What is the Role of Communication and Language Across the Core Deficits of Autism?

Communication impairment is one of 3 core deficit areas used to determine a diagnosis of autism in the Diagnostic and Statistical Manual of Mental Disorders (4th edition) (DSM-IV-TR). Communication impairment is characterized by a delay or lack of communicative gesture use and spoken language development, challenges in the ability to initiate or maintain conversation, and unusual language use such as echolalia or idiosyncratic use of words. Unusual uses include private metaphors (eg, child says “ice cream trees” to refer to snow-covered trees, or “fix the alligator” to refer to fixing a tear on a book page that looks like an alligator); gestalt or unanalyzed phrases (eg, child repeats “Don’t touch the pizza” whenever they see something hot); and video scripts (eg, using exact dialog from the Cars movie when playing with a friend). In addition, limitation of or a lack of symbolic or pretend play is associated with communication impairment.

In the DSM-IV-TR, autism was categorized as one of several types of pervasive developmental disorder (PDD). The new umbrella category label proposed for the Diagnostic and Statistical Manual of Mental Disorders (5th edition) (DSM-V) ( http://www.dsm5.org ) is ASD. The change from PDD to ASD as the overarching label is driven by identification of a common set of behaviors that characterize ASD as a single diagnostic category, with individual variability in severity, language level, intelligence, and change over time. Within the proposed DSM-V revision, language and communication remain critical to understanding ASD. However, the revision modifies the traditional triad of symptoms by integrating communication impairment with the social impairment that distinguishes children with ASD from those with other neurodevelopmental disabilities. This action is being taken to address the frequent overlaps and often indistinguishable boundaries between the social and communication difficulties that characterize autism. This change also recognizes the role of context in understanding the impact of social communication deficits. Further, because language deficits are not unique to autism, an integrated view of the role of language and communication within the social impairment in ASD more accurately reflects the clinical symptoms of this disorder.

The core deficits in the proposed DSM-V revision for ASD now include “persistent deficits in social communication and social interaction,” with 3 specified criteria, all of which must be met for a diagnosis. In addition, the presence of “restricted, repetitive patterns of behaviors, interests or activities” must be documented about 4 criteria, 2 of which must be met for a diagnosis ( http://www.dsm5.org ). The social communication and social interaction deficits include challenges in social-emotional reciprocity, ranging from a lack of initiation, to an abnormal approach in a social context, to failure in back-and-forth conversational exchanges, including limited interest in sharing emotional and affective responses. Other symptoms include poorly integrated verbal and nonverbal communication abilities that contribute to social interactions, including abnormal eye contact and lack of gestures or facial expressions, as well as difficulties in developing and maintaining relationships. Relationship problems range from adjusting to a variety of social contexts, including sharing imaginative play with peers, to showing an interest in people and making friends. Considering the newly proposed social communication and social interaction criteria, the significant role language and communication play in the diagnosis becomes even clearer. Individuals must have an ability to understand the language that typically occurs in a social context (eg, how to interpret a joke, recognize tone of speech, or understand vocabulary used), as well as an ability to formulate a response (eg, answer questions, ask questions, or offer ideas).

The second core deficit area in the newly proposed diagnostic criteria for ASD is restricted, repetitive patterns of behavior ( http://www.dsm5.org ). These patterns of behavior include interests or activities that involve language and communication. For example, restrictive, repetitive behaviors may be characterized by stereotyped or repetitive speech (eg, idiosyncratic phrases or echolalia) and ritualized patterns of verbal behavior (eg, repetitive questioning) in addition to repetition or restricted patterns of nonverbal motor movements or object use; insistence on adherence to routines or resistance to change; restricted, fixated interests that are abnormal in intensity or focus (eg, perseverative interests); and overreactivity or underreactivity to sensory input or unusual sensory interests (eg, excessive smelling or object touching, fascination with lights or spinning objects).

