Comparison of Clinical Symptoms in Autism

and Asperger’s Disorder

RICHARD EISENMAJER, MARGOT PRIOR, PH.D., SUSAN LEEKAM, PH.D., LORNA WING, M.D.,
JUDITH GOULD, PH.D., MICHAEL WELHAM, M.D., AND BEN ONG, PH.D.

ABSTRACT
Objective: To determine what clinical symptoms clinicians have been using to distinguish between Asperger’s disorder
(AsD) and autistic disorder (AD). Method: Parents of children and adolescents with high-functioning AD (n = 48) and
AsD ( n = 69) were given a structured interview based on DSM-///-Rand ICD-10 diagnostic criteria. Information regarding
early and current symptom presentation and family, developmental, and verbal mental age information were collected.
Logistic regression analyses were conducted to determine which variables best predicted clinician’s diagnosis. Results:
A number of clinical variables predicted diagnosis. Delayed language onset was the only variable of the family and
developmental variables that predicted diagnosis. The AsD group was also significantly higher than the AD group in
verbal mental age. Conclusion: Clinicians appear to be diagnosing AsD and AD on the basis of published research
and case study accounts. The findings question whether DSM-/V and ICD-10 criteria adequately describe the AsD
individual, particularly in the communication domain. J. Am. Acad. Child Adolesc. Psycbiafry, 1996, 35(11):1523-1531.
Key Words: autism, Asperger’s disorder, diagnosis, communication.

The nosological integrity of autistic disorders listed
under the DSM umbrella term, “pervasive develop-
mental disorders” (PDD), has long been a contentious
area (Rutter, 1989; Schopler, 1985; Wing, 1986).
Accepted April 1 6 1996.
Mr. Eisenmajer is a psychologist and Ph.D. candidate and Dr. Ong is
Lecturer, School of Psychology, La Trobe University, Bundoora, Victoria,
Australia. Dr. Prior is Profissor, Department of Psychology, Royal Children i
Hospital, Melbourne, Australia. Dr. Leekam is Lecturer, Department ofPsychol-
ogy, University of Kent at Canterbuy, U.K Dr. Wing is a psychiatrist and
Dr. Gould is a clinicalpsychologist, The Centrefor Social and Communication
Disorders, Kent, U.K. Dr. Welham is a psychiatrist, Department of Child and
Adolescent Psychiany, Austin Hospital, Melbourne, Australia.
Presented in part by thefirst author to the 1995 NationalAutism Conference,
Brisbane, Australia.
This research wm supported in part by a grant to Dr. Leekam fiom the
University of Kent (1991-1993) and a travel grant fiom the Royal Society.
Richard Eisenmajer was supported by the Apex Trustfor Autism (1993). The
authors thank Emma Hunnisen ( U K ) f o r help with coding, Sonia Jordan
(U.K ) with data colkrtion, Amanda Golding (Australia), the Autism and
Asperger Syndrome Associations in Victoria and South Australia, and all the
parents and children who gave their time f i r this project. The authors also
thank the anonymous reviewersfor their helpfil comments on an earlier version
of this paper.
Reprint requests to Mr. Eisenmajer, School of Psychology, La Trobe University,
Bundoora, Victoria, Australia 3083.
0890-8567/96/3511- 1523$03.00/001996 by the American Academy
of Child and Adolescent Psychiatry.
Labels such as atypical autism, residual autism, PDD-
not otherwise specified, and, more recently, Asperger’s
syndrome/disorder have all at one time been used to
describe a group of individuals who do not appear to
strictly fulfill autism criteria. The recent description
of Asperger’s disorder (AsD) in DSM-IV (American
Psychiatric Association, 1994) with criteria that are
nearly identical with those for autistic disorder (AD)
would suggest that there is not currently any clear
boundary between the two disorders. Since Wing’s
(198 1) account of Asperger’s syndrome, clinicians have
been using this diagnostic label for certain individuals.
The aim of this study was to determine what symptom
characteristics clinicians have been using to distinguish
between AD and AsD.
Asperger’s syndrome has recently been included in
the DSM-Was AsD under the section of PDD. The
DSM-IV diagnostic criteria for AD and AsD were
modeled from ICD-10 draft criteria (World Health
Organization, 1988) after field trials suggested that
ICD- 10 criteria had certain advantages over DSM-III
and DSM-III-R criteria for autism (Volkmar et al.,
1994). The criteria for AsD in DSM-Ware the same
as those for AD, with three exceptions. First, the
communication and imagination impairment criteria

