Domains of Social Communication Handicap

in Autism Spectrum Disorder

JULIA M. ROBERTSON, M.D ., PETER E. TAN G UAY, M.D ., SUZAN NE LECUYER , M .D., ALLISON SIMS, 8.S.,
AN D COURTN EY WALTRIp, M.D.

ABSTRACT
Objective: To investigate whether specific "social communication" handicaps could be identif ied in autism spectrum dis-
order using the Autism Diagnostic Observation Schedule and to compare the results with those found in a previous factor-
analysis study using the Autism Diagnostic Interview-Revised. Method: All subjects were evaluated with both instruments.
J.R. and P.E.T. independently diagnosed autism, Asperger's disorder, or pervasive developmental disorder-not otherwise
specified in 51 children . Items from the Autism Diagnost ic Observation Schedule that represen ted social communication
behaviors were factor-analyzed . Results: Three factors were identified: joint attention , affective reciprocity, and theory of
mind. These are the same social communication doma ins that were identified in the previous study. Conclusions: These
3 social commun ication doma ins have been discussed in the literature regarding normal development and in previous
research on autism spectrum disorders . If these doma ins are replicated in larger sample sizes. they could be used to mon-
itor the results of pharmacological and psychotherapeutic interventions in autism spectrum disorders. J. Am . Acad. Child
Ado/esc. Psychiatry, 1999,38(6):738-745. Key Words: autism, Asperger's disorder, affective reciprocity, joint attention,
theory of mind, social communication .

Social communication refers to a set of behavioral pro -
pensit ies in whi ch co m p lex co g n it ive and emotional
information is communicated through facial expres sion,
emo tio nal gesture, the prosod ic melody of speech, and
knowledge of the social rules of communication or prag-
matics. Children come into th e world with biologically
based capacity for the perception of, and empathic respon-
siveness to, the bodily expressed feelings and attitudes of
other people (Hobson , 1997).
The initial phase in the development of social commu-
n ication (0-6 months) involves sharing affective states
through the sending of emotional signals between th e
caregiv er and the child (Bakeman and Adamson, 1984;
Werner and Kaplan , 1963). C h ild ren and their mothers
(caretakers) seem dri ven to inte ract intersubjectively, with
th e caretaker using exaggerated tone of voice, gestures,
and facial expressions (Stern, 1974) in play with the child.
Accepted December 15. 1998.
From rllt D i vision of Child and Adolrscrnt P~ychi'll ry. Drparrmrnt of
Psychiatry. University of Louisville School ofM edici ne.
Reprin t rtq urJlJto D r. Robertson. Bingham Chi ld Guidanrr Center; 200 East
Chestnut Street, Louistnllr, K Y 40202.
0890·8 567/9 913806-0738(01999 by the American Academy of Child
and Adolescent Psychiatr y.
By the age of 10 or 12 months, ch ild ren not only attend
to others' emotional expressions, but also read them as
meaningful. For example. if a baby is placed across a "vis-
ual cliff" from its mother, the baby w ill only cross the
clear Plexiglas if the mother sm iles. If she looks fearful,
the baby will not cross (So rce et al., 1985).
In his original description of the syndrome of early
infantile autism, Kanner (1943) emphasized the central-
ity of a basic, pervasive disturbance in social development
which he felt represented an inborn autistic disturbance
of affect ive contact. Other investigators (Borm ann-
Kischkel et al., 1995; Hobson , 1986) have noted th at
aut istic children appear to lack the constitutional com-
ponents of emotional reactivity which normally em erge
in the first months of life.
The parents of autistic child ren frequently report very
early deviance in the development of quite basic nonver-
bal interpersonal skill s, including eye contact (Farran
and Kasari, 1990; Ornitz er al., 1977; Phillips et al., 1998;
Volkmar and Mayes, 1990) a n d facial expressiveness
(Walker-And rews, 1997; Yirmiya er al., 1989). Autist ic
children have been described as lacking almost all proso-
cial behaviors as youngsters, including giving, sharing,
helping, offering co m fo rt, offering affection , greeting

