Introduction
It has long been known that autism spectrum disorders (ASD) have a strong genetic component, and that relatives of probands with ASD are at higher risk for the disorder. The risk for any form of ASD in siblings of probands with autism is 2–8% (Muhle et al.
2004; Szatmari et al.
1998), much higher than the current 0.6% base rate for the general population (Levy et al.
2009). Researchers report an increased risk for siblings of probands with ASD to develop the more subtle form of ASD characteristics, referred to as the “broad autism phenotype” (e.g., Bolton et al.
1994; Pickles et al.
2000; Virkud et al.
2008). More specific characteristics beyond those comprising the triad of communication, social and behavioral impairments such as executive dysfunctions (Delorme et al.
2007; Happé et al.
2001; Pilowsky et al.
2007; Wong et al.
2006), externalizing and internalizing behavior problems (Fisman et al.
1996; Gold
1993), learning disabilities (Plumet et al.
1995), theory of mind abilities (Shaked et al.
2006), general cognitive abilities (Folstein et al.
1999; Fombonne et al.
1997; Pilowsky et al.
2007), and a range of linguistic features (Chuthapisith et al.
2007; Folstein et al.
1999; Le Couteur et al.
1996; Pilowsky et al.
2003; Smalley and Asarnow
1990) were proposed as additional possible components of the broad autism phenotype (BAP).
Given the high risk of siblings of probands with ASD (SIBS-A) to receive a diagnosis of ASD or to develop BAP-related difficulties, we conducted a longitudinal study in which we followed a sample of SIBS-A and siblings of children with typical development (SIBS-TD) from infancy to childhood. The main aims of the original study were to identify early markers of the risk for developing ASD or the BAP and to delineate the developmental trajectories of the siblings from birth into childhood (4 months to 7 years). The aim of the present study was to re-evaluate the sample at the preadolescence stage—age of 9–12 years.
During their first 24 months of life, 28% (11/39) of the SIBS-A in our sample were identified as having cognitive and/or language delays according to standardized assessments. Examination of the developmental trajectories of those SIBS-A identified with delays revealed that most of the difficulties observed up to age 36 months disappeared at 54 months, with the exception of continued lower language scores for some of the SIBS-A (Gamliel et al.
2007; Yirmiya et al.
2006; Yirmiya et al.
2007). At age 7 years, 40% (15/37) of the SIBS-A group were identified as having cognitive, language and/or school-related difficulties according to standardized assessments and parental reports. Examination of developmental trajectories from age 14 months to age 7 years revealed that for some of the SIBS-A, the difficulties were continuous and appeared throughout the years, whereas for other SIBS-A the difficulties were transient—present only at some stages of the study, and still for others, BAP-related difficulties appeared for the first time at age 7 years (Gamliel et al.
2009).
In our recent report regarding SIBS-A aged 9–12 years (Seidman et al., in press), after removing the 2 children diagnosed with ASD, 39% of the SIBS-A (13/33) were identified with BAP-related difficulties (SIBS-A-BAP). In the current report, we set out to examine pragmatics, a linguistic skill that is severely impaired in individuals with ASD, as well as other specific linguistic aspects relevant to school-age children: school achievements (i.e., reading, spelling, and arithmetic skills) and underlying reading processes (i.e., decoding processes, orthographic knowledge, phonological awareness, short term phonological memory, and auditory discrimination).
Pragmatic impairments are universal in autism and comprise a significant element of the disorder; therefore, pragmatic difficulties are considered a natural candidate for the BAP. Pragmatics refers to the use of language in communication (Richards et al.
1985). It encompasses the organization of verbal discourse and the meaning derived from aspects of communication beyond the sentential level (Chapey
1994; Grice
1975; Paradis
1998; Prutting and Kirchner
1987). Whereas several researchers demonstrated pragmatic impairments in parents of probands with ASD (Folstein et al.
1999; Hurley et al.
2007; Landa et al.
1991,
1992; Piven et al.
1997; Whitehouse et al.