J . AM. ACAD. C H I L D ADOLESC. PSYCHIATRY, 3 5 : 1 1 , NOVEMBER 1996 1523

E I S E N M A J E R E T AL.
for AD are not listed for AsD. Second, it is claimed that
individuals with AsD do not suffer from a “clinically
significant general delay in language (e.g., single words
by 2 years, communicative phrases by age 3 years)”
(American Psychiatric Association, 1994, p. 77). Third,
the child with AsD does not have a “clinically signifi-
cant delay in cognitive development or in the develop-
ment of age-appropriate self-help skills, adaptive
behavior (other than in social interaction), and curiosity
about the environment in childhood” (p. 77). These
criteria are in accordance with those ofAsperger (1944),
who believed that the main handicap was of a social
nature and not due to intellectual or language delays.
Unlike Kanner, Asperger did not list essential criteria
for his patients. Among the many behaviors he referred
to, he did note a tendency for pedantic speech patterns
and uncoordinated, “clumsy” gross motor movements.
There is no mention of these features in the DSM-
IV criteria, although the Course description of AsD
recognizes that “motor delays or motor clumsiness may
be noted in the pre-school years” (American Psychiatric
Association, 1994, p. 76),and the Associated Features
section states that “motor milestones may be delayed,
and motor clumsiness is often observed” (p. 76).
Prior to the publication of DSM-II/: prominent
researchers in autism used Asperger’s descriptions to
identify such individuals in order to further investigate
and elaborate on areas such as cognitive skills and early
developmental history (Gillberg, 1989; Szatmari et al.,
1989a; Tantam, 1988; Wing, 1981). Social impair-
ments, clumsiness, pedantic or unusual speech, and
circumscribed interests were noted as essential criteria.
Szatmari et al. (1989b) differed from other research
groups by not stating in their criteria whether cognitive
and speech delays were admissible. Other researchers
believed that such delays could be present and still
allow a diagnosis of AsD (e.g., Gillberg, 1989; Wing,
1981). Ghaziuddin et al. (1992) warned that different
conceptions of AsD between investigators could make
comparisons between studies difficult. Studies compar-
ing AsD and AD groups on a range of factors (e.g.,
developmental indices, IQ) have been compromised
by methodological limitations, such as unclear sampling
procedures to exclude AsD subjects from an AD group
and failing to match groups on IQ, thereby allowing
mental retardation as a potential explanation for ob-
served differences (Szatmari, 1992).
1524 J . A M . A C A D . C H I L D A D O L E S C . P S Y C H I A T R Y , 3 5 : 1 1 , N O V E M B E R 1996
It is of interest to ascertain how clinicians have put
into clinical practice the research on AsD. The aim of
this study is to identify the clinical features used by
clinicians to distinguish between a diagnosis of AD
and AsD (prior to the publication of DSM-IV). W e
wish to clarify whether diagnosis was dependent on
the presence/absence of specific autism symptomatol-
ogy, on developmental factors such as presence/absence
of language delay, or on level of intelligence. Once
these factors are identified, it is possible to compare
these features with those described by Asperger (1944)
and other researchers (e.g., Szatmari et al., 1989b;
Wing, 1981). A further question is to what extent
any identified distinguishing features corroborate those
proposed by DSM-K
Two methods could be used to investigate clinicians’
practice in the use of AD and AsD diagnoses. One
approach would be to interview a cross-section of
clinicians in child and adolescent psychiatry and ask
which criteria they use to make a distinction between
the two groups. A recent Australian survey of child
and adolescent health professionals found that no clear
consensus was available on which differential criteria
were used to distinguish AsD from AD (Brooks and
McGillivray, personal communication). Another ap-
proach would be to assess individuals from each clini-
cally diagnosed group using a structured interview to
find possible distinguishing clinical features between
the two groups. By this process it may be possible to
detect characteristics that clinicians do not readily
report through an interview process but that may be
manifest in the diagnoses they give. This second method
is used in this study.
METHOD
Sample
Subjects were recruited from autism and Asperger’s syndrome
support groups in Melbourne and Adelaide, referrals to the child
and adolescent outpatient clinic of a major Melbourne metropolitan
hospital in Australia, and the Centre for Communication Disorders,
Kent, England. Twenty-two clinicians including child psychiatrists,
pediatricians, and psychologists were responsible for diagnosing
the cases. Only children described as “high hnctioning” by a
clinician were recruited. All children had language skills, and overall
there was a nonsignificant difference between chronological age
(CA) (10.65 years; range 2.7 to 21.3 years) and verbal mental age
(10 years; range 2.5 to 33.7 years). This study makes no claim to
represent the more prevalent moderate-to-low-functioning children
with autistic behaviors, for whom the diagnosis of AsD is rarely
an issue.
 C O M P A R I S O N OF A U T I S M A N D ASPERGER’S D I S O R D E R
Forty-eight subjects with AD (mean CA 10.5 years, SD 4.5; 39
male, 9 female) and 69 subjects with AsD (mean CA 10.7 years,
SD 3.6; 61 male, 8 female) were recruited, making a total of 117
subjects. The groups did not differ in mean CA or ratio of males
to females.
Measures
Families were seen either in the various research clinics or at
home. T o obtain information concerning ICD- 10 (World Health
Organization, 1993) and DSM-Iff-R(American Psychiatric Associa-
tion, 1987) diagnostic criteria for PDD, a checklist of items to be
used in an interview with parents was devised. This gave a range
of specific examples of the types of behavior that were expressed