Again, the role of language and communication becomes evident as verbal children with ASD use language in ways that are restricted, stereotyped, ritualized, and perseverative. Unconventional verbal behaviors such as echolalia, perseverative speech, and excessive questioning are common in autism. Echolalia, which involves repeating exactly what is said or heard, can serve functional purposes, such as to request, label, maintain contact, or take a turn with a potential communicative partner. These functions can be used as a bridge to more conventional communicative behavior. Perseverated speech involves imitated or self-generated utterances that are produced repeatedly with no real intent (eg, “Come on down” from a favorite TV program). It appears in contexts related to increased anxiety or language-processing difficulties. A child or adolescent who exhibits excessive questioning may direct the same question to a communicative partner with an expectation for a response even although the answer has been provided previously, perhaps related to increased anxiety or language-processing difficulties. Talking about specific interests that may not be shared by the conversational partner is also a common social communication problem for this population, using language that interferes with the reciprocal nature of communication and social interaction. Each of these behaviors complicates the ability of an individual with ASD to engage fully in the give-and-take of conversational discourse expected during social exchanges and used for supporting the development of friendships.

What is the Role of Language and Communication Across the Subthreshold Diagnoses of ASD?

In DSM-IV-TR, autism is categorized under the umbrella label of PDD, along with the subthreshold diagnoses of Rett disorder, childhood disintegrative disorder, Asperger disorder, and pervasive development disorder-not otherwise specified (PDD-NOS). The language and communication deficits across these disorders vary in severity and development, with associated implications for meaningful social communication. For example, Rett disorder is characterized by severe communication deficits, whereas childhood disintegrative disorder usually involves regression in receptive and expressive language skills and deficits in communication and social interaction typical of classic autism. With Asperger disorder, there is no significant delay in language development but frequent abnormalities in prosody, speech that is considered pedantic or bookish, deficits in conversation and nonliteral language, and a high incidence of faux pas in social contexts. Individuals with Asperger disorder often have difficulty identifying another’s attentional focus, emotional state and intentions, and selecting appropriate conversational topics based on context, the listener’s perspective, and repairing communicative breakdowns. In the proposed revisions for DSM-V, ASD is the umbrella label, and the category of ASD includes autistic disorder, Asperger disorder, childhood disintegrative disorder, and PDD-NOS.

What Developments During Infancy Contribute to Later Language and Communication?

Communicative behavior can be observed at birth in the intense mutual eye gaze that connects neonates to their parents, sealing the bond between them. Communication thus precedes language developmentally, and any difficulties can serve as early red flags so that preventative steps may be taken to engage the baby actively in reciprocal exchanges and shared attention. Early in infancy the establishment of joint attention is particularly important. It starts as mutual gaze between caregiver and infant and then proceeds to incorporate shared attention on a third object, person, or family pet, with the parent often commenting verbally as well as gesturally on the thing that is the focus of the child’s attention. If development proceeds typically, the infant soon learns to recruit the attention of the caregiver by using body orientation, vocalization, and shifting gaze (ie, first looking at the parent and then the object of interest). The parent can use similar means to recruit the child’s attention to new events or phenomena. The unfolding of this dance of social interaction requires the ability to coordinate visual attention around an object or activity and share an interest with another person.

Research has shown that young children with ASD are less likely to use joint attention acts and gestures and are less able to coordinate their vocalizations, eye gaze, and gestures than typically developing peers and children with other developmental disabilities. Poorly developed joint attention communicative acts are predictors of later language outcomes, and they have implications for development of conversational language. The level of communicative competence achieved by individuals with ASD predicts their long-term positive outcomes. These findings have led to a high interest in providing early interventions that teach parents to foster joint attention, with some promising results.

What Roles are Played by Language and Communication in Later Academic and Social Learning?