2007), the degree to which such impairments are evident in siblings remains unclear. Bishop et al. (
2006) found that compared to typically developing children, significantly more SIBS-A scored more than two standard deviations below the mean on the Children’s Communication Checklist-2 (CCC-2) total score, which includes pragmatic use of language as well as structural language skills. Yet, no group differences emerged for the CCC-2 index that was specific to pragmatic impairments. Folstein et al. (
1999) and Pilowsky et al. (
2003) did not find differences on the Pragmatic Rating Scale (PRS; Landa et al.
1992) scores between SIBS-A and comparison groups comprised of siblings of children with other developmental disorders.
Examining language abilities other than pragmatics, a growing body of research regarding infant and toddler SIBS-A supports language difficulties as a major component of the BAP in the preschool years (Elsabbagh and Johnson
2007; Landa and Garrett-Mayer
2006; Mitchell et al.
2006; Orsmond and Seltzer
2007; Toth et al.
2007; Yirmiya and Ozonoff
2007; Zwaigenbaum et al.
2005). Yet evidence for the manifestations of language difficulties among older SIBS-A is inconsistent. Some researchers found elevated rates of language impairments and specific learning disabilities in SIBS-A, as well as decreased achievements on a variety of language measures (Chuthapisith et al.
2007; Le Couteur et al.
1996; Plumet et al.
1995). For example, Plumet et al. (
1995) found that siblings (aged 13–35 years) of female probands with autism achieved significantly lower scores than siblings of female probands with Down syndrome on measures of repetition, reading, spelling, vocabulary, phonological knowledge, and short-term verbal memory. Yet, others found no differences on language measures such as reading, spelling (Folstein et al.
1999; Freeman et al.
1989), phonological processing (Bishop et al.
2004), and receptive and expressive language (Pilowsky et al.
2003) between SIBS-A and different comparison groups or published norms. Moreover, SIBS-A scored higher on cognitive, language and reading abilities measures than siblings of children with specific language impairment (Lindgren et al.
2009).
Variability of previous findings regarding linguistic abilities among SIBS-A may be attributed at least in part, to methodological issues. These include age variability between and within samples of different studies (which constitutes a significant methodological issue as linguistic abilities are developmental in nature); variability in the types of measures employed for assessing language abilities (e.g., measures of general language level, or assessments of specific language aspects); and the variability within the SIBS-A groups tested, which included children who exhibited BAP difficulties and children who did not. In the current study, the relative homogeneity of ages, the use of measures assessing both specific and general language abilities, and the potential reduction of variability within groups by dividing our SIBS-A group into SIBS-A-BAP and SIBS-A-TD, were expected to enable a better depiction of the language profiles of SIBS-A. We hypothesized that indeed SIBS-A who are diagnosed with the BAP would show lower language-related abilities. Furthermore, whereas language abilities and severity of symptoms were not found to be associated among individuals with autism (Gotham et al.
2009) we were interested in examining whether the lower language abilities, if found, would or would not be associated with the severity of the BAP as measured by the Autism Diagnostic Observation Schedule (ADOS; Lord et al.
2002) among SIBS-A-BAP.
Discussion
Pragmatic language abilities, acquired school-related abilities, and reading processes of school-age SIBS-A and SIBS-TD were compared. Dividing our sample of SIBS-A into those identified with BAP (SIBS-A-BAP) and those identified with TD (SIBS-A-TD) enabled us to better illustrate the pattern of linguistic abilities that characterizes BAP in SIBS-A. SIBS-A-BAP showed poorer performance only on a measure of pragmatic language compared to SIBS-A-TD and SIBS-TD-TD, whereas no significant findings emerged for general linguistic measures as well as for school achievement and reading processes measures.
Taken together, these findings suggest that lowered pragmatic abilities, which constitute a universal impairment in ASD, also comprise the BAP in school-age SIBS-A, whereas cognitive abilities, receptive and expressive language abilities, and other school-related abilities, as examined in the current study are intact. Furthermore, the performance of SIBS-A-TD indicates that this group is indeed developing typically, at least as measured in this study.