in more general terms in the two international classification systems.
The version used in this study was based on an earlier checklist
devised by Wing (in Rapin, 1996) plus some items from the
Diagnostic Interview for Social and Communication Disorders
(known as DISCO). This is an extensive interview schedule, not
yet published, that is being developed by Wing and Gould (personal
communication). The checklist contains 89 questions encompassing
the social, communication, and behavioral domains. These items
cover DSM-ffZ-R, ICD-10 research criteria, Kanner’s syndrome,
Asperger‘s syndrome, and Wing and Gould’s triad of social impair-
ments. For the purpose of this article, only DSM-Iff-Rand ICD-
10 criteria for AD were used in the analyses, as it was considered
that these were the two systems that would have been most likely
to be used by clinicians in the period preceding recruitment (up
to 1994). All interviewers were experienced in working with the
checklist and with families and children with autism-related
conditions.
Each child received two scores per item. Parents were asked
whether the itendbehavior had occurred earlier in the child’s life
(an appropriate age would be given, usually between infancy and
6 years), denoting an “early” response, and whether the behavior
was still present, denoting a “current” response. A positive response
to an item was recorded only if it was indicative of the child’s
usual behavior. Absence of the behavior and occasional or “one-
off” instances of behavior would score a negative response.
The suitability of an “early” item would depend on the behavior.
For example, the item “Concern for personal modesty” is usually
observed in normal children 6 years of age or older. Parents would
be asked to recall an example of their child’s either being modest
(e.g., worrying about visitors entering the house while he or she
was undressed) or not (e.g., leaving the school toilet without pulling
up his or her pants). Other items were of interest between the
ages of 1 and 3 years. For example, the item “Reciprocation in
simple games” concerned whether the very young child would
engage with a parent in simple “peek-a-boo” type games. Although
some children in the sample would develop more interest in these
types of games after they reached 7 or 8 years, the absence of the
behavior when it was developmentally appropriate was significant
and was scored accordingly (i.e., positive). Other items were devel-
opmentally appropriate only for older children. For example, an
“early” response for the item “Embarrassing remarks in public”
would apply only to speaking children older than 9 years of age.
No score would be given for items that could not be performed
because the subject was either too young or old.
A negative score was recorded when a parent could not recall
an example of a behavior. Although earlier childhood behaviors
were more difficult for parents to remember than current behaviors,
most parents could recall vivid examples of their child’s behavior
and how it compared with that of another sibling or a friend’s
J . AM. ACAD. C H I L D ADOLESC. PSYCHIATRY, 35:11, N O V E M B E R 1996
child. When available, clinical diagnostic reports describing the
child’s earlier behaviors were used to confirm parents’ reports. A
recent study by Yirmiya et al. (1994) found that parents of autistic
children, similar in age to those in the present study, were highly
reliable reporters of early clinical information.
Developmental and historical information, including the follow-
ing, was also recorded: ante-, peri-, and postnatal complications;
physical health in the first 2 years of life; motor milestones; early
language information; the child’s age when parents first recognized
the existence of a problem: age at diagnosis: presence of other
diagnosed medical conditions (apart from AD and AsD); family
history of AD or AsD-like conditions; sibling psychopathology:
and use of medication.
The Peabody Picture Vocabulary Test-Revised (Dunn and Dunn,
1981) and the British Picture Vocabulary Scale (Dunn et at., 1982)
were used as measures of verbal mental age (raw scores converted
to standard score) in Australia and Britain, respectively.
Analysis
Logistic regression analyses were performed to determine the
clinical variables that distinguish between AD- and AsD-diagnosed
groups. Stepwise logistic regressions were performed to select the
best predictors within each domain of clinical symptoms: social,
communication/imagination, and stereotyped/repetitive behaviors
variables. Variables selected in these three subsets were then used
in a standard logistic regression to evaluate their utility in predicting
membership of AsD and AD groups. The same method of variable
selection was used for “early” data as with the “current” data.
Separate analyses were performed for DSM-Iff-R and ICD-10
criteria (Table 1).
T o determine whether any developmental history variables were
more predictive of AD or A D , variables were dichotomized (into
presence/absence of symptoms) and a stepwise logistic regression
analysis was performed. Multivariate tests of significance (Ho-
telling’s 72) were used to compare groups on CA, verbal mental
age standard scores (VMASS), and age at diagnosis.
RESULTS
Diagnostic Variables
The results show that the AsD-diagnosed subjects
were more likely to engage in more prosocial behaviors
than the AD-diagnosed group. Important predictors
of diagnosis across time were desire for friendship and
an ability to engage with another person who had the
same circumscribed interest. The AsD children were
also more likely to have less severe eye contact avoidance
when young and more willingness and ability at playing
with others as they got older.
In the communication/imagination domain, the
AsD-diagnosed subjects were less likely to use echolalic
speech when young compared with the AD subjects.
Their speech content was more likely to be repetitive
without appropriate turn-taking and contain idiosyn-
cratic words or phrases. Their tone of voice would also
1525
EISENMAJER ET AL.

