Behavior Predictors of Language

Development Over 2 Years

in Children With Autism
Spectrum Disorders
Karen D. Bopp
Pat Mirenda
Bruno D. Zumbo
The University of British Columbia,
Vancouver, Canada

Purpose: This exploratory study examined predictive relationships between 5 types of

behaviors and the trajectories of vocabulary and language development in young
children with autism over 2 years.
Method: Participants were 69 children with autism assessed using standardized
measures prior to the initiation of early intervention (T1) and 6 months (T2), 12 months
(T3), and 24 months (T4) later. Growth curve modeling examined the extent to which
behaviors at T1 and changes in behaviors between T1 and T2 predicted changes
in development from T1 to T4.
Results: Regardless of T1 nonverbal IQ and autism severity, high scores for inattentive
behaviors at T1 predicted lower rates of change in vocabulary production and language
comprehension over 2 years. High scores for social unresponsiveness at T1 predicted
lower rates of change in vocabulary comprehension and production and in language
comprehension over 2 years. Scores for insistence on sameness behaviors, repetitive
stereotypic motor behaviors, and acting-out behaviors at T1 did not predict the rate
of change of any child measure over 2 years beyond differences accounted for by
T1 autism severity and nonverbal IQ status.
Conclusions: The results are discussed with regard to their implications for early
intervention and understanding the complex factors that affect developmental outcomes.
KEY WORDS: autism, child development, problem behavior, predictors

esearch suggests that a number of variables are related to differences in the development of children with autism spectrum disorders
(ASD). For example, for children who receive early intervention, initial
IQ score (Gabriels, Hill, Pierce, & Rogers, 2001; Harris & Handleman, 2000;
Liss et al., 2001; Lovaas & Smith, 1998; Sallows & Graupner, 2005; T. Smith,
Eikeseth, Klevstrand, & Lovaas, 1997), chronological age at the onset of
intervention (Fenske, Zalenski, Krantz, & McClannahan, 1985; Harris &
Handleman, 2000; Lovaas, 1987), and autism severity score (DeMyer, 1973;
Eaves & Ho, 1996; Liss et al., 2001) have all been found to be related to
cognitive, language, and adaptive behavior outcomes over time. However,
even with early intervention, it is estimated that only approximately 15%
of individuals with autism are reasonably self-sufficient as adults and
another 15% to 20% function well with periodic support (Volkmar & Pauls,
2003). In addition, in a review of treatments for young children with ASD,
Schreibman (2000) noted a wide heterogeneity in the outcomes of intervention and remarked that there is no one size fits all treatment for this
population. The lack of 100% effectiveness of early intervention leads one to

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conclude that there are other variables affecting outcomes

that have not yet been identified (Ingersoll, Schreibman,
& Stahmer, 2001). Identifying these variables and understanding the process of language development in
autism and the factors that influence differential outcomes are critical for improving treatment efficiency.
What are some of the factors that may influence differential language outcomes in ASD? Performance-based
theory suggests that language disorders are secondary to
limitations in individual child factors such as cognitive
processing (e.g., motivation, attention, memory, and retention) and socialaffective skills (e.g., imitation, joint
attention, reciprocity, etc.; Evans, 2001). According to a
socialinteractionist perspective, language is developed
through a motivation to interact socially with others; social experiences, in turn, motivate the acquisition of many
dimensions of language (Abbeduto & Boudreau, 2004). In
fact, a number of specific socialaffective behaviors have
been found to predict language development in this population. These behaviors include, for example, motor imitation skills (Sallows & Graupner, 2005; Stone & Yoder,
2001; Toth, Munson, Meltzoff, & Dawson, 2006), verbal
imitation skills (Sallows & Graupner, 2005; V. Smith,
Mirenda, & Zaidman-Zait, 2007), the ability to initiate
and /or respond to joint attention (e.g., Charman et al.,
2003; Rollins & Snow, 1998; Sigman & McGovern, 2005;
V. Smith et al., 2007; Travis, Sigman, & Ruskin, 2001),
and pretend play skills (e.g., Sigman & McGovern, 2005;
V. Smith et al., 2007; Toth et al., 2006; Yoder, 2006).
Socialaffective behaviors may not be the only factors that influence language development in children
with autism. One area that has received little attention
to date is child problem behaviors and their potential
impact. Of course, the extent to which any given behavior
can be deemed problematic depends both on ones perspective and on the context in which the behavior occurs.
The National Research Council (2001) described the complexity of this issue as follows:
From a childs perspective, problem behaviors include the inability to understand demands of a classroom or a parent and to communicate his or her needs
and wants, severe difficulty in initiating and maintaining social interactions and relationships, confusion about the effects and consequences of any of his
or her behaviors, and engagement in restrictive and
repetitive behaviors and interests that may limit the
childs ability to learn and to fit in with peers. From a
teachers or parents perspective, problem behaviors
include lack of compliance with or disruption of classroom routines, tantrums, destruction of property,
and aggression against self or others. ( pp. 115116)
Problem behaviors such as acting-out, repetitive stereotypic motor behaviors, insistence on sameness, social
unresponsiveness, and inattentiveness may place a child

at risk for isolation within or exclusion from typical home,

school, and community settings and thus may put him/
her at risk for delayed or even disordered language development. However, although these behaviors are often observed in clinical settings, almost no studies to date have
examined them as sources of variability in language
development. This study attempted to explore the relationship between these five behaviors and language
development.