The observation of lower pragmatic performance of SIBS-A-BAP in our sample coincides with Bishop et al. (
2006) but contradicts Folstein et al. (
1999) and Pilowsky et al. (
2003), who reported no differences between SIBS-A and a control group on the PRS scores. Dividing our group of SIBS-A into SIBS-A-BAP and SIBS-A-TD subgroups enabled us to better detect the pragmatic impairments of some of these siblings. The use of a group of SIBS-A as a whole in other studies may have masked differences that existed in the pragmatic domain. Furthermore, the inconsistencies between research outcomes may result from the utilization of different measures. Although both the PRS and SPP ratings are based on an interaction of the examiner and the child, it is possible that the latter affords more opportunities to observe abnormal pragmatic behaviors because its coding system (the ADOS) requires approximately 45 min of interaction, whereas the PRS only requires a minimum of 15 min.
Regarding language abilities, Kjelgaard and Tager-Flusberg (
2001) promoted the hypothesis regarding genetic and phenotypic overlap between specific language impairment (SLI) and autism by noting that poor nonword repetition which is considered as a psycholinguistic marker of SLI, is evidenced in children with autism who have borderline or low language abilities. Our findings that structural linguistic impairments do not comprise BAP manifestations in SIBS-A, and more specifically that SIBS-A-BAP reveal similar performance to SIBS-TD-TD on the phonological processing measures, do not lend support to this hypothesis. The current findings replicate Bishop et al.’s (
2004) report of a lack of differences in phonological processing measures among siblings and parents of children with autism. Along the same lines, Whitehouse, Barry, and Bishop (
2008) suggest that structural language deficits, including poor nonword repetitions, do not reflect etiological overlap between SLI and autism but that they arise as a consequence of substantial impairments in multiple autistic domains. These researchers showed that although probands with autism with structural language difficulties presented nonword repetition difficulties, their pattern of errors on this test was different than that of children with SLI.
Furthermore, examination of the correlations between severity scores for autistic features and cognitive and linguistic measures in the SIBS-A-BAP subgroup suggested an interesting pattern: Whereas as a group SIBS-A-BAP showed better verbal IQ scores and similar full scale IQ scores to the other two groups (Seidman et al., in press), their performance on these measures was negatively correlated with the severity of their autistic features. In other words, lower verbal and full IQ scores were associated with a higher expression of autistic features in the SIBS-A-BAP subgroup. Gotham et al. (
2009) found that the severity of scores in their sample of ASD participants was independent of participants’ performance IQ scores and was relatively independent of participants’ verbal IQ scores, whereas in their combined sample of nonspectrum participants (children with other disorders) and ASD participants, verbal IQ was a significant predictor of severity. Our findings add to this literature by revealing that among SIBS-A, severity of autistic symptoms is associated with Full scale and Verbal IQ scores. Finally, no associations were found between probands’ level of functioning (low vs. high functioning) and siblings’ cognitive and linguistic functioning, indicating no evidence of familial liability for these abilities in this ample.
Limitations of the current study include its small sample size, as well as the lack of other comparison groups. However, using a comparison group of typically developing children enabled us to conclude that the SIBS-A identified with TD truly show a picture similar to that of siblings of typically developing children in the domain of linguistic aspects, including pragmatics, which is significantly impaired in SIBS-A identified with BAP. The use of the ADOS score of SPP as a measure of pragmatic impairment comprises another limitation as it includes ADOS items, which served to identify BAP in our former report regarding 9–12 years (Seidman et al., in press). We solved this problem by showing that SIBS-A-BAP exhibit poorer pragmatic abilities not only on the SPP items comprising the ADOS algorithm with which BAP classification was made but also separately on the SPP items that did not comprise the ADOS algorithm. Nevertheless, further studies are required to replicate our findings.
Acknowledgments
This study was supported by the United States-Israel Binational Science Foundation (BSF), Grant # 2007209, awarded to NY, MS, and CL, and by grant no. 300000-4950 from the Public Committee for Allocation of Estate Funds, Ministry of Justice, Israel. We are grateful to the families who took part for their cooperation and to Dee B. Ankonina for her editorial assistance.