TABLE 1
Early and Current DSM-III-R and ICD-10 Variables That Best Predicted Asperger’s Disorder (AD)
Subjects as Diagnosed by Clinicians
Diagnostic Systems
Criterion DSM-III-R DSM-III-R ICD-10 ICD- 10
Domains a Clinical Variables Current Early Current Early

A Some avoidant eye contact (not severe) Yes

A Desire for friendship (though has poor grasp Yes Yes Yes Yes
of concept of friendship)
A More willing/able to join others in play Yes -b -b
activities
A Engages with one other who has same circum- Yes Yes -b -b
scribed interest
B One-sided, repetitive conversations Yes
B No evidence of immediate or delayed echolalia Yes Yes
B Idiosyncratic use of words or phrases or signs Yes
B Long-winded, pedantic speech Yes Yes -b -b
B Tone of voice Yes Yes
C Asks repetitive questionsltalks on repetitive Yes Yes Yes Yes
themes
C Collecting facts on specific subjects Yes Yes
% Correct prediction of diagnosis of AsD 74.4 77.8 69.2 78.6
(x2[61= 37, (xz[7] = 58.9, (x’[3] = 20.3, (x2[61= 46.8,
p < .01) p < .01) p < .01) p < .01)
Goodness-of-fit statistic Z z = 105.0 Z 2 = 105.8 Z 2 = 116.4 Z z = 113.8

aCriterion domains: (A) corresponds to social, (B) communication, and (C) stereotyped/repetitive behaviors.
’Variables that are not mentioned in the diagnostic system.

