Residual Language Deficits in Optimal Outcome Children with a History of Autism

Abstract

This study examined whether language deficits persist even in children with optimal outcomes. We examined a group of children with prior diagnoses on the autism spectrum who had IQs in the normal range, were in age-appropriate mainstream classes, and had improved to such an extent that they were considered to be functioning at the level of their typically developing peers. Fourteen such children between the ages of five and nine were matched on age and sex with typically developing children, and were given a battery of 10 language tests to investigate their language abilities. Results indicated that while these children’s grammatical capabilities are mostly indistinguishable from their peers, they are still experiencing difficulties in pragmatic and semantic language.

Appendix

T.C. was seen by the third author at 38 months. At this time he had mild nonverbal communication difficulties, problems in peer relations, a lack of emotional reciprocity, poor conversation skills, stereotyped language, stereotyped play, and a preoccupation with parts of objects. Format criteria for Autistic Disorder were not met because his nonverbal communication difficulties were too mild; he met the formal criteria for PDD-NOS. Regarding his language history, he had a few words at 18 months and two-word phrases at 20 months, but did not seem to comprehend much language and much of his expressive language was echolalic. He did not point until he was taught to do so at age two years. At 38 months he had a receptive language delay on the Preschool Language Scale of seven months, and his expressive language was nine months delayed. His Vineland Communication age equivalency at this time was two years, seven months; he was just beginning to relate experiences to others. T.C. was diagnosed with PDD-NOS on the basis of the following symptoms from the DSM-IV criteria: poor eye gaze, difficulty forming friendships, withdraws from social interaction, echolalia, stereotypies, and preoccupation with parts of objects.

C.F. was seen by the third author at 13 months. At this time she had nonverbal communication difficulties, no joint attention, a lack of emotional reciprocity, delayed language, and preoccupations. She met the formal criteria for PDD-NOS at this time. Regarding her language history, she had babbled from six to nine months and then suddenly stopped. At eleven months she showed a regression in eye contact, response to language, and social interaction. At thirteen months she made almost no vocalizations across the two hours of the testing session and demonstrated flat affect. At home she would vocalize only in whispers and jargons in monotone and she no longer responded to her name or other language although she would respond to gesture. Her testing at 13 months showed a Vineland Communication age equivalence of one to three months, a Socialization age equivalence of four to eight months, and an average Daily Living score. An SLP evaluation at thirteen months found interaction, receptive language, and expressive language to all be between the ages of three to six months, with a few higher scattered skills. C.F. was diagnosed with PDD-NOS on the basis of the following symptoms from the DSM-IV criteria: impaired eye gaze, lack of pointing and gestures, lack of social or emotional reciprocity, delayed language and repetitive behaviors.

D.K. was seen by the third author at 64 months. At this time he had nonverbal communication deficits, difficulties in peer relations, a lack of joint attention and emotional reciprocity, difficulties in conversation, stereotyped language and play, preoccupations and routines, and preoccupations with parts of objects. At this time he met the formal criteria for Autistic Disorder. Regarding his language history, he had spoken his first sentences at 23 months, but his language and play were both repetitive and scripted. In playgroup at ages two-and-a-half to three, he talked about other children but did not interact with them. When tested at 64 months, conversation was impeded by aggression, poor attention, and insensitivity to his conversational partner. His Preschool Language Scale showed scores in the superior range, and Vineland Communication scores were only slightly depressed (age equivalence was 5–0), but his Daily Living and Socialization scores were more than two years delayed. D.K. was diagnosed with Autistic Disorder on the basis of the following symptoms from the DSM-IV criteria: lack of gestures, poor eye gaze, failure to develop peer relationships, lack of pointing to share attention, lack of social emotional reciprocity, delayed echolalia, lack of make-believe play, delayed language, over-adherence to routines, preoccupation with parts of objects, and repetitive self-stimulatory behaviors.