738 J. AM. ACAD. CHILD AD O L ESC. P SYCHIATRY. 38:6. J UN E 1'1'19


others, and responding to humor (Dunn, 1995; Ohta
et al., 1987). They appear to have selective impairments
in the expression of emotion as compared with other
developmental tasks (Herrzig et al., 1989). Lord (1997)
noted that all the behaviors that best discriminate autis-
tic children at the age of 2 involve communication of
affect: greeting, seeking to share enjoyment of an event,
and responding to others' indications of pleasure. As
adults, persons with autism seem not to understand the
social requirements of human interchange, even if they
have good semantic or syntactic speech (Shapiro and
Herrzig, 1991).
It may also be that the exchange of affect between the
young child and others provides a unique source of infor-
mation that plays an important early role in the devel-
opment of certain aspects of social cognition (Malatesta
and Izard, 1984). The onset of intentional communica-
tion in normal development has been found to occur at
about 9 months of age (Bakeman and Adamson, 1984;
Hannan, 1987; Leung and Rheingold, 1981). At this time,
infants begin to engage in triadic exchanges involving
coordination of the child's and caregiver's attention with
respect to some third object (Masur, 1983). These triadic
exchanges have been differentiated into protoimper-
atives, or requesting behaviors, and protodeclararives, or
joint-attention behaviors.
Numerous researchers have noted deficiencies in the
development of prorodeclaratives or joint-attention skills
in autism (Curcio, 1978; Mundy and Sigman, 1989;
Sigman et al., 1986). Several investigators (Kasari et al.,
1990; Mundy et al., 1992) have suggested that the abil-
ity to engage in joint-attention interactions is an elab-
oration of the earlier capacity to share affect. Joint-
attention behaviors, rather than requesting behaviors,
may be the more direct descendants of early affective in-
teractions, because a primary purpose of joint-attention
behavior appears to be to share the experience of an
event or object with others (Baron-Cohen, 1989; Kasari
et al., 1990; Mundy et al., 1986) . Mundy (1995) con-
cludes that autistic children's deficits in joint-attention
skill development have a lifelong negative effect on the
social cognitive development of these children.
Theory ofmind involves explicit awareness that others
have thoughts and feelings different from our own that
can be ascertained and used to enhance our interper-
sonal relationships (Wellman, 1988). The capacity for
theory of mind may be more fully evident only after a
child has achieved a mental age of 30 to 36 months
J. AM . AC A D . C H I L D AD()LES C. PSYCHIATRY. .IX :(" JUNE 1"9'1
AUTISM SP ECTRUM DISORDER
(Lewis and Osborne, 1990; Wellman, 1988). Pretend
play skills are hypothesized to be the earliest indicators
of the capacity for pragmatics and theory of mind
(Leslie, 1987; Lillard, 1993).
Baron-Cohen (1991) hypothesized that the primary
deficit in autism involves an innate lack of the capacity
for meta-representation or theory of mind. While others
(Boucher, 1989; Mundy and Sigman, 1989) have chal-
lenged the primacy of theory of mind deficits in the eti-
ology of autism, few disagree that symbolic play represents
the earliest manifestation of this capacity and that sym-
bolic play is lacking in children with autism (Charman,
1997; Leslie, 1987; Leslie and Frith, 1988). Several
accounts of the impaired development of theory of
mind in autism emphasize the crucial role played by the
earlier emerging abilities of joint attention and pretend
play (Charrnan, 1997; Mundy et al., 1997).
The current investigation was undertaken as an exten-
sion of our previous work in which we attempted to
develop a tentative solution to the problem of classifying