be unusual (e.g., flat, monotonous). The AsD children
were also more likely to engage in long-winded ped-
antic speech patterns from a young age to current
presentation.
In the stereotyped/repetitive behaviors domain, AsD
children were likely to have always asked repetitive
questions, talked repetitively on one theme, and col-
lected facts on specific subjects.
(To ensure that variables with more than 5% missing
data did not influence the results, analyses were rerun
without five “current” and seven “early” variables.
There was no change in selected variables.)
Developmental Variables
All subjects, regardless of “clinical” diagnosis, ful-
filled criteria for DSM-ZZZ-R and ICD-10 AD. ICD-
10 (and now DSM-ZV) stipulates that AsD children do
not experience a language delay or have communication
difficulties as listed for AD. In this study, significantly
more of the AD group (73.8%) compared with the
AsD group (43.1%) were reported to have experienced
a delay in language onset ( ~ ’ [ l=] 9.74, p < .01). In
a stepwise logistic regression analysis using all develop-
mental indices, no one or set of variables could predict
diagnosis. Most of the sample had some disturbance
or deviance in communication, with only 7.5% of the
total sample (2.4% of AD and 10.8% of AsD, not
significant) reported by parents as communicating nor-
mally. Significantly more AsD children had attention-
deficit/hyperactivity disorder (ADHD) as a comorbid
condition ( ~ ’ [ l =] 5.2, p < .02), and children with
AD were more likely to have experienced a delay in
walking (x2[1] = 5.6, p < .02) (Table 2).
Table 2 shows that the groups were not different
on relative incidence of other diagnosed problems in
siblings; use of medication; pregnancy, birth, and in-
fancy complications; presence of AsD-like conditions
in the father and family; and sitting and crawling
milestones.
CA, VMASS, and Age at Diagnosis
The multivariate Hotelling’s T2 conducted between
AD and AsD groups on CA and VMASS, and age
at diagnosis variables, was statistically significant

1526 J . A M . A C A D . C H I L D A D O L E S C . P S Y C H I A T R Y , 3 5 : 1 1 , N O V E M B E R 1996
 C O M P A R I S O N OF A U T I S M A N D ASPERGER’S D I S O R D E R
(F[3,96] = 12.5, p < .01). Follow-up univariate F
tests showed that the AsD group had a significantly
higher VMASS than the AD group (F[1,98] = 13.9,
p < .01). The AsD group were diagnosed significantly
later than the AD group (F[1,98] = 15.6, p < .01).
DISCUSSION
This study does not make any claims about the
diagnostic validity of AsD and the differences from
AD. Rather, it is a study about the extent to which
clinicians can usefully apply existing criteria to higher-
functioning PDD children. The results suggest that
few clinical differences exist between high-functioning
AD and AsD groups as categorized by clinicians. Al-
though all of the subjects fulfilled criteria for DSM-
ZZZ-R and ICD-10 (and by default DSM-ZV) versions
of AD, the results suggest that a few key characteristics
may influence clinicians’ use of the label AsD rather
than AD. AsD individuals were more likely to look
for social interaction, even from an early age. AsD
children sought friendships more than the AD children,
though both groups equally experienced difficulties in
attaining and keeping friends. Parents in both groups
were unable to report any friendship that shared the
depth, quality, and range of experiences of normal
children. It is possible that the notion of autistic
children desiring friendships is incompatible with the
more commonly reported descriptions of them as “liv-
ing in their own world” and aloof; hence clinicians
prefer to use AsD rather than AD. In a similar vein,
children with the AsD diagnosis were more likely to play
with a person with whom they shared a circumscribed
interest (e.g., chess, computer games, train-spotting)
than were children with the AD diagnosis. The ability
to interact meaningfully or play with another person
is not commonly identified in autism. In clinicians’
judgment, a diagnosis of AsD may allow for such
interactions, limited as they may be. The DSM-ZV
Course description for AD alludes to an “increased
interest in social functioning as the child reaches school
age” (p. 69). However, the results from this study
would suggest that interest in social functioning is
more characteristic of the AsD individual. No such
description is offered for AsD children in DSM-ZK
It is the communication variables that are of most
interest, especially since both ICD- 10 and DSM-IV
J . AM. ACAD. C H I L D ADOLESC. PSYCHIATRY, 3 5 : 1 1 , N O V E M B E R 1996
fail to list any of these criteria for AsD children, apart
from insisting that there is a normal onset of language.
The results suggest that clinicians may support this
notion, since a significantly greater proportion of chil-
dren with the AsD diagnosis were described as having
a normal onset of language compared with the AD
group. Of note, however, was the finding that almost
half (43%) of the AsD group reportedly had a delayed
onset of language. From these results it is clear that
clinicians have not been using a delay in onset of
language as an exclusion criterion for AsD in many
cases. This criterion was included in ICD-10 in accord-
ance with Asperger’s (1944) original view that in AsD
children there is no delay in language. However, con-
temporary accounts of AsD agree that language delays
are possible (Gillberg, 1989; Tantam, 1988; Wing,
198 1). Recent research findings have found age-depen-
dent results using early language delay as a differentiat-
ing variable between AsD and AD. Szatmari et al.
(1995) compared language-delayed with normal-lan-
guage-onset 4- to 6-year-old children with PDD and
found that delayed children showed more autistic symp-
tomatology, fewer adaptive skills, and lower receptive
language abilities. A similar study by Eisenmajer (1996)
replicated the finding that language delay predicted
autistic symptomatology for young PDD children;
however, this was not the case when the children
approached preadolescence (average age 11 years). He
concluded that early language delay is not a suitable
differentiating variable for PDD subtypes.
Other results question the decision to use language
onset as an exclusion criterion and not to document
communication impairment criteria in ICD- 10 and
DSM-ZVfor AsD. The diagnosis of AsD is defined
only in terms of the social impairments and repetitive
routines and stereotyped behaviors as for AD. However,
this study found that all of the subjects experienced
some type of communication problem and would meet
criteria for AD. This is problematic, as DSM-ZVstipu-
lates that AsD is not to be used if the criteria for AD
are met. If this were the case, none of these subjects
would be diagnosed with AsD. The results also show
that normal language onset does not necessarily pre-
clude later communication disturbances, as were evi-
denced in more than half of the AsD group. The
parents of both groups reported some sort of deviancy
in their children’s communication, such as absence of
1527
EISENMAJER ET AL.