Inattentiveness
Inattentiveness refers to behaviors that indicate high
distractibility (e.g., difficulty staying focused on relevant
people or activities) and/or decreased awareness of objects, activities, or the environment. There is no direct
empirical evidence of a relationship between inattentiveness and language development in autism; however,
there is some indirect evidence. Recent research has found
that the inability to both initiate and respond to joint attention is closely related to language difficulties in this
population (e.g., Charman et al., 2003; Rollins & Snow,
1998; Sigman & McGovern, 2005; V. Smith et al., 2007;
Travis et al., 2001). Three basic componentsattention,
shared affect, and shared intentionsconstitute the capacity for joint attention (Yoder & McDuffie, 2006).
Hypothetically, children who lack the first component,
attention, may be less likely to engage in joint attention
interactions and this, in turn, may result in delayed language development over time (Mundy & Markus, 1997).

Socially Unresponsive Behavior

Socially unresponsive behavior refers to a decreased
capacity to either initiate or respond to social and /or
emotional exchanges by other people and is one of the
hallmarks of ASD. Such behaviors include a failure to
smile in response to others, avoidance of eye contact, and
failure to respond to verbal or physical overtures (e.g.,
ones name being called or pointing by others). In their
early description of three subgroups of children with autism, Wing and Gould (1979) noted that the children who
were most socially impaired (i.e., those in their socially
aloof group) were also the most language impaired, especially with regard to comprehension. More recently,
Mundy and his colleagues proposed a social orienting
model to explain the relationship between social and language development in autism (Mundy & Markus, 1997;
Mundy & Neal, 2001). They hypothesized that early impairments in social attention deprive the child with
autism of social information input during infancy and
preschool development and that this deprivation disrupts normal brain and behavioral development. This
cycle then acts like a negative feedback loop, affecting
subsequent socio-communicative development. Dawson

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1107

et al. (2004) provided evidence to support this hypothesis

in a recent study in which structural equation modeling
was used to demonstrate that social orienting was directly related to joint attention ability and indirectly related to language ability in young children with autism.
Indeed, a recent study aimed at identifying a multidimensional model for the autism phenotype suggested
that sociocommunication skillswhich are currently
separated into separate social and communication domains in the DSMIVTRshould be combined to constitute a single domain (American Psychiatric Association,
2000; Georgiades et al., 2007). Together, these findings
provide support for the hypothesized relationship between behaviors that reflect social unresponsiveness and
subsequent communication and language development.

Restricted and Repetitive Behaviors

Restricted and repetitive behaviors (RRBs) include
both repetitive stereotypic motor behaviors (RSMBs) such
as hand flapping, rocking, and humming and insistence
on sameness (IS) behaviors such as lining up objects or
insisting that routines always occur in the same way
(American Psychiatric Association, 2000). By definition,
an ASD diagnosis requires the presence of RRBs; however, relatively few studies have examined the relationship between this broad category of behaviors and other
developmental variables. Bodfish, Symons, Parker, and
Lewis (2000) examined the relationship between autism
severity and rate of occurrence of stereotypy, self-injury,
compulsions, dyskinesia (i.e., repetitive, involuntary movements), and akathisia (i.e., repetitive, restless movements
such as pacing) in 32 adults with autism. They found that
adults with more severe RRBs had more severe autism.
Similarly, Gabriels, Cuccaro, Hill, Ivers, and Goldson
(2005) examined the relationship between a number of
RRBs (i.e., repetitive motor phenomena, narrow or circumscribed interests, and self-injurious behaviors) and
cognitive and adaptive communication skills in 14 children with autism (mean age: 10;7 [years;months]). They
found that children who had more RRBs had significantly
lower nonverbal cognitive and communicative abilities.
These studies provide some evidence for a general relationship between RRBs and other variables.
Recently, a number of researchers have examined
RSMBs and IS behaviors as distinct subclasses of behavior that appear to be related to different aspects of
development in individuals with ASD (e.g., Richler, Bishop,
Klienke, & Lord, 2007). With regard to IS behaviors,
Szatmari et al. (2006) found that, in 339 children with
pervasive developmental disorder (mean age: 8;5), those
who had more atypical IS behaviors on the Autism Diagnostic InterviewRevised (ADIR; Rutter, Le Couteur,
& Lord, 2003) had better language abilities as measured
by the communication subscale of the Vineland Adaptive

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Behavior Scales (VABS; Sparrow, Balla, & Cicchetti, 1984).

However, these same children also had more atypical,
stereotyped, repetitive, and idiosyncratic speech as measured on the ADIR. With regard to RSMBs, associations with a variety of developmental variables have been
reported. Both lower adaptive behavior scores (Cuccaro
et al., 2003; Szatmari et al., 2006; Venter, Lord, & Schopler,
1992) and lower IQ scores (Bishop, Richler, & Lord, 2006;
Campbell et al., 1990; Szatmari et al., 2006) appear to be
related to more atypical RSMB scores. Similarly, lowerlevel language skills (Carcani-Rathwell, Rabe-Hasketh,
& Santosh, 2006; Dadds, Schwartz, Adams, & Rose, 1988)
and lower academic achievement outcomes, as measured
by either school placement or standardized measures,
have been associated with more atypical RSMBs (Epstein,
Taubman, & Lovaas, 1985; Venter et al., 1992).

