Clearcut cases of autism and specific language impairment are easy to distinguish, but some children don't fit neatly into these diagnostic categories. Professor Dorothy Bishop discusses research looking at the issues around diagnostic differentiation of these conditions.

1. Autism and specific language
impairment: diagnostic distinctions
Dorothy V. M. Bishop
Dorothy V. M. Bishop
Dorothy V. M. Bishop

2. The traditional view
Specific
Autistic Language
disorder Impairment

3. Textbook view of specific
language impairment (SLI)
• Selective problem with language
development
• Other aspects of development – self help
skills, socialisation, nonverbal abilities,
motor skills – all developing normally
• Overall impression is that language is like
that of a much younger child

4. Textbook view of autistic
disorder
• Difficulties are pervasive and affect three
areas of development (the autism ‘triad’)
• Communication
• Social interaction
• Behaviour/interests – repetitive and restricted
• Qualitative differences from typical
development

5. The autistic triad
social
communication
autistic
disorder
interests

6. However!
Some children don’t fit neatly
into these categories

7. Evidence for development of autistic
features in some children with
receptive language impairments
Bartak, L., Rutter, M., & Cox, A. (1975). A comparative study of infantile
autism and specific developmental receptive language disorder: I. The
children. British Journal of Psychiatry, 126, 127-145.

8. Selection criteria: Bartak et al, 1975
• Impaired verbal comprehension
• Boys, aged 5-10 years
• Nonverbal IQ of 70+
• Normal hearing
• No neurological disease
19 23 receptive 5 mixed
autistic language
disorder disorder

9. proportion
Very similar language findings for autistic and language-impaired

10. Bartak et al: nonlanguage
autistic receptive SLI
lacks imaginative play
attachment to odd objects
resistance to change
ritualistic activities
quasi-obsessional activities
difficult adaptation to new situations
0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9
proportion
But very different behaviour findings for autistic and language-impaired

11. Bartak et al: language use
autistic receptive SLI
never used gesture
fails to respond to questions
no spontaneous chat
inappropriate remarks
metaphorical language (ever)
stereotyped utterances (ever)
echolalia (ever)
pronoun reversal (ever)
0 0.2 0.4 0.6 0.8 1
proportion
And very different in language use for autistic and language-impaired

12. autistic-like behaviours seen in SLI at follow-up
autistic receptive SLI
rituals
lacks imaginative play
stereotyped mannerisms
fails to show sympathy
no group participation
metaphorical language
stereotyped utterances
0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9
proportion
But SLI start to show more autistic behaviours at follow-up in middle childhood
Cantwell, D., et al. (1989). Infantile autism and developmental receptive dysphasia: a
comparative follow-up into middle childhood. J Autism and Developmental Disorders, 19, 19-31.

13. Howlin et al, 2000
• Follow-up of original sample into
adulthood
• Some of the original language-impaired
sample show more evidence of social and
behavioural problems, similar to autism
Howlin, P., Mawhood, L., & Rutter, M. (2000). Autism and developmental receptive
language disorder - a comparative follow-up in early adult life. II. Social, behavioural, and
psychiatric outcomes. Journal of Child Psychology and Psychiatry, 41, 561-578.

14. Example of man with receptive SLI diagnosis in childhood
"In all aspects of self-care he was entirely independent and
he could use a telephone and manage his finances
himself. Most of his spare time was spent pursuing his
preoccupation with buses and his less intense interest in
CB radio. He spent a lot of time hanging around bus
stations, going on bus journeys when he could afford it,
and looking at bus magazines. His social overtures were
somewhat limited and he would speak if spoken to but
would not make the first move. There were two friends
that he visited regularly; one shared his interest in buses,
the other was interested in CB radio. These relationships
were clearly selective, did involve some apparent pleasure
in each other's company, and some sharing of
confidences, but there was still nonetheless a slightly odd
quality to them because of their restricted range of
interests. He did not appear to be lonely." (p. 384).

15. Autistic-like impairments in
communication and social
interaction in some cases of
language impairment

16. Bishop & Norbury, 2002
• Study of children receiving special educational provision
for language/communication disorders
• Direct observation, language assessment and parental
report
• Significant numbers of children with autistic-like
language features but who did not meet criteria for
autism on ‘gold standard’ autism assessments
Bishop, D. V. M., & Norbury, C. F. (2002). Exploring the borderlands of autistic
disorder and specific language impairment: A study using standardised diagnostic
instruments. Journal of Child Psychology and Psychiatry, 43, 917-929.

17. Fractionating the autistic triad
communication
social
autistic
disorder
Elements of the triad
that form autistic disorder
can be dissociated: many
children with just one or
two areas of difficulty
interests

18. Diagnostic dilemmas
q Diagnosis complicated by:
q Changing clinical picture with age
q Difficulties in evaluating autistic-like
symptoms in children with receptive
language problems

19. Diagnostic dilemmas, ctd.
q Categorical diagnosis not well suited to capturing
clinical variation
q Textbook cases of SLI and autism are easy to
recognise but many children less clearcut
q No clear dividing line between SLI and autism
q Current deliberations for revisions of DSM and ICD
diagnostic classifications:
 Considering removing requirement of third triad element
(repetitive behaviour) for ASD diagnosis
 Considering adding new category of ‘social communication
impairment’ that would incorporate intermediate cases