wider ASD population. Further investigation is warranted to examine whether cognitive
performance is a marker that differentiates individuals with ASD.

5. Conclusions

The approach adopted in the current study, which combines methodological aspects
from previous studies, offers findings relevant to both research and clinical practice.
Relative to normally developing peers, children with ASD presented with intact receptive
skills, but compromised overall language, expressive language, language content, and
language memory skills. The finding that children with ASD could not be differentiated on
linguistic performance when re-classified as AS and HFA using DSM-IV (APA, 1994)
language criterion supported previous research results. The methodological constraints
inherent in using developmental language history as the defining categorical distinction
between the two disorders, however, limit the diagnostic and clinical potential of this
finding.
The examination of subgroups within ASD based on severity of linguistic difficulties
has important therapeutic, but not diagnostic, implications. One subgroup had above
average skills across all language indices. All five language indices were found to be
impaired to varying degrees in the other three subgroups. This included receptive language,
which was not impaired in the non-differentiated ASD group relative to controls.
Linguistic competence for the children with ASD involved in the present study ranged from
above average through to severe difficulties, suggesting it is imperative that those identified
as having ASD undergo a comprehensive linguistic assessment to allow for specific
assistance tailored to their individual needs.
The results of the current study suggest that a dimensional view of ASD, rather than the
categorical approach as stipulated by DSM-IV (APA, 1994), is likely to provide clinically
relevant research findings which can be utilised to form the basis for management planning.
A dimensional view of ASD necessitates a comprehensive language assessment for each
diagnosed individual, which then facilitates individualised planning of language support
and intervention. Studies that further examine the relationship between linguistic
competence and cognition, however, would be of interest, as cognitive skill may be more
reliable than developmental history as a marker differentiating individuals within the
spectrum of autistic disorders.
 F.M. Lewis et al. / Research in Autism Spectrum Disorders 1 (2007) 85–100 97

Acknowledgements

The authors thank the children and adults who participated in the study. A particular
acknowledgement goes to the principal of St. Augustine’s College for his zeal in recruiting
control participants, and the students of the college for their willingness to be involved in
the research.

Appendix A. DSM-IV diagnostic criteria for Autistic Disorder

A. A total of six (or more) items from (1), (2), and (3), with at least two from (1), and one
each from (2) and (3):
(1) qualitative impairment in social interaction, as manifested by at least two of the
following:
(a) marked impairment in the use of multiple nonverbal behaviors such as eye-to-
eye gaze, facial expression, body postures, and gestures to regulate social
interaction;
(b) failure to develop peer relationships appropriate to developmental level;
(c) a lack of spontaneous seeking to share enjoyment, interests, or achievements
with other people (e.g., by a lack of showing, bringing, or pointing out objects
of interest);
(d) lack of social or emotional reciprocity.
(2) Qualitative impairments in communication as manifested by at least one of the
following:
(a) delay in, or total lack of, the development of spoken language (not
accompanied by an attempt to compensate through alternative modes of
communication such as gesture or mime);
(b) in individuals with adequate speech, marked impairment in the ability to
initiate or sustain a conversation with others;
(c) stereotyped and repetitive use of language or idiosyncratic language;
(d) lack of varied, spontaneous make-believe play or social imitative play
appropriate to developmental level.
(3) Restricted repetitive and stereotyped patterns of behavior, interests, and activities,
as manifested by at least one of the following:
(a) encompassing preoccupation with one or more stereotyped and restricted
patterns of interest that is abnormal either in intensity or focus;
(b) apparently inflexible adherence to specific, nonfunctional routines or rituals;
(c) stereotyped and repetitive motor mannerisms (e.g., hand or finger flapping or
twisting, or complex whole-body movements);
(d) persistent preoccupation with parts of objects.
B. Delays or abnormal functioning in at least one of the following areas, with onset prior to
age 3 years: (1) social interaction, (2) language as used in social communication, or (3)
symbolic or imaginative play.
C. The disturbance is not better accounted for by Rett’s disorder or childhood
disintegrative disorder (APA, 1994, pp. 70–71).
98 F.M. Lewis et al. / Research in Autism Spectrum Disorders 1 (2007) 85–100

Appendix B. DSM-IV diagnostic criteria for Asperger’s Disorder

A. Qualitative impairment in social interaction, as manifested by at least two of the

following:
(1) marked impairment in the use of multiple nonverbal behaviors such as eye-to-eye
gaze, facial expression, body postures, and gestures to regulate social interaction;
(2) failure to develop peer relationships appropriate to developmental level;
(3) a lack of spontaneous seeking to share enjoyment, interests, or achievements with
other people (e.g., by a lack of showing, bringing, or pointing out objects of interest
to other people);
(4) lack of social or emotional reciprocity.
B. Restricted repetitive and stereotyped patterns of behavior, interests, and activities, as
manifested by at least one of the following:
(1) encompassing preoccupation with one or more stereotyped and restricted patterns
of interest that is abnormal either in intensity or focus;
(2) apparently inflexible adherence to specific, nonfunctional routines or rituals;
(3) stereotyped and repetitive motor mannerisms (e.g., hand or finger flapping or
twisting, or complex whole-body movements);
(4) persistent preoccupation with parts of objects.
C. The disturbance causes clinically significant impairment in social, occupational, or
other important areas of functioning.
D. There is no clinically significant general delay in language (e.g., single words used by
age 2 years, communicative phrases used by age 3 years).
E. There is no clinically significant delay in cognitive development or in the development
of age-appropriate self-help skills, adaptive behavior (other than in social interaction),
and curiosity about the environment in childhood.
F. Criteria are not met for another specific pervasive developmental disorder or
Schizophrenia (APA, 1994, p. 77).

Appendix C. Portion of the questionnaire pertaining to developmental language

history

Communication history (if able to recall):

 Did your child babble as an infant (e.g., ‘‘mum mum’’, ‘‘doo ga’’)?
 At what age (approximate) did your child use recognisable words for objects or actions
(e.g., ‘‘up’’, ‘‘more’’, ‘‘dog’’, ‘‘mum’’, ‘‘dad’’)?
 At what age did your child start putting two or more words together to make little
sentences (e.g., ‘‘me up’’, ‘‘where mum’’)?
 Did you have any concerns about how your child was developing with using or
understanding words? If so, please write what your concerns were.
DSM-IV language criterion (APA, 1994) was used as the standard in determining the re-
classification of ASD participants according to developmental language history. If a child’s
reported onset of single words was prior to age 2 years, this was documented as Normal
 F.M. Lewis et al. / Research in Autism Spectrum Disorders 1 (2007) 85–100 99

onset, and these children were re-classified as AS. Where the reported onset of first words
was after age 2 years, this was documented as Delayed, and the child was re-classified as
HFA. Where language history could not be provided, this was documented as unsure. Inter-
rater reliability for decisions made was 100%.

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