milder but clinically handicapping forms of "autism
spectrum disorder." In that study, we showed that when
a factor analysis was applied to data derived from the
Autism Diagnostic Interview-Revised (ADI-R) (Le
Couteur et al., 1989; Lord et al., 1994), a 3-factor solu-
tion resulted . These factors were similar to the domains
of social communication described above, that is, affictive
reciprocity, joint attention, and theory of mind (Tanguay
etal.,1998).
The ADI-R is designed to obtain a historical overview
of a child's symptoms of autism and social communication
from the parent. In contrast, the Autism Diagnostic
Observation Schedule (ADOS) (Lord et al., 1989) pro-
vides direct observation of the child's current symptoms of
autism as well as a description of specific social communi-
cation skills. The ADOS is composed of 9 social "presses"
in which the interviewer sets up the social situation and the
child's or adolescent's responses are videotaped for later
scoring. After the interview has been completed, the
administrator of the ADOS or other trained raters score
the child 's performance in terms of 41 items on the scale.
These include language ability, social communication
behaviors, stereotypical behaviors, and specific factors that
might have interfered with the interview (temper tan-
trums, hyperactivity, erc.). Scores range from 0, indicating
no abnormality, to 3, indicating severely deviant or defi-
cient functioning. Anchor points for behaviors expected
for 0, 1, 2, and 3 are given for each item in the scales.
739
ROBERTSON ET AL.
The goals of the present investigation were (1) to
determine whether domains of social commun ication
handicap could be identified in data obtained with the
ADOS instrument. and (2) to compare the results from
the ADOS with those of th e ADI-R. recognizing that
these 2 instruments rate different perspectives on the
child's functioning.
METHOD
SUbjects
All subjec ts had alread y been evalua ted using th e ADI -R (Tanguay
et al., 1998). When our analysis of ADI-R data was begun in late 1996,
interview data had be en co llecred for each subj ecr using eithe r rhe
ADOS or th e PL-ADOS (Prelingu istic Aurism Diagnostic Observarion
Sched ule, used wirh non verbal su bjec ts). There were nor en o ugh sub-
jecrs in eirh er o f rhe larrer groups ro pe rm it an adeq ua te facro r anal-
ysis; hen ce th e resulr s of the ADI-R and ADO S evaluarions co uld
nor be published together,
All AD O S evaluati o ns were done within 10 days of rhe child's AD! -
R evaluation by P.ET, wh o had bee n trained in irs usc. The records for
each of the subjects (including the videotape of th e ADOS) were inde-
pendenrly reviewed by 2 clin ician s O.R. and P. E.T.) using a rat ing form
rhar includ ed all of rhe sym p ro ms of aurism o r of o rher per vasive
developmental d isord er (PO D ) caregor ies lisred in rhe DSM -1V. Each
rarer d iagn osed eirher au tism, Asp erger's di sord er, per vasive devel-
o pment al d isorder-nor o rhe rwis e speci fied (PO D- N O S), ot he r dis-
o rde r, or no disorder. On ly thos e child ren wh o were given 1 of the 3
POD diagnoses by borh raters indep end entl y were entered int o the
project. Mo st subjects w ith diagnosed POD-NO S had marked ab nor-
malities in th e first 2 dom ains of th e DSM -l v' but not in the th ird. A
few subjects had symptoms from all 3 dom ain s but rhey failed ro reach
th e DSM -1V qu antitative crireria (i.e., musr have 6 o r more roral sym p-
ro ms fro m all 3 domains). No subject had fewer th an 5 sym pro ms
from the 3 dom ains . PO D-NOS subjects were included because th is
was nor solely a study o f autism , bur of th e wide r specrru m of the d is-
o rder as represented with in the full classificatio n of POD.
Sub jects were excluded if they were younger than 36 months or