Acting-Out Behavior
Acting-out behaviors are those that cause harm or
damage to the child him/herself, to another person, and/or
to the environment (e.g., tantrums, aggressive behaviors,
and property destruction). They also include noncompliant
behaviors (i.e., refusing to follow directions, stubbornness) and other behaviors that indicate emotional dysregulation or distress (e.g., screaming, crying, whining).
Acting-out behaviors have often been linked to communication, cognitive, and social skills. This may be because
childrens inability to regulate their behavior during cognitively demanding tasks or situations places them at a
learning disadvantage over children who are able to do
so (Bronson, 2000). In addition, children with acting-out
behaviors may be rejected by their peers and, as a result,
may be deprived of opportunities to practice and develop
prosocial skills such as sharing and cooperating (Kaiser
& Rasminsky, 2003). Acting-out behaviors have also been
viewed as communicative, as they can function to enable
an individuals access to desired items, activities, or interactions (I want ____) or escape from undesired tasks or
interactions (I dont want ___; Bopp, Brown, & Mirenda,
2004). Despite these potential links, no research has examined the relationship between acting-out behavior and
language development over time in children with ASD.

Summary
The literature examining child problem behaviors
as predictors of language development in ASD is still in
its infancy. Very few investigations have examined the
relationships between these behaviors and development
in children with autism under the age of 6. Finally, with
some exceptions (e.g., Dissanayake, Sigman, & Kasari,
1996; Epstein et al., 1985), the majority of studies conducted in this area have been descriptive or have only
examined relationships at one point in time, providing a

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restricted view of the relationships between child problem behaviors and other developmental domains. Thus,
the purpose of this exploratory study was to examine the
extent to which problem behaviors predicted changes
in the developmental trajectories of vocabulary and language skills in young children with ASD over 2 years.
Specifically, we were interested in whether the presence
of problem behaviors prior to the onset of intervention
and /or changes in problem behavior during the first
6 months of intervention were related to changes in child
development over 2 years. Identifying these relationships is important for understanding the process of language development in ASD and the factors that influence
the differential outcomes reported in the literature. In the
end, such information may also help to improve treatment effectiveness by allowing therapists to set priorities
based on empirical information rather than on simple
heuristics. The specific questions addressed in this study
were:
1.

2.

Do scores in one or more types of child problem behavior at the onset of intervention predict changes
in the developmental trajectories of vocabulary and
language skills in young children with ASD over
2 years?
Do changes in scores related to one or more types of
child problem behavior over a 6-month period predict
changes in the developmental trajectories of vocabulary and language skills in young children with ASD
over 2 years?

Method
Participants
Data for this study were accessed from a database
established for a project examining early intervention
outcomes for 69 children with ASD and their parents in
British Columbia (BC), Canada. Prior to entry into the
study, 55 children were diagnosed with autism and 14
were diagnosed with pervasive developmental disorder,
not otherwise specified (PDD-NOS). All diagnoses were
made by experienced community-based clinicians who
were not involved in the study. Specifically, 28 children
(41%) received a diagnosis from an autism team that included, at a minimum, a psychologist or psychiatrist, a
pediatrician, and a speech-language pathologist; 22 (32%)
received a diagnosis from a pediatrician; 12 (17%) received a diagnosis from a psychiatrist; and 7 (10%) received a diagnosis from a registered psychologist or
another qualified professional. In addition, the Childhood Autism Rating Scale (CARS; Schopler, Reichler, &
Renner, 1988) was administered at the outset of the
study by psychologists who were naive to the original
diagnosis.

Participants were 58 males and 11 females (mean

age at T1: 4;2; range = 1;96;0). Their mean CARS score at
T1 was 36.3 (range = 25.050.5). Scores below 30 (n = 12)
were considered to be indicative of PDD-NOS, based on
the results of a 2005 study by Perry, Condillac, Freeman,
Dunn-Geier, and Belair, who examined the concordance
rate between the CARS and DSMIV clinical diagnoses
in 274 preschool children (aged 2 to 6). The childrens ethnic backgrounds included European-Canadian (n = 37),
Asian (n = 21), Hispanic (n = 4), Caribbean/African (n = 2),
Middle Eastern (n = 1), and multiple ethnicities (n = 4). At
baseline, mothers had completed some college or university courses (on average) and were considered semiskilled workers (e.g., machine operator, grocery store
clerk; Hollingshead, 1962). Fathers had completed some
university training (on average) and were considered
skilled workers (e.g., department manager, administrative assistant; Hollingshead, 1962). The families included
55 two-parent families, three separated families, four divorced families, six other arrangements (e.g., commonlaw), and one single-parent family.
All of the children received approximately 15 to
20 hours per week of year-round early intervention services for 2 years. The interventions for all children were
eclectic and were administered from either one of three
Early Intensive Behavior Intervention sites throughout
the province of BC (n = 39) or from private behavior consultants and other professionals who were hired by the
family (n = 30). In general, intervention consisted of 1:1
instruction based on the principles of applied behavior
analysis as well as services from speech-language pathologists, occupational therapists, and other professionals.
The majority of children (87%) also attended preschool
or school while they received intervention services. The
degree to which the five specific problem behaviors examined in this study were addressed during intervention
varied widely, depending on individual child and family
needs. Families reported that, in the first 6 months of intervention, only 2 children (3%) took prescription medications that were related to problem behavior; 4 (6%) were
on a dairy-free diet; 4 (6%) were on a supplemental diet;
and 7 (10%) were on another type of special diet. Because
there were no differences between the two service delivery groups with regard to language outcomes over 2 years
(Mirenda, Bopp, Kavanagh, Smith, & Zaidman-Zait,
2005), the two groups were combined for this analysis.