TABLE 2
Developmental History Variables for AD and AsD Groups
AD AsD
Variable ( n = 48) ( n = 69) P
Mean verbal mental age (yr) (standard 78.2 95.2 < .01
score) SD = 25.77 SD = 19.78
Mean age (yr) when parent(s) first recog- 1.79 1.63 NS
nized existence of a problem with SD = 1.05 SD = 1.2
child n = 37' n = 57
History of language onset Normal = 26.2% Normal = 56.9% < .01
Delayed = 73.8% Delayed = 43.1%
History of language deviance Normal = 2.4% Normal = 10.8% NS
Deviant = 97.6% Deviant = 89.2%
Mean age at diagnosis (yr) 6.02 8.88 < .01
SD = 3.28 SD = 4.08
Other diagnosed problems No problems = 82.5% No problems = 67.2% NS
Yes problems = 17.5% Yes problems= 32.8%
n = 40' n = 64
Diagnosed ADHD ADHD yes = 2.5% ADHD yes = 17.2% < .02
NO ADHD = 97.5% NO ADHD = 82.8%
List of other diagnosed problems ADHD = 1 ADHD = 11
(in addition to autism) Tourette's syndrome = 1 Tourette's syndrome = 2
Cerebral palsy = 1 Cerebral palsy = 1
Schizophrenia = 0 Schizophrenia = 1
Semantic-pragmatic language Semantic-pragmatic language
disorder = 1 disorder = 0
Epilepsy = 1 Epilepsy = 5
Dyspraxia = 0 Dyspraxia = 1
Other = 2 Other = 0
Sibling diagnosed problems No problems = 82.1% No problems = 79.4% NS
Yes problems = 17.9% Yes problems = 20.6%
n = 39' n = 63

List of sibling diagnosed AD = 3 AD = 0

problems AsD = 0 h D = 2
Learning problems = 2 Learning problems = 3
Genetic disorder = 0 Genetic disorder = 1
Mental illness = 0 Mental illness = 2
Language disorder = 1 Language disorder = 1
ADHD = 0 ADHD = 4
OCD = 1 OCD = 0
Use of medication No medication = 82.1% No medication = 72.1% NS
Yes medication = 17.9% Yes medication = 26.9%
n = 39' n = 63
List of medication Dextroamphetamine = 0 Dextroamphetamine = 3
Methylphenidate = 0 Methylphenidate = 7
Sodium valproate = 2 Sodium valproate = 1
Albuterol = 4 Albuterol = 1
Other = 1 Other = 5
Difficulties during pregnancy No problems = 56.8% No problems = 66.1% NS
Yes problems = 43.2% Yes problems = 33.9%