older than 16 years. Except for 2 sub jeers who had uncomplicared sei-
zures, no subjects had any othe r known neurological or genet ic disorder.
) .R. and P.E.T. independen tly diagnosed DSM -1VPDD in 5 1 subjects.
Data Analysis
V id eo ta pes o f th e ADOS fo r 33 su bjects were indepe nd en tly
rated by 2 sets of rra ined raters (S.L.-A.S. and ).R.-C.W.). T heir
mean inrerrarer reliabiliry was 78 % with a range of 70% ro 90%. All
d isagreements were serried by having th e rat ers review the rap es and
reac h co nse nsus. Two raters (J. R. and P.E.T. ) train ed ro an inrerrarer
reliabili ry of >80%. T hey indepe nd en tly rated the video tapes for the
rem aining 18 subj ecrs. Thirteen variables, th ose judged ro measur e
soc ial communicarion items. were chos en fro m th e O verall Rating
Scales of th e AD O S fo r further ana lysis. T hey arc listed in Ta ble I .
Da ra were an alyzed using the SPSS Facro r An alysis program (No rusis,
1996) with varimax ro ration.
RESULTS
Forty-four subjects were male and 7 were female. Their
ages ranged from 36 months to 191 months (mean age
740
88 months). Six ch ild ren (12 % ) had Full Scale IQs
below 70. Sixteen (31 %) of the children were receiving
med ication. Ten were receiving low co moderate doses of
stimulants (methylphenidate. dextroamphetamine) for
symptoms of easy d istractibility, short attention span,
and hyperactivity. Two of the latter were also receiving
clonidine. Two children were receiving tricyclic antide-
pressants, 2 were receiving selective serotonin reuptake
inh ibitors, and 2 were receiving medications for seizures.
Other than tho se children on a combination of a stimu-
lant and clonid ine, onl y 2 were receiving more than on e
medication. One was receiving sertraline and methyl-
phenidate, and another was receiving doxepin , Huoxe-
tin e, and haloperidol. The haloperidol was given for
Tourerre's disorder, which emerged at age 8 after a trial
of methylphenidate and included characteristic motor
and vocal tics th at were well-m an aged with the med -
ication. The subject also tore paper into strips and waved
them in front of his eyes, a symptom classified as one of
the "restr ictive, repetitive, and stereotyped behaviors"
described under PDD in DSM-IV.
Before proceeding to the factor an alysis, we examined
several indices to determine the suit ability of using this
particular stat istical approach. The Kaiser-Meyer-Olkin
measure of sampling adequacy was 0.865 and the
Bartlett test of sphericity was 0.0000, indicating the data
were sui table for factor analysis. All variables had high
Communality scores (range 0.53 4-0. 841).
A 3-factor solution, accounting for 72% of the vari-
ance , appeared to best represent the data. The factor
scores and the variable loadings are shown in Table 1.
Variables that had a factor loading greater than 0.55 on a
factor were chosen as representing the factor in question.
Eight variables loaded on factor 1, joint attention; 4 var-
iables loaded on affective reciproci ty; and 1 loaded on
theory of mind.
The ADOS factor scores for each subject were com -
pared using a correlation analysis to his or her factor scores
on th e previous (Tanguay et al., 1998) ADI-R analysis
(Table 2). The results are shown in Table 3.
A third analysis was carried our to examine the rela-
tion ship of specific deficits in affective reciproci ty, joint
attention, and th eory of mind to each other. Each sub-
ject's scores for each of the 3 domains were added togethe r
to create a new variable representing each subje ct's over-
all sever ity of dysfunction. The 51 cases were divided
into 3 equal groups based on their overall severity scores
(Table 4) . An an alysis of variance indicated that there
I . AM ACA D. CHI !.D A D OLESC. PSYCHIATRY, .) H :(" JU N E 1') ') ')
 AUTI SM SP ECTRUM DIS ORDER