Measurement
Data were collected at baseline (i.e., prior to the initiation of early intervention, T1) and 6, 12, and 24 months
later (T2T4). Data collection occurred in each childs
home or early intervention center and was administered
by an assessment team that included registered psychologists, certified speech-language pathologists, and trained

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1109

graduate students who acted as family interviewers. At

each time point, the data collection location was consistent for each child and data collection was typically conducted by the same assessment team members. None of
the assessors were involved in service provision, either
to the children or to their families.

Measures of Child Problem Behavior

Measures of Child Development

Identify relevant predictor variables. The first step was

to conduct a thorough literature review to identify relevant variables that were potential predictors of language/
communication abilities in young children with autism
and related disorders. The five problem behavior variables that were selected from this review were all hypothesized to impact socialaffective development and, as a
result, language development.

The dependent variables were each childs raw scores

on measures of vocabulary and language at all four time
points (T1T4). All vocabulary and language measures
were administered by a certified speech-language pathologist. The independent variables, problem behaviors,
were not taken from standardized measures and were
constructed in a process described below.
Vocabulary skills. Single word receptive vocabulary
skills were measured with the Peabody Picture Vocabulary TestIIIA/B (PPVTIII; L. M. Dunn & Dunn, 1997),
which provides raw and standard scores for total words
understood. The PPVT has been shown to be a reliable and
valid measure of receptive vocabulary for persons from
2;6 (years;months) to over 90 years, with standard and
raw scores well correlated to chronological age and intellectual functioning. Internal reliability coefficients of raw
scores on the PPVT are reported to be a median alpha of
0.95 (range: 0.890.97; L. M. Dunn & Dunn, 1997).
Single word expressive vocabulary skills were assessed using the Expressive One-Word Picture Vocabulary Test (EOWPVT; Brownell, 2000), which provides
raw and standard scores of total words expressed. The
EOWPVT has been normed on individuals without disabilities, ages 218;11 and is a reliable and valid measure
of expressive vocabulary. Standard and raw scores are
highly correlated with chronological age and measures of
cognitive ability, language, academic achievement, and
receptive vocabulary. Internal reliability coefficients of
scores on the EOWPVT are reported to be a median alpha
of 0.96 (range: 0.930.98; Brownell, 2000).
Language skills. Language skills were measured with
the Preschool Language Scale3 (PLS3; Zimmerman,
Steiner, & Pond, 1992). This instrument measures both
receptive and expressive language abilities and provides
raw and standard scores for total language and for two
subscales, Auditory Comprehension (PLS AC) and Expressive Communication (PLS EC). The PLS3 has been
found to be a reliable and valid measure of auditory comprehension, language expression, and overall language.
Standard and raw scores are highly correlated with chronological age and other measures of language. For children ages birth to 6 years, 11 months, internal reliability
coefficients range from 0.47 to 0.88 for Auditory Comprehension, 0.69 to 0.90 for Expressive Communication, and
0.74 to 0.94 for overall Total Language Score (Zimmerman
et al., 1992).

1110

The database did not include specific measures of

the five categories of problem behaviors that were utilized as independent (i.e., predictor) variables; thus, scores
for these variables were constructed in a seven-step
process.

Identify relevant item indicators. The second step

was to identify individual item indicators related to the
behavior variables, using existing assessment measures
in the data set. This process was completed by the first
and second authors independent examination of every
item in five measures that were collected at each assessment time point but were not used as measures of child
language or vocabulary development. The five measures
were all parent-report measures and included the Autism Behavior Checklist (ABC; Krug, Arick, & Almond,
1980/1983), the Vineland Adaptive Behavior Scales (VABS;
Sparrow et al., 1984), the Temperament and Atypical
Behavior Scale (TABS; Bagnato, Neisworth, Salvia, &
Hunt, 1999), the Sensory Profile (W. Dunn, 1999), and
the Parenting Stress IndexShort Form (PSISF; Abidin,
1995). The interrater agreement for identification of potential items related to the five behavior variables was
90%.
The ABC is a 57-item checklist of behaviors related
to autism and was completed by the parent or primary
caregiver. The VABS Interview Edition Survey Form is
a measure of social, daily living, communication, and motor skills and was administered by a psychologist through
a semistructured interview with the parent. The TABS
consists of 55 questions regarding a childs emotional disposition and regulatory behavior and was completed by
the parent or primary caregiver. The Sensory Profile was
also completed by the parent or primary caregiver and
consists of 125 questions that report the frequency with
which a child responds to various sensory experiences. It
is used for children between the ages of 3 to 10 and provides a standardized method of reporting childrens sensory and processing abilities. Finally, the PSI-SF is a
parent/caregiver response form that consists of 36 key
items derived from the long form of the PSI and assesses
the level of parenting stress.
Choose item indicators. The third step was to choose
specific items for each problem behavior variable using
an expert jury to address content validity (Sireci, 1998).