The ability to decode verbal and nonverbal communication and then encode a response that is meaningful and socially relevant requires an intact language system. Wetherby and colleagues reported that children with autism who can use fluent speech by age 5 years have a better prognosis for continued academic and social development. Some children and adolescents on the spectrum, especially those with Asperger disorder, have little difficulty learning language symbols and conventions for communicating and receiving literal messages. Some even show precocious reading without instruction, which is called hyperlexia. However, all children and adolescents with ASD have social communication problems related to the inability to imagine what others think, know, and find interesting. This ability to imagine what is in another person’s mind, which is termed having a theory of mind, is critical for developing social relationships and responding appropriately to the social moves of others. Challenges experienced by children with high functioning autism for coping with the demands of school often relate to these difficulties, as well as to coping with anxiety about unpredictable routines, shifting schedules, and difficulty organizing their approaches to learning. Students on the autism spectrum who have the basic academic skills to be successful in postsecondary education may risk failure because of problems with executive functions and self-regulation rather than with the academic demands themselves. Youth with ASD who have comorbid problems with cognition, speech, and language face challenges that may make it difficult for them to live independently.

What is the Role of Physicians in Early Identification?

In providing early care, pediatricians play a critical role in the early detection of children with or at risk for ASD. Physicians are likely to see children during critical periods for identifying behaviors that differentiate children with ASD from children developing typically or showing other developmental disabilities. In recent years, clinical researchers have identified several early markers for ASD. Some researchers have used techniques such as retrospective video analysis of the social, communication, and play behaviors shown in the first 2 years of life by children later meeting diagnostic criteria for autism. Other researchers have conducted prospective longitudinal studies in which children at risk for autism based on observation and screening results are followed over time to determine if hypothesized early markers are maintained and predictive of outcomes at 24 and 36 months of age. Shumway and Wetherby suggested that early identification of ASD is most often triggered by impairments in early social communication and repetitive behaviors. It is important, then, that primary care physicians follow the guidelines from the American Academy of Pediatrics for early screening and that they collaborate with families to identify those behaviors that place a child at risk for ASD. It is equally important that providers recognize the unique contribution of language understanding and use to the early markers for children with ASD. Early markers that research has shown to best differentiate children with ASD from those with other developmental disabilities are summarized in Table 1 .

Ventola and colleagues found children with ASD to score lower than children with developmental disabilities and other developmental language disorders in adaptive skills, expressive and receptive language, and fine motor and visual reception skills on a screening measure for autism; further, deficits in joint attention and social interaction seemed to be particularly unique to autism. Considering a more integrated view of screening and assessment, it is important to consider all aspects of development when screening children with or at risk for autism and to recognize the likely delays in language understanding and expression as they relate to responding to and engaging with others to share experiences and interests.

Socially, toddlers with ASD have greater difficulty in joint attention, imitation, pointing to express interest, interest in other children, and displaying a range of facial expressions and empathic responses compared with other children with developmental disabilities. This characteristic requires providers to have a clear understanding of typical development and developmental delays, and to use available developmental screenings tools (eg, Ages and Stages Questionnaire ), and autism-specific screening tools (eg, Modified Checklist for Autism in Toddlers [M-CHAT] ) to facilitate earlier diagnosis of ASD. Children with a lack of appropriate gaze or warm, joyful expressions with eye gaze and alternating vocalization patterns as well as a failure to recognize familiar voices (eg, parents) and decreased use of gestures are red flags for a potential diagnosis of ASD.

Understanding the developmental trajectory of communication is critical to the ability to make an early diagnosis. However, existing screening instruments have limitations ranging from methodological flaws to small samples, often missing children who are eventually diagnosed with ASD. Another barrier to early diagnosis is that it is more difficult to make a diagnosis at 2 to 3 years because early delays in saying first words, establishing joint attention, and engaging socially may be attributed to normal variation, whereas at 5 to 6 years discrepancies from normal development are more obvious. However, the evidence that early intervention is more effective than later is so compelling that health care providers must remain on high alert for early danger signs. This challenge requires practitioners to have a developmental perspective on the assessment of language and communication difficulties and subsequent intervention in young children with ASD. Vigilance also is required. Almost 30% of children with ASD present with periods of normal development followed by regression before 3 years. Thus, any signs of language regression represent a serious concern that requires follow-up.