TABLE 1
Factor Analysis of Social Communication Symptoms in the Aut ism D iagnostic O bservatio n Schedule
Factor I: Factor 2: Factor 3:
Variables Joint Attention Affective Reciprocity Theory of Mind

Shared enjoyment in int eraction 0.799 0.210 0.196

Report of th ings, acti vities, int erests 0.640 0.359 0.231
Amount of reciprocal communication 0.801 0.277 0.213
Amount of social overtures 0.871 0.286 0.037
Socially modulated eye contact 0.655 0.531 0.105
Quality of social overtu res 0.807 0.273 0.255
Quality of social responses 0.693 0.297 0.054
Quality of rapport 0.813 0.302 0.109
Rang e of facial expression 0.216 0.700 0.532
Inronation/volume/rare/rhyrhm of speech 0.169 0.705 0.094
Appropriate social smiling 0.441 0.555 0.507
Vocalization accom panied by appropriate changes
in eye contac t and facial expression 0.540 0.625 0.075
Var iety of invent ive. creative play 0.137 0.037 0.903

Note: Variables th at had a facto r loading greater than 0.55 were chosen as representing the factor in que stion and are in
bold face type .

were significant d ifferen ces in scores as a fun ction of theory of mind (p < .001) , and between joint att ention
severity (F = 59.9, P < .00 1) and as a function of social and theory of mind (p < .015).
communication domains (F = 13.9,p < .00 1). There was Finally, we studied the relationship between the sever-
no severity by domain interaction (F = 0.9, P not signif- ity of social communication handicap and diagnosis. The
icant). Preplan ned Bonferroni contrasts showed th at number of cases with auti sm , Asperger's disorder, and
overall mean scores, irrespective of severity, were signifi- POD within each severity group is shown in Table 5.
cantly different between affective reciprocity and joint An analysis of variance was carried out using total social
attention (p < .02), between affective reciprocity and com m unicatio n score as the dependent variable and
TABLE 2
Factor Analysis of Social Co mm unica tion Symptoms in the Autism Di agno stic Inte rview-Revised
Facto r I: Facto r 2: Facto r 3:
Affective Joint T heo ry of
Variables Recip rocity Attention Mind