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The jury consisted of 15 masters- or doctoral-level

professionals whose academic focus was autism and who
had an average of 11 years (SD = 8.45) of experience
working directly with young children with ASD. Each
jury member was provided with a list of all of the potential behavior items in random order. They were asked to
read definitions of the five categories of problem behavior and to then sort the items from the list into the categories. They were instructed that each problem behavior
item could fall under only one behavior category, and
they were provided with an other category for items that
did not appear to fit any of them. Individual items that
were selected for a category by at least 80% of jury members were retained for use in the study.
Convert items to dichotomous responses. The fourth
step was to convert the individual item indicators into
dichotomous item responses (i.e., yes/no scores), as needed.
In cases where ordinal or Likert-type scales were originally used to score an item, the following steps were
taken. For the VABS, yes, usually and sometimes or
partially were both coded as yes (1), and no was
coded as no (0); for the Sensory Profile, always, frequently, occasionally, and seldom were coded as yes
(1), and never was coded as no (0); for the PSI-SF,
strongly agree and agree were coded as yes (1), and
strongly disagree or disagree responses were coded
as no (0), whereas not sure was not coded.
Eliminate item overrepresentation. The fifth step
was to eliminate overrepresentation of any single behavior within a predictor variable. The question for this
step was Which item is most representative of a specific behavior of concern? Answering this question involved several phases. First, items related to the same
behavior were grouped into subdomains on the basis of
similar wording. For example, the three separate items
from the ABC, the Sensory Profile, and the TABS that
refer to avoidance or resistance of eye contact were
grouped into one subdomain within the variable social
unresponsiveness.
Second, a series of decision rules was applied to eliminate redundant items within each subdomain. Multiple
items from the same measure were retained even when
they referred to similar behaviors. For example, Sensory
Profile Items 27 and 28 both refer to rocking behaviors;
however, both were retained because they were originally considered to be separate items on this measure.
This rule was applied to improve content validity such
that the constructed variables included sets of items that
sampled several similar, but slightly different, aspects of
a specific behavior.
In only two instances did items with similar wording
within a subdomain originate from different measures.
One of these occurred for the eye contact behavior in the
social unresponsiveness variable, as described previously;

the other occurred in the acting-out variable, where two

items, one from the Sensory Profile and another from the
ABC, both referred to temper tantrums and thus constituted a subdomain. A decision was made to choose items
originally coded as dichotomous (i.e., those from the ABC
and TABS) over items originally coded on a Likert-type
scale (i.e., items from the PSI-SF, Sensory Profile, and
VABS). On this basis, the temper tantrum item from the
ABC was retained over the item from the Sensory Profile. The ABC item was also selected for eye contact to
keep the origin of items as consistent as possible across
behavior variables.
Calculate coefficient alphas. The sixth step was to
examine the psychometric properties of the items within
each predictor variable to compute a composite score
(Zumbo, Gelin, & Hubley, 2003). Coefficient alpha is used
to gauge the reliability of a measure and is based on the
average correlation among items (Cronbach, 2004). Typically, a coefficient alpha score of .70 indicates that
items used to calculate a composite score are internally
consistent with little measurement error (Streiner &
Norman, 1989). However, lower alpha values of .60 have
been accepted as adequate (e.g., Clark & Watson, 1995;
Milfont & Gouveia, 2006), especially in exploratory
research.
Calculate composite scores. In the final step in the
process, the sum of items was calculated (i.e., 1 = the behavior was present and 0 = the behavior was not present) to create a composite score for each of the predictor
variables at T1 (Zumbo et al., 2003). A summary of the
items that were included in each behavior variable and
their interrater reliability percentages based on the expert jury judgments (Step 3) are available from the first
author on request.

Data Analysis
Following construction of the predictor variables,
individual growth curve modeling (IGCM) using SAS
Proc Mixed computer software was used to answer each
research question. Individual growth trajectories developed through latent trajectory analysis are a rich and
flexible alternative to traditional methods for analyzing
longitudinal data (e.g., regression). IGCM was used in
order to take advantage of the multiwave data that were
available for investigation. IGCM enables the examination
of change as a continuous process, such that the amount
of change between time periods for a given participant is
a result of that participants underlying growth trajectory (Francis, Fletcher, Stuebing, Davidson, & Thompson,
1991). In addition, IGCM includes path analysis and regression to explore relationships among changes in individual variables over time (Keith, 1993; Schumacker &
Lomax, 2004).

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1111

Data analysis using SAS Proc Mixed was completed

using a four-step process. In all four steps and in all
models, an unstructured correlation structure was used
(Singer, 1998); age was used as the measure of time to
take into account the wide age range at T1, and age was
centered (age minus the mean age at T1) to facilitate
interpretation of the output (Singer and Willet, 2003).
In Step 1, unconditional models were run separately for
each language measure (i.e., PPVT, EOWPVT, PLS AC,
and PLS EC). During this step, the shape of the growth
curve and the variance in the intercept and slope for the
group overall and between individuals was examined.
In Step 2, separate conditional models were run for each
language measure to determine the influence of T1 autism severity and of T1 nonverbal IQ (NVIQ) scores on
each trajectory over 2 years. This was done because past
research has found a relationship between autism severity scores and NVIQ (DeMyer, 1973; Eaves & Ho, 1996;
Liss et al., 2001) and between NVIQ and other developmental outcomes (e.g., Luyster, Qui, Lopez, & Lord, 2007).
Autism severity was measured by CARS total scores.
NVIQ was missing for 9 of the children (13%) and was
estimated for the remaining 60 children (87%) by combining the t-scores from the Visual Reception and Fine
Motor subscales of the Mullen Scales of Early Learning
(Mullen, 1995; see Luyster et al., 2007). In Step 3, conditional models were run for each measure that included,
when warranted, T1 CARS total scores and/or T1 NVIQ
and each child behavior variable in isolation. In Step 4,
final conditional models were run for each measure and
included all variables from Steps 2 and 3 that were significant in predicting variance in the slope of a given
measure.