To ensure effective assessment and intervention decision making, practitioners should engage family members in the process, and highly individualized profiles should be considered in program planning. Social communication profiles can predict both developmental level and autism symptoms within 20-month-old children, who have a distinct social communication profile, with language understanding being a strong predictor of developmental level, and behavior regulation and gesture inventory being a strong predictor of autism diagnosis at age 3 years. Programming is best supported by an integrated developmental framework that considers natural language samples, parental report, and standardized measures. These are the types of assessments conducted by speech-language pathologists.

What is the Role of Physicians in Early Identification?

In providing early care, pediatricians play a critical role in the early detection of children with or at risk for ASD. Physicians are likely to see children during critical periods for identifying behaviors that differentiate children with ASD from children developing typically or showing other developmental disabilities. In recent years, clinical researchers have identified several early markers for ASD. Some researchers have used techniques such as retrospective video analysis of the social, communication, and play behaviors shown in the first 2 years of life by children later meeting diagnostic criteria for autism. Other researchers have conducted prospective longitudinal studies in which children at risk for autism based on observation and screening results are followed over time to determine if hypothesized early markers are maintained and predictive of outcomes at 24 and 36 months of age. Shumway and Wetherby suggested that early identification of ASD is most often triggered by impairments in early social communication and repetitive behaviors. It is important, then, that primary care physicians follow the guidelines from the American Academy of Pediatrics for early screening and that they collaborate with families to identify those behaviors that place a child at risk for ASD. It is equally important that providers recognize the unique contribution of language understanding and use to the early markers for children with ASD. Early markers that research has shown to best differentiate children with ASD from those with other developmental disabilities are summarized in Table 1 .

Ventola and colleagues found children with ASD to score lower than children with developmental disabilities and other developmental language disorders in adaptive skills, expressive and receptive language, and fine motor and visual reception skills on a screening measure for autism; further, deficits in joint attention and social interaction seemed to be particularly unique to autism. Considering a more integrated view of screening and assessment, it is important to consider all aspects of development when screening children with or at risk for autism and to recognize the likely delays in language understanding and expression as they relate to responding to and engaging with others to share experiences and interests.

Socially, toddlers with ASD have greater difficulty in joint attention, imitation, pointing to express interest, interest in other children, and displaying a range of facial expressions and empathic responses compared with other children with developmental disabilities. This characteristic requires providers to have a clear understanding of typical development and developmental delays, and to use available developmental screenings tools (eg, Ages and Stages Questionnaire ), and autism-specific screening tools (eg, Modified Checklist for Autism in Toddlers [M-CHAT] ) to facilitate earlier diagnosis of ASD. Children with a lack of appropriate gaze or warm, joyful expressions with eye gaze and alternating vocalization patterns as well as a failure to recognize familiar voices (eg, parents) and decreased use of gestures are red flags for a potential diagnosis of ASD.

Understanding the developmental trajectory of communication is critical to the ability to make an early diagnosis. However, existing screening instruments have limitations ranging from methodological flaws to small samples, often missing children who are eventually diagnosed with ASD. Another barrier to early diagnosis is that it is more difficult to make a diagnosis at 2 to 3 years because early delays in saying first words, establishing joint attention, and engaging socially may be attributed to normal variation, whereas at 5 to 6 years discrepancies from normal development are more obvious. However, the evidence that early intervention is more effective than later is so compelling that health care providers must remain on high alert for early danger signs. This challenge requires practitioners to have a developmental perspective on the assessment of language and communication difficulties and subsequent intervention in young children with ASD. Vigilance also is required. Almost 30% of children with ASD present with periods of normal development followed by regression before 3 years. Thus, any signs of language regression represent a serious concern that requires follow-up.

To ensure effective assessment and intervention decision making, practitioners should engage family members in the process, and highly individualized profiles should be considered in program planning. Social communication profiles can predict both developmental level and autism symptoms within 20-month-old children, who have a distinct social communication profile, with language understanding being a strong predictor of developmental level, and behavior regulation and gesture inventory being a strong predictor of autism diagnosis at age 3 years. Programming is best supported by an integrated developmental framework that considers natural language samples, parental report, and standardized measures. These are the types of assessments conducted by speech-language pathologists.