Affection ate to others 0.69018 0.04543 0.23488

C omes for comfort when hurt 0.76355 0.06529 - 0.030 11
Offers com fort to others in distress 0.55728 0.45477 0.03900
Gree ts others with pleasure 0.74748 0.33442 0.16840
Offers to share toys/ food with others 0.52477 0.36067 0.36286
Vocalizes with others to be social/friendly -0.14253 0.57265 0.4330 1
Reciprocal conversation - 0.14331 0.62373 0.27324
Tries to share enjoyment with others 0.13508 0.60100 0.25250
Dire cts other's attention to toy/ob jects in wh ich he/she
has an intere st 0.26118 0.68656 0,34457
Asks about other's interest/ideas/attitudes 0.03867 0.67544 -0 .09197
Shares other's pleasure and excitement 0.34355 0.68734 -0.02050
Inter est in watch inglinteractin g with other ch ildren 0.25753 0.13709 0.70469
Responds positively to other ch ildren's approach 0.21733 0.03252 0.68660
Imaginative play alone ; creat ive use of actions and objects 0.17400 0.38019 0.54926
Imaginati ve play with peers -0.01136 0.37991 0.76983
Group play with peers 0.25630 0.33226 0.67580

No te: Variables th at had a facto r load ing greater than 0.55 were chosen as representing the factor in qu estion and are in
bold face type.

J . AM . ACA D . C H I LD AD O LESC. PS YCHIAT RY. 3 8:6 , JU N E 1999 741

ROB ERT SO N ET AL.

TABLE 3 TABLE 4
Co rrelatio ns (Pearson Product Mom ent C oefficient) Division In to G roups Based o n Severity of Socia l
Between the ADI-R Facto r Analysis Domains and Co mm unication Dysfun ct ion
the AD O S Factor Analysis Do mains
Social Co m munication Affective Joint T heo ry of
ADI-R Factors Deficits Reciprocity Attention Mind
Affective Joint Theory of Most severe (n = 17 ) 1.48 1.8 2 2.24
ADOS Factors Recipro city Atte ntion M ind Int er mediate severity
(11 = 17) 0.97 1.44 1.50
Affective reciprocity 0.084
Least severe (11 = 17) 0.46 0.55 0.93
Joint atte nt ion 0.202
Theor y of mind 0.312· Note : An overall socia l comm unicatio n score was calculated for
Note: AD1-R = Aut ism D iagnos tic Int erview-Revised; AD O S = each case by ad ding tog ethe r the sco res from all 3 dom ains and
sorti ng the cases into 3 groups by severity. H igher mean scores in
Aut ism D iagnostic Observat ion Sched ule.
• p < .05. each do ma in (the range co uld be from 0.0 to 3.0) repr esent more
severe handicaps. An analysis of variance indicated th at th ere were
significant differences in scores as a fun ction of severity (F = 59.9, P <
diagnosis as the independent variable. Significant between- .001 ) and between ind ividu al social communication dom ains (F =
group differences were identified (F = 9.5, P < .03 ). Post 13.9,P < .00 I ). Prepla nn ed Bonferron i cont rasts show ed th at overall
hoc Bonferroni contrasts indi cated th at the differences mean sco res, irrespective o f severi ty, were sig n ifica ntly d ifferent
between affective reciprocity and joint attent ion (p < .02), between
were primarily between autism and POD-NOS at a trend affective recipro city and theo ry of mind (p < .00 1), and between
level (p = .059); differences betw een aurism /Asperger's joint attentio n and th eor y of mind (p < .01 5).
disorder and Asperger's disorder/POD-NOS were non -
sign ificant. resented by a single score. Although the theory of mind
scores in the ADI-R and the ADOS were correlated to a
DISCUSSION
statistically significant degree, the single-variable nature
As was found for the ADI-R, factor analysis of the of the domain in the ADOS dem ands a cautious inter-
ADOS data resulted in the identification of 3 social com- pretation of th e theory of mind scores in th e ADOS.
munication factors: affective reciprocity, joint att ention, Future work mu st strive to add variables to this domain.
and theory of mind. Examining the specific beh aviors The new version of the ADOS , the ADOS-G (Lord,
associated with the facto rs for each of the instruments, personal communication , 1997), includes a greater num-
we see that the y differ to some deg ree. Variables describ- ber of items pert aining to imagin ation in older children
ing sha red , reciproc al, and socially mediated interactions and adults, and it may be a better instrument for mea-
assume a more prominent place in the factor structu re of surement of theory of mind .
the ADOS data compared with that of the ADI-R. Var- It must be acknowledged th at our assignment of
iables prominent in the factor structure of the ADI-R label s to the factors identified in the ADI-R and the
are on es more likely to be observed by parents over a ADOS is subjective, even if the items in the specific
period of time, such as em pathic and greeting behaviors, dom ain s appear to match beh aviors de scribed in the
spontaneous sharing, capacity to sustain a con versation social communicat ion literature under the terms "affec-
or ch at , and shared enjoyment o r inquiries ab out
another person's int erests. TABLE 5
Relation ship of C linician's Di agn osis to the O verall Severity
In the ADOS factor analysis, the greatest part of th e of Social Co m munica tion Sco res
variance was explained by the factor j oint attention, in
Social C o mmunicatio n No. of Subjects
contrast to the ADI-R, where the factor affictivereciprocity
Deficits Auti sm Asperger 's PD D- N O S
represented the greater part of th e variance. The ADOS
appears to best represent interactive behaviors measured Most severe (n = 17) 10 5 2
in the here-and-now, while the ADI-R represents factor s Int ermedi ate severity (11 = 17) 8 5 4
Least severe in = 17) 4 7 6
best seen by a parent over a longe r period of time.
The theo ry of mind domain appe ars to represent, in Note: Altho ugh there were significant overall mean d ifferences
each instrument, observations about the child 's ability to between soc ial co m munica t ion dom ains independe nt of severity
level (F = 9.5, P < .03), post hoc Bon ferroni co ntr asts showed trend
engage in symbolic play. In the ADI-R, the domain rep- differences between only aut ism and pervasive developmental disorder-
resented scores in 4 variables, but in the ADOS it is rep: not o therwise specified (PD D- NOS) (p = .0 59).