& Norman, 1989), and lower alpha values of .60 indicated

adequate internal consistency (e.g., Clark & Watson, 1995;
Milfont & Gouveia, 2006).
Composite scores were calculated for each category
of problem behavior. Table 2 summarizes the mean, range,
and standard deviation for each of the five problem behavior variables at T1 and T2 for all 69 children.

Child Language Development (T1T4)

Table 3 summarizes the raw score, mean, range, and
standard deviation for each of the measures of vocabulary and language development and autism severity from
T1 to T4 for all 69 children.

Unconditional Model
Before analyses were conducted to examine the predictors of change in child development, unconditional
models were examined to determine whether there was
significant variance in the initial value and slope for each
of the child measures over 2 years and to examine whether
the model was linear or quadratic. Table 4 presents these
findings and the Akaike Information Criterion (AIC), the
unconditional model goodness-of-fit statistic, for each measure. There is no statistical test available to assess the
differences in AIC between models; however, models
with lower AIC values are preferred and are considered
a better fit (Tabachnick & Fidell, 2007). Overall, the results indicated that the children changed significantly
over 2 years on all measures (i.e., the variance in the
rate of change over 2 years was significant). With regard to the shape of the growth curves, the linear effect
was significant and the quadratic was not, in all cases.

Results

Conditional Model

Predictor Variable Creation: Total Item

Correlations and Composite Scores

Multilevel modeling was used to examine whether T1

autism severity (i.e., CARS total score), T1 NVIQ, and/or
one or more categories of problem behavior, measured
either prior to the start of intervention (T1) or with a
difference score between T1 and T2, predicted the individual difference variance in the rate of change of any
child measure over 2 years.

Table 1 summarizes the total number of items chosen

and the corresponding coefficient alpha found for each
predictor variable. Coefficient alpha .70 indicated that
the items used to calculate the composite score were internally consistent with little measurement error (Streiner
Table 1. Coefficient alpha for each child behavior variable.

Child behavior variable

Total number
of items

Coefficient
alpha

Acting-out behavior
Repetitive sensory motor behavior
Insistence on sameness behavior
Socially unresponsive behavior
Inattentiveness

19
22
6
20
10

.84
.75
.62
.78
.56

1112

T1 scores for autism severity and NVIQ as predictors

of vocabulary and language development. Table 5 presents the results of the relationship between T1 CARS
and NVIQ scores and changes in vocabulary and language
measures over 2 years. Overall, the results revealed
that high T1 CARS scores alone predicted significant
decreases in the slopes of PPVT, EOWPVT, and PLS EC.
High T1 NVIQ scores alone predicted significant increases in the slopes of PPVT, EOWPVT, and PLS EC.
However, when both T1 CARS and T1 NVIQ were combined, T1 CARS scores no longer significantly predicted
the individual difference variance in the slopes of either

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Table 2. Scores for Time 1 (T1) behavior variables used to predict changes in child development over 2 years.
Child behavior variable

T1 M (range)

T1 SD

T2 M (range)

T2 SD

Acting-out behavior (maximum score = 19)

Repetitive sensory motor behavior (maximum score = 22)
Insistence on sameness behavior (maximum score = 6)
Socially unresponsive behavior (maximum score = 20)
Inattentiveness (maximum score = 10)

8.86 (118)
10.25 (220)
3.94 (16)
5.78 (013)
6.72 (310)

3.92
3.68
1.51
2.96
1.72

7.41 (017)
9.07 (017)
3.31 (06)
4.04 (013)
5.87 (19)

4.00
3.83
1.66
3.15
1.80

Note. T2 = Time 2.

PPVT or EOWPVT. In the final analysis, the inclusion

of T1 NVIQ in the models for PPVT and EOWPVT and
the inclusion of both T1 NVIQ and T1 CARS in the model
for PLS EC resulted in models that were a better fit, as
reflected in the lower AIC values in Table 5 compared
to those in Table 4. Thus, both T1 CARS and T1 NVIQ
scores were included in all subsequent models for PLS
EC, and T1 NVIQ scores alone were included in all subsequent models for PPVT and EOWPVT.
T1 scores for child behavior as predictors of vocabulary and language development. Table 6 presents the
results of the child behaviors as predictors of vocabulary and language development from T1 to T4 (i.e., over
2 years). The results revealed that two of the five behavior variables measured at T1 predicted significant
changes in vocabulary or language development measures. First, a high score on inattentive behavior at T1
was predictive of less of an increase in the rate of change
for EOWPVT and PLS AC over 2 years, regardless of T1
NVIQ. Second, a high score on social unresponsiveness
at T1 was predictive of less of an increase in the rate of
change for EOWPVT, PPVT, and PLS AC over 2 years,
regardless of T1 NVIQ. Scores for IS behaviors, RSMBs,
and acting-out behaviors at T1 did not predict the rate of
change of any child measure over 2 years beyond differences accounted for by T1 CARS and NVIQ status.
The IGCM software used in this analysis (SAS Proc
Mixed) does not yield conventional effect size estimates