P.B. was 46 months when seen by the third author. At this time she had deficits in nonverbal communication, problems in peer relations, stereotyped language and play, and routines. She met the formal diagnostic criteria for PDD-NOS at this time. Regarding her language history, she spoke her first single words at 10 months and two-word combinations at 12 months. At 30 months she had no conversation and would repeat or ignore others’ questions. Symbolic play emerged at 42 months but was highly repetitive. At age three, an SLP evaluation noted atypical language and social skills, and poor social use of language. P.B. had pronoun reversal difficulties until 44 months. At 46 months P.B. did well on formal language testing except on items requiring responses to open-ended questions or word definitions. Her WPPSI Vocabulary scaled score was five, Comprehension was six, and Information was nine. Vineland Communication score was age equivalent (3–8), but Daily Living and Socialization were delayed by about a year. P.B. was diagnosed with PDD-NOS on the basis of the following symptoms from the DSM-IV criteria: impairment in eye-to-eye gaze, failure to develop peer relationships, lack of pointing to express interest, poor social use of language, restricted play, and adherence to routine.

M.K. was 49 months when seen by the third author. At this time he had deficits in nonverbal communication, problems in peer relations, a lack of joint attention, poor conversational skills, stereotyped language and play, and preoccupations and routines. At this time he met the formal diagnostic criteria for Autistic Disorder. Regarding his language history, he showed no response to his name at 16 months. Single words emerged at 22 months, and two-word phrases at 27 months, although his language was echolalic. What and Where questions did not emerge until almost four years of age. Repetitive symbolic play emerged around 30 months. At 49 months, his Preschool Language Scale was in the average range, as was his Vineland Communication score. His Vineland Daily Living age equivalence was 3–0 and Socialization was 3–2. Spontaneous language was one-sided, tangential, scripted, and perseverative, and he still demonstrated some pronoun confusion. M.K. was diagnosed with Autistic Disorder on the basis of the following symptoms from the DSM-IV criteria: restricted nonverbal gestures, problems with eye gaze, difficulties developing peer relationships, lack of pointing to express interest, perseveration on topics of interest, stereotyped language, repetitive play, restricted and obsessive interests, and inflexible adherence to routines.

C.B. was 58 months when seen by the third author. At this time he had difficulties in nonverbal communication, peer relations, joint attention and emotional reciprocity. Conversational skills were delayed and he demonstrated stereotyped language and play, preoccupations and routines, and preoccupations with parts of objects. C.B. met the formal diagnostic criteria for Autistic Disorder at this time. Regarding his language history, he had a few single words by 18 months and some two-word phrases by 30 months. His speech at two years of age was echolalic and he did not ask questions until taught to do so at age three years. At 58 months C.B. still talked mainly on preferred topics and ignored conversational overtures by others. He had average performance on all formal language tests and Vineland Communication scores were within normal range, but Vineland Socialization and Daily Living scores were still delayed. C.B. was diagnosed with Autistic Disorder on the basis of the following symptoms from the DSM-IV criteria: restricted eye gaze, impaired nonverbal gestures, failure to develop peer relationships, lack of spontaneous pointing, impaired awareness of others, stereotyped language, lack of pretend play, adherence to routines, and preoccupation with parts of objects.

N.E. was 77 months when seen by the third author. He demonstrated continuing difficulties in peer relations, delayed language skills, impaired conversational abilities, and preoccupations and routines. N.E. met the formal diagnostic criteria for PDD-NOS at this time. Regarding his language history, N.E. said his first single words at 30 months and his first two-word phrases at 42 months. He often failed to respond to language and was echolalic at age three. An SLP evaluation at age six noted age appropriate language with maximal structure and support, but speech was often unintelligible and formulation was impaired. Testing by the third author at 77 months concurred and found language scores low average to average with particular problems with open-ended questions. Vineland Communication score age equivalence was 4–0, Daily Living was 2–9, and Socialization was 3–1. N.E. was diagnosed with PDD-NOS on the basis of the following symptoms from the DSM-IV criteria: inconsistent use of eye gaze, immature peer relationships, insensitive to others’ distress, limited conversational skills, restricted patterns of interests, and inflexible adherence to routines.