742 J AM . ACAD. CHIl. D A[) Ol. ES C. PSYC H IATRY ..\8: 6 , J UN E 1999


tive reciprocity," "joint attention," and "theory of mind."
The term "theory of mind" is itself cumbersome and may
be poorly representative of what must be a very broad set
of human knowledge and skills (Baron-Cohen, 1991).
When the domain scores from the ADOS analysis
were compared with the same child's score on the AOI-
R, there is a strong correlation between the theory of
mind domain scores on the 2 instruments, but there is
less correlation between the other domains (Table 3).
Because it was our clinical impression that children's
AOI-R and ADOS domain scores were generally repre-
sentative of their clinical characteristics (i.e., children
with abnormal affective reciprocity scores were isolated
and unresponsive to human contact, whereas children
with good affective reciprocity but poor joint attention
emitted social signals but did not engage in referential
communication) , we suspect that individual differences
in factor scores between the 2 instruments indicate that
the instruments measure somewhat different manifesta-
tions of the social communication skills in question.
Table 5 demonstrates that while there is a relationship
between clinical diagnosis and overall social communi-
cation scores, it is weak. This was expected, as diagnosis
was only partly a function of severity. A subject with
POD-NOS could have DSM-IV social and communica-
tion handicaps which were as great as those seen in
autism, but not receive a diagnosis of autism because he
or she had few stereotyped behaviors. Similarly, a person
with Asperger's disorder might have marked social deficits
but normal communication. This finding emphasizes
that it would be incorrect to assume that the categories
of autism, Asperger's disorder, and POD-NOS represent
decreasing degrees of severity of POD. They are simply
different symptom categories.
Our results in this project apply only to our sample of
subjects, whose IQ and language abilities were higher
than those would be in a random sample of persons with
POD. Children with "profound" degrees of autism, who
respond very little to persons around them, might be
expected to have more severe disorders in affective reci-
procity than were found in our group. On the basis of
our clinical experience , we have no reason to believe that
the relationship between the 3 domains would be differ-
ent in a group of profoundly autistic subjects. We would
not expect that such children would have poor affective
reciprocity in the presence of goodjoint attention or good
theory of mind scores. Just as the 3 domains appear to
develop sequentially with age, we suspect that failure to
J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, .\H:(" JUNE I'J'J'J
AUTISM SPE C T R U M DI SORDER
develop these skills follows a similar order. This is only
supposition, however, and it could be that affective reci-
procity and theory of mind represent distinct but related
skills, only loosely associated in a sequential cause-and-
effect relationship. In such a scheme, poor affective reci-
procity would inevitably lead to poor theory of mind,
but good affective reciprocity could be still be followed
by failure to develop an adequate theory of mind.
It should be understood that while we have focused
on social communication skills in the current project
and not on language and intelligence, we did so because
we suspect that social communication is the core deficit
in POD. As was noted in a previous publication (Tanguay
et al., 1998), we have hypothesized that language and
cognitive disorders, as well as certain abnormalities such
as hyper- and hyposensitivity to sensory stimuli, are closely
related but not necessary characteristics of POD. Persons
with communication handicaps may have varying degrees
of language and cognitive problems, as well as of specific
sensory-motor abnormalities.
Clinical Implications
The goal of this study was not to ascertain whether a
social communication model would be better than some
other model, or whether POD is a spectrum disorder.
Rather, it asked whether a socialcommunication approach
would appear to have some heuristic value in examining
the phenomena of POD and in making sense of its var-
ious clinical manifestations. Parents, educators, and
other professionals wish to know "What is wrong with
this child and what can we do about it?" We have found
that the social communication model can be useful in
helping caretakers understand the nature of POD and
its treatment. We include, in our written clinical reports,
printouts from our database showing the child 's DSM-
IV algorithm scores, as well as his or her social commu-
nication domain scores. The latter are meant to extend
the DSM-IV diagnosis, focusing more specifically on the
nature and degree of the child 's social communication
handicaps. We emphasize that the domain scores, while
they may appear impressively scientific in their numeric
form, are, in fact, no more than our clinical best-estimate
of the child's social communication development. Our
approach is a "work-in-progress," to be further devel-
oped, revised, and eventually replaced with a better sys-
tem when one is found. We hope these findings will be
replicated by other researchers.
743
ROBERTSON ET AL.
If other explanations for autism are shown to be
important (e.g., that there is a failure in executive func-
tions), it seems possible that this development may
expand our hypothesis rather than replace it. If POD is
not a spectrum disorder, then there will need to be con-
siderable changes made in our current nosology to include
those cases that do not meet the DSM-IV criteria for
autism or Asperger's disorder.
The findings of this study and the earlier AOI-R fac-
tor analysis strengthen previous reports of the presence
of social communication handicaps in autism with
respect to affective reciprocity, joint attention, and the-
ory of mind. Such a dimensional approach could lend
itself to clarification of the severity and type of disability
of different autistic patients and assist in developing treat-
ment strategies that target the specific areas of handicap.
Those children with significant deficits in affective reci-
procity are likely to require the earliest, most aggressive
interventions, including pharmacological strategies tar-
geted at affect arousal and regulation. Behavioral interven-
tions in such instances might emphasize affect sharing,
social referencing, and joint attention. Those children
with good affective reciprocity and adequate joint atten-
tion but poorly developed theory of mind might re-
spond best to social coaching and cognitive-behavioral
approaches. As a result of our clinical observations, we
have recently become interested in whether medication
(e.g., selective serotonin reuptake inhibitors) might
increase affective reciprocity. Anecdotally, it has seemed
to us that deficits in affective reciprocity may not be
absolute (i.e., the child simply cannot emit the expected
affective signals) but relative. If affective signals from
others are sufficiently intense, then these children appear
to respond in a more normal way. Could their response
threshold be decreased with medication? And if not with
any known medication, might a medication be found
someday which could do this? We do not know.
Conclusion
We suggest that the domains identified in our factor
analysis constitute a somewhat arbitrary delineation of
what is a seamless process of social development in nor-
mal children beginning soon after birth. Moreover, we
suggest that the findings of this study further implicate
these 3 areas as central aspects of the social communica-
tion handicaps in persons with autism spectrum dis-
order. They also lend themselves to describing severity
along a continuum, as implied in the concept of autism
744
as a "spectrum disorder." With further validation of this
dimensional approach, scores in the identified social
communication domains could be useful for tracking
clinical progress quantitatively over time, as well as for
studying the results of psychosocial, educational, and
pharmacological treatments.
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