such as those available in other statistical packages (e.g.,

SPSS). However, the statistical effects can be illustrated
by examining the average rate of change in language
or vocabulary growth for a prototypical child with mean
inattentiveness and/or social unresponsiveness scores at
T1 and with scores 1 standard deviation above and below the mean (Brooks & Meltzoff, 2008; Singer & Willet,
2003). Figures 13 display these results.
Figure 1 displays the results for the EOWPVT, suggesting that a child with fewer inattentive and socially
unresponsive behaviors at T1 (1 SD) would have a rapidly accelerating growth curve, whereas a child with more
inattentive and socially unresponsive behaviors at T1
(+1 SD) would have a much slower acceleration in growth
of vocabulary production over 2 years. In Figure 2 (PLS
AC), a child with fewer inattentive and socially unresponsive behaviors at T1 (1 SD) would have greater rate of
acceleration over the first 12-month period only, compared to a child with more inattentive and socially unresponsive behaviors at T1 (+1 SD). Finally, in Figure 3
(PPVT), a child with fewer socially unresponsive behaviors at T1 (1 SD) would have a slightly more rapid growth
acceleration over the first 12 months only, compared to
a child with more socially unresponsive behaviors at
T1 (+1 SD).
Difference scores for problem behavior from T1 to T 2
as predictors of vocabulary and language development.
The results indicated that changes in any of the problem

Table 3. Raw scores for measures of child development from Time 1 to Time 4.
Time 1
Child measure
PPVT
EOWPVT
PLS AC
PLS EC
CARS

Time 2

Time 3

Time 4

M (range)

SD

M (range)

SD

M (range)

SD

M (range)

SD

9.87 (085)
10.51 (065)
12.96 (348)
13.96 (447)
36.34 (2550.5)

17.68
14.79
9.15
7.36
5.72

20.94 (097)
19.07 (075)
19.62 (344)
18.01 (644)
35.54 (17.549)

23.50
18.05
11.05
8.38
6.75

27.87 (0108)
24.45 (086)
23.56 (548)
21.21 (548)
34.83 (1949.5)

26.74
22.48
12.78
9.90
7.19

38.19 (0125)
33.90 (096)
28.86 (848)
25.67 (748)
34.53 (16.550.5)

29.27
26.29
13.25
12.19
7.83

Note. PPVT = Peabody Picture Vocabulary Test; EOWPVT = Expressive One Word Picture Vocabulary Test; PLS = Preschool Language Scale;
AC = Auditory Comprehension; EC = Expressive Communication; CARS = Childhood Autism Rating Scale.

Bopp et al.: Behavior Predictors

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1113

Table 4. Unconditional models of change in measures of child language development from

Time 1 to Time 4.
Value

PPVT

EOWPVT

PLS AC

PLS EC

Intercept estimate
t -value
Slope estimate
t -value
Goodness of fit (AIC)

12.78
5.88***
1.11
11.59***
2149.8

12.35
6.54***
0.93
10.59***
1988.5

14.77
11.55***
0.63
13.12***
1782.5

14.77
15.39***
0.48
12.01***
1571.2

Note. AIC = Akaike Information Criterion.

***p < .0001.

behaviors from T1 to T2 did not predict changes in any

of the vocabulary or language outcome measures over
2 years.

Discussion
This study provides an initial exploration of the interrelationships between five types of behaviors and vocabulary and language development over time. It is unique
in that individual growth curve modeling was used to explore the impact of problem behaviors at T1 and changes
in problem behaviors 6 months later on changes in vocabulary and language development over 2 years.
Results of the conditional analyses related to autism
severity and NVIQ generally confirmed past research
that has found a relationship between these two measures
themselves and between NVIQ and other developmental

outcomes. More specifically, the results revealed that

autism severity scores prior to the onset of intervention
were predictive of only one communicative measure over
time: language production. CARS scores at T1 when combined in the model with T1 NVIQ did not predict differential outcomes over 2 years in either vocabulary or
language comprehension skills. Autism severity scores
have often been linked to developmental outcomes for
children with ASD (DeMyer, 1973; Eaves & Ho, 1996;
Liss et al., 2001); however, the results of this study suggest that they may have little bearing on childrens rate
of development on a broad range of language skills. On
the other hand, NVIQ prior to the onset of intervention
was found to predict changes related to receptive and
expressive vocabulary development and expressive language development over time. These results echo the findings of previous research (Gabriels et al., 2001; Harris
& Handleman, 2000; Liss et al., 2001; Lovaas & Smith,

Table 5. T1 CARS and nonverbal IQ (NVIQ) as predictors of vocabulary and language

development from Time 1 to Time 4.a
Value

PPVT

EOWPVT

PLS AC

PLS EC

T1 CARS alone
0.04
3.10*
1977.1

0.01
1.75
1769.5

0.02
3.77**
1557.8

Slope estimate
t -value
AIC

0.04
2.73*
2137.5

Slope estimate
t -value
AIC

T1 NVIQ alone
0.02
0.02
3.85**
3.38**
1820.4
1676.1

0.004
1.26
1501.1

0.009
3.57**
1295.6

T1 CARS slope estimate

t-value
T1 NVIQ slope estimate
t-value
AIC

T1 CARS plus T1 NVIQ

0.016
0.03
0.88
1.82
0.02
0.015
3.09*
2.36*
1815.5
1672.1

0.004
0.45
0.003
0.87
1492.5

0.02
2.11*
0.007
2.45*
1289.4

Centered age as calculated by age minus mean age at T1 was used as the measure of time.

*p < .05. **p < .001.