-Continued

1528 J. AM. ACAD. C H I L D ADOLESC. PSYCHIATRY, 35:11, N O V E M B E R 1996

 C O M P A R I S O N OF A U T I S M A N D ASPERGER’S D I S O R D E R

TABLE 2
Continued
~

AD AsD
Variable ( n = 48) (n = 69) P
Dificulties during birth No problems = 29.7% No problems = 42.4% NS
Yes problems = 70.3% Yes problems = 57.6%
n = 37’ n = 59
List of difficulties during birth Induced labor = 1 Induced labor = 5
Forceps delivery = 8 Forceps delivery = 18
Cesarean = 9 Cesarean = 4
Low oxygen = 3 Low oxygen = 2
Other = 5 Other = 5
Significant illness during first 2 yr of life No problems = 48.6% No problems = 35.6% NS
Yes problems = 51.4% Yes problems = 64.4%
Sitting milestone (delayed: >9 mo) Normal = 87.5% Normal = 82.8% NS
Delayed = 12.5% Delayed = 17.2%
Crawling milestone (delayed: > 12 mo) Normal = 65% Normal = 78.1% NS
Delayed = 35% Delayed = 22.2%
Walking milestone (delayed: >20 mo) Normal = 60% Normal = 81% < .02
Delayed = 40% Delayed = 19%
Reported family history of AD or AsD- No family history = 57.5% N o family history = 39.1% NS
like behavior Yes family history = 42.5% Yes family history = 60.9%
n = 40* n = 64
Reported AsD-like traits in father No father traits = 87.5% No father traits = 71.9% NS
Father traits = 12.5% Father traits = 28.1%
List of AsD-like traits in family (relative Father = 5 Father = 17 NS
to child) Mother = 1 Mother = 1
Grandfather (paternal) = 1 Grandfather (paternal) = 5
Grandfather (maternal) = 0 Grandfather (maternal) = 1
Paternal relative =7 Paternal relative = 9
Maternal relative = 3 Maternal relative = 6

Note: AD = autistic disorder; AsD = Asperger’s disorder; ADHD = attention-deficit/hyperactivity disorder; OCD =
obsessive-compulsive disorder.
* Reduced sample sizes due to parents unable to offer age when they first recognized a problem in their child.

babbling, repetitive use of words, impaired prosody
(e.g., too loud, too soft, monotonous), pronoun rever-
sal, poor response to instructionslsimple communica-
tions, literal understanding of language, and problems
in initiation or ability to sustain a conversation. Never-
theless clinicians still saw fit to diagnose AsD in children
who had experienced a delay in a language or showed
communication disturbances but were less socially im-
paired and thus more “AsD-like.” More research is
needed on communication development in AsD to
determine whether future revisions of DSM and ICD
need to include particular kinds of communication
impairments as AsD criteria, or at least consider deleting
the lack of language delay as an exclusion criterion.
The results show that the early communication
history may be important for clinicians making a
diagnosis of AsD. AsD subjects were more likely to
have been one-sided in their conversation and to have
used idiosyncratic wordslphraseslsigns, long-winded
pedantic speech, and an unusual tone of voice. They
were also less likely to have been echolalic than the
AD subjects. At current presentation only the long-
winded, pedantic speech variable predicted the AsD
group. This finding probably reflects the less impaired
communication skills that are found in the AsD child
compared with the more language-delayed, echolalic
AD child. There were relatively fewer reported differ-
ences in communication as the groups got older. The