L.X. was 56 months when seen by the third author. He continued to experience deficits in nonverbal communication, peer relations, and conversational skills. His language was delayed and stereotyped, and he had preoccupations and preoccupations with parts of objects. At this time he met the formal diagnostic criteria for Autistic Disorder. Regarding his language history, he had single words by 14 months, but his two-word phrases came in quite late. According to his mother, he was almost mute at age three. At age three-and-a-half, phrase speech showed notable echolalia. He followed one-step directions at age three, two-step directions at age four, used sentences and questions at age four, and his pretend play emerged at age four. At 56 months his Preschool Language Scores were above average on both the Receptive and Expressive subscales. His Vineland Communication score was within normal range, although he still did not volunteer information about experiences. Daily Living and Socializations subscales of the Vineland were both more than one year delayed. His language at this time showed a residual scripted quality and he still was unable to carry on a conversation. L.X. was diagnosed with Autistic Disorder on the basis of the following symptoms from the DSM-IV criteria: impaired eye gaze, lack of nonverbal gestures, difficulties in peer relationships, delayed language, limited conversational skills, stereotyped language, restricted pattern of interests, and preoccupation with parts of objects.

M.S. was 40 months when seen by the third author. At this time he had deficits in nonverbal communication, peer relations, joint attention, and emotional reciprocity. His language was delayed and conversational skills were a problem. He showed stereotyped language and play, as well as motor stereotypies and preoccupations with parts of objects. M.S. met the formal diagnostic criteria for Autistic Disorder at this time. Regarding his language history, he did not babble as an infant and did not speak his first words until 33 months. He followed one-step directions at 36 months, two-step directions at 38 months, and pretend play emerged at 38 months. His emerging language was marked by flat prosody, echolalia, and scripts. He made rapid progress with ABA but at 40 months his language was still used only to protest and request and he showed no response to social language. At 40 months his vocabulary and grammar were within normal range on standardized tests although he still demonstrated difficulty with prepositions. Vineland Communication age-equivalence was 2–5, Daily Living 2–2, and Socialization 2–0. M.S. was diagnosed with Autistic Disorder on the basis of the following symptoms from the DSM-IV criteria: impaired eye-to-eye gaze, lack of nonverbal gestures, little interest in other children, lack of pointing to show interest, lack of emotional reciprocity, delayed language, impaired conversational skills, stereotyped language, restricted play, motor stereotypies, and preoccupation with parts of objects.

T.S. was 40 months when seen by the third author. He displayed deficits in nonverbal communication and peer relations, and had delayed language, preoccupations, routines, and preoccupations with parts of objects. At this time he met the formal diagnostic criteria for Autistic Disorder. Regarding his language history, he spoke his first single words at 17 months and first two-word phrases at 29 months. By thirty months response to sounds was inconsistent and deafness was questioned; humming and screaming were prevalent. He followed familiar one-step directions by two years, and two-step directions by three years. At 40 months he showed a thirteen-month receptive delay on the Preschool Language Scales and a fifteen-month expressive delay. Vineland Communication receptive age equivalence was 2–6, but his expressive age equivalence was 1–11. Socialization and Daily Living scores were in the low average range. T.C. was diagnosed with Autistic Disorder on the basis of the following symptoms from the DSM-IV criteria: delayed gestures, impaired eye gaze, difficulties in peer relationships, delayed language, delayed pretend play, stereotyped actions with objects, inflexible adherence to routines, and preoccupations with parts of objects.