J . AM. ACAD. C H I L D ADOLESC. PSYCHIATRY, 3 5 : 1 1 , NOVEMBER 1996 1529

E I S E N M A J E R E T AL.
results suggest that with age, this able AD group
developed “AsD-like” communication characteristics.
This finding concurs with published clinical accounts
(e.g., Kanner, 1973; Wing, 1981) where individuals
may show “typical” AD characteristics in early child-
hood, only to develop “AsD-like” features as they
mature.
It is also proposed that clinicians are identifying a
less delayed or retarded group of children as having
AsD. The AsD group were less likely to have experi-
enced walking delays and at current presentation had
a higher VMASS than the AD group. Results from
intelligence testing of a subsample of the total group
in this study (Manjiviona, 1996) support the VMASS
finding, with the AsD group more able in the visuospa-
tial domain and marginally more able in the verbal
area. The AsD group is less cognitively impaired than
the A D group. The results also suggest that the lower
verbal skills of the AD group at current presentation
may reflect the delays first experienced in language
onset.
Another factor that points to a less severe impairment
suffered by the AsD group compared with the AD
group is the increased likelihood for the AsD group
to be diagnosed at a later age. This occurred despite
finding no difference in the age when parents first
recognized a problem in their child’s functioning. Dif-
ferent explanations could account for this finding.
Diagnostic confusion on the part of the clinician may
have delayed a diagnosis if there was an absence of
early “classic” autistic signs (e.g., echolalia); if the
individual’s problems went undetected until later in
childhood when significantly more social, communica-
tive, and cognitive demands were encountered, such
as at school; or if parents were not sufficiently concerned
in the early years to seek a diagnosis of an “odd” child.
Also of clinical interest is the increased likelihood
of a diagnosis of A D H D as a comorbid condition with
AsD. Although DSM-ZVstates that A D H D is not to
be diagnosed in individuals with a PDD, in some cases
this had taken place. The DSM-IV description of
the A D H D features of inattention, impulsivity, and
hyperactivity resembles the behavior of some AsD
children; however, whether the two conditions actually
do coexist or simply manifest in similar behaviors will
only be known in the future after the biological bases
of both disorders are found.
1530 J . AM. ACAD. C H I L D ADOLESC. PSYCHIATRY, 3 5 : 1 1 , N O V E M B E R 1996
O f significance is the finding that the two groups
were not different on many of the “classic” autism
impairments, such as in imagination, imitation, nonver-
bal communication, awareness of social rules, presence
of stereotyped movements (e.g., rocking, spinning,
hand-flapping), routines and resistance to change, and
literal understanding of language. The methodological
limitations of this study mean that the lack of differ-
ences between the two groups could be the result of
either no differences between the two groups, clinicians
misclassifying individuals, or unreliable or biased re-
porting of symptoms by parents. It is also possible that
differences do exist in degree or severity of symptom;
however, this issue was not able to be addressed in
this study. It is possible that AsD children display
more subtle or less frequent demonstrations of these
behaviors than do A D children. In this study each
variable was measured in a presendabsent format and
was probably too gross to detect more subtle differences.
Future research may find differences between groups in
symptom severity by using more fine-grained methods.
It appears that clinicians are identifying a group of
autistic children who seem to desire friends and who
make flawed attempts at social activities; who are less
likely to have experienced a delay in language onset
or echolalia, who use idiosyncratic words and pedantic
speech patterns, and who engage in one-sided, repetitive
conversations; and who have narrow, circumscribed
interests. Although this group fulfill criteria for AD,
clinicians are using the label AsD. The AsD group is
less cognitively delayed than the AD group, and it is
possible that the clinical differences reflect this factor.
No suboptimal birth, genetic, or developmental factors
(apart from delay in language onset and walking) appear
to reflect differences in diagnosis. The clinical picture
was also shown to change over time, where the young,
high-functioning AD child later came to resemble (in
some respects) the child with an AsD diagnosis.
These results suggest that clinicians have generally
accepted the descriptions outlined by Asperger himself
and further elaborated by other authors such as Wing
(1981, 1991), Gillberg (1989), and Szatmari (1989b).
The above description of AsD is also very similar to
Wing and Gould’s (1979) “active but odd” subcategory
of autistic children (the others being “aloof’ and “pas-
sive”). The “active but odd” children were noted to
make clumsy social approaches, to use repetitive and
 C O M P A R I S O N O F A U T I S M A N D ASPERGER’S D I S O R D E R
one-sided communication, and to engage in developed,
circumscribed interests. Follow-up into adolescence and
adulthood found roughly a fifth of the cohort had
changed from an “aloof’ to a “passive” or “active but
odd” style of interaction (Wing and Gould, 1979).
Our results confirm this change in symptom profile
over time and highlight the dilemma of affixing discrete
diagnostic categories to potentially “fluid” symptom
states. It is argued that the nosological validity of AsD
and other PDD subtypes as discrete categories will
occur only if there are differences in outcome, etiology,
or treatment; however, there is little evidence to date
to support such a notion (Szatmari, 1992). Wing
(1991) and others have argued for a broadening of
the traditional conceptual boundaries of autism by
recognizing different manifestations of autistic behav-
iors on an “autistic spectrum.” We hope that future
revisions of autism criteria more adequately reflect the
symptom profile of high-functioning autistic individu-
als that is increasingly being recognized by clinicians.
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