T.M. was 79 months when seen by the third author. At this time he was still demonstrating deficits in nonverbal communication, peer relations, and conversational abilities. He had stereotyped play, preoccupations and routines, and motor stereotypies. T.M. met the formal diagnostic criteria for Autistic Disorder at this time. Regarding his language history, he spoke his first single words at 12 months and first sentences at two years. He did have some wh-questions at age three, but would still get them confused. Symbolic play and understanding two-step directions emerged at age three. He had been diagnosed by a child neuropsychologist and a child psychiatrist as Asperger’s due to poor pragmatic language and poor social competence. A recent SLP evaluation had shown average language except in the areas of listening, formulation, and pragmatics. Testing at 79 months showed all cognitive areas to be above average except processing speed, visuo-motor, and visuo-spatial skills. Vineland Communication score was average, Daily Living was low average, and Socialization showed a mild delay. T.M. was diagnosed with Autistic Disorder on the basis of the following symptoms from the DSM-IV criteria: limited nonverbal communication, lack of friends, lack of interest in peers, restricted conversational skills, restricted and stereotyped play, preoccupations and routines, inflexible adherence to routines, and stereotyped motor mannerisms.

U.N. was 71 months when seen by the third author. He was still experiencing mild delays in nonverbal communication and peer relations. He had delayed language and conversational skills, and demonstrated preoccupations and routines, and motor stereotypies. Formal diagnostic criteria for Autistic Disorder were not met because nonverbal communication and peer-relations deficits were regarded as being too mild; formal criteria for PDD-NOS were met. Regarding his language history, U.N. spoke his fist single words before 15 months but experienced a regression and age 15 months in social relatedness and a plateau in language development at 15–18 months, and showed no further gains in language development until he began treatment at age 27 months. At 71 months his Preschool Language Scale scores were within average range. Vineland Communication age-equivalence was 6–4, but Daily Living was 4–11 and Socialization was 4–2. U.N. was diagnosed with PDD-NOS on the basis of the following symptoms from the DSM-IV criteria: inconsistent eye contact, mild difficulties interacting with peers, restricted conversational skills, some stereotyped language, restricted patterns of interest, adherence to routines, and motor stereotypies.

T.B. was 56 months when seen by the third author. He demonstrated deficits in nonverbal communication, peer relations, and joint attention, and had delayed language and conversational skills. His language and play were stereotyped, and he experienced preoccupations with parts of objects. T.B. met formal diagnostic criteria for Autistic Disorder at this time. Regarding his language history, T.B. spoke his first single words at 28 months, his first phrases at 32 months, and his first sentences at 40 months. At age four-and-a-half, T.B. demonstrated prominent echolalia and pronoun reversal, and his expressive output was limited and scripted. At 56 months his language was still echolalic and scripted, with stilted prosody and pronoun reversal. His Preschool Language Scales Expressive age-equivalence was 3–0, and his receptive age-equivalence was 3–6. The Vineland Communication age-equivalence was 3–5, Daily Living was 2–7, and Socialization was 2–9. T.B. was diagnosed with Autistic Disorder on the basis of the following symptoms from the DSM-IV criteria: impaired imitation, delayed nonverbal communication, lack of pointing to express interest, lack of social emotional reciprocity, lack of interest in other children, restricted play, difficulties with conversation, stereotyped language, and preoccupation with parts of objects.

Q.K. was 92 months when seen by the third author. He continued to experience problems in nonverbal communication, and had obsessive routines and motor stereotypies. He met the formal criteria for PDD-NOS. Regarding his language history, his early milestones were within normal range; however, his parents first became concerned at age three when he could not carry on a conversation, did not respond to questions, and was echolalic. Q.K. showed little or no joint attention or pretend play until he was taught at age five and his parents felt that he really did not understand language well until age six. Testing at 64 months shoed a VIQ of 55 and a PIQ of 99. Testing at 92 months showed listening comprehension low average and reading comprehension average. His Vineland Communication and Daily Living subscales were in the average range, with Socialization in the low average range. Q.K. was diagnosed with PDD-NOS on the basis of the following symptoms from the DSM-IV criteria: impaired eye gaze and nonverbal gestures, language delay, adherence to routine and motor stereotypies.