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Table 6. Results from final models showing effects of child behavior predictors on language
outcomes from Time 1 to Time 4. Models also included T1 NVIQ and CARS scores.
Value

PPVT

EOWPVT

PLS AC

PLS EC

Inattentiveness slope estimate

t-value
Social unresponsiveness slope estimate
t-value
Acting-out slope estimate
t-value
RSMB slope estimate
t-value
Insistence on sameness slope estimate
t-value

0.11
1.84
0.07
2.68*
0.02
0.98
0.04
1.46
0.02
0.35

0.13
2.19*
0.06
2.21*
0.04
1.59
0.04
1.49
0.09
1.54

0.07
2.53*
0.03
2.10*
0.004
0.30
0.02
1.55
0.02
0.43

0.03
1.23
0.02
1.94
0.006
0.58
0.003
0.31
0.05
1.79

Note. RSMB = Repetitive stereotypic motor behaviors.

*p < .05. **p < .001.

1998; Sallows & Graupner, 2005; T. Smith et al., 1997),

although they reveal little about specific child characteristics that may affect differential outcomes.
Five problem behaviors were examined as potential
predictors of language development in children with autism. The results indicate a relationship between inattentive behaviors and language development over time.
Inattentive behaviors in this study included, for example, not paying attention to sights and sounds in the
environment; being distracted by noise; not listening to
instructions or a story; and looking away from tasks to
notice other actions in the room. The results suggest that
children with more inattentive behaviors at T1 made significantly less progress in expressive vocabulary and language comprehension development over 2 years. Thus,
prior to the start of treatment, it appeared that inattentiveness hindered language development. These results
support the suggestion that inattention is a correlate of
Figure 1. Average growth curve of Expressive One Word Picture
Vocabulary Test (EOWPVT) scores over 2 years for a prototypical
child with T1 inattentive (IA) and social unresponsiveness (SU) scores
that were at the mean and 1 standard deviation above and below
the mean.

change and that poor attending skills negatively impact

childrens ability to learn from the environment (Edelson,
Schubert, & Edelson, 1998). The results also lend support
the common practice of providing focused instruction on
attending skills early in the treatment process (e.g.,
Lovaas, 2003).
The number of socially unresponsive behaviors at
T1 also predicted childrens vocabulary or language development over 2 years. Socially unresponsive behaviors
in this investigation included, for example, rarely smiling, not looking at faces, actively avoiding eye contact,
and failing to respond to ones own name. The results suggest that children with more socially unresponsive behavior at T1 made significantly less progress over 2 years
in both vocabulary comprehension and production and
in language comprehension. Although social deficits are
central to the diagnosis of autism, researchers have only
recently started to examine how these deficits impact
Figure 2. Average growth curve of Preschool Language Scale Auditory
Comprehension (PLS AC) scores over 2 years for a prototypical child
with T1 inattentive and social unresponsiveness scores that were at the
mean and 1 standard deviation above and below the mean.

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1115

Figure 3. Average growth curve of Peabody Picture Vocabulary Test

(PPVT) scores over 2 years for a prototypical child with T1 social
unresponsiveness scores that were at the mean and 1 standard
deviation above and below the mean.

other developmental domains such as language (Carter,

Davis, Klin, & Volkmar, 2005). The current findings support the notion that socialaffective skills play a central
role in language development in this population (Mundy
& Markus, 1997). Perhaps children with few social interaction skills have fewer social experiences, which, in turn,
results in fewer opportunities to hear, respond to, produce, and learn language in social contexts. This study
adds to the growing body of research in this regard and
emphasizes the importance of early social behaviors on
later language development.
Insistence on sameness and repetitive stereotypic
motor behaviors were found to have a nonsignificant relationship with language development after differences
in NVIQ and CARS scores were considered. This finding
was unexpected, as past correlational studies have identified relationships between one or both of these behavioral categories and language ability (Campbell et al.,
1990; Carcani-Rathwell et al., 2006; Dadds et al., 1988;
Szatmari et al., 2006; Venter et al., 1992). In addition,
past intervention studies have identified an inverse relationship between RSMBs and the acquisition of communication skills (Koegel, Koegel, Hurley, & Frea, 1992;
Lee & Odom, 1996). One explanation is that the IS and
RSMB variables in this study were not sufficiently sensitive to identify changes across time and /or included
too wide a range of behaviors in these two areas. Past
studies that have identified a relationship between communication and RSMBs have typically focused on only a
few ADIR items to measure this variable (e.g., Bishop
et al., 2006; Cuccaro et al., 2003; Szatmari et al., 2006).
Acting-out behaviors were also found to have no relationship with vocabulary or language development over
2 years. This finding was also somewhat unexpected, as
past researchers have suggested that acting-out behaviors may interfere with learning and/or restrict childrens
opportunities to practice and develop skills in other areas

1116

(Bronson, 2000; Hauser-Cram, Warfield, Shonkoff, &

Krauss, 2001; Kaiser & Rasminsky, 2003). In addition,
acting-out behaviors are often viewed as serving one or
more behavioral functions, at least some of which can
be viewed as communicative (Durand & Merges, 2001).
Again, because the acting-out variable in this investigation was not taken from an existing valid and reliable
standardized measure, the items that comprised it may
not have represented the construct adequately. In addition, the relationship between acting-out behavior and
communication is complex, and additional factors (e.g.,
parenting skills related to acting-out behavior, variables
related to treatment, etc.) are likely to enter into the
equation. Additional research that clarifies the complex
dynamics involved in both the origins and treatment of
acting-out behavior are sorely needed (e.g., Lucyshyn,
2007).

Limitations
This study attempted to examine behavioral predictors of developmental trajectories in young children with
ASD over time and, as is often case with exploratory studies, it has several limitations. First, a relatively small
sample size (N = 69) was used. Although small sample
sizes are not uncommon in ASD research (e.g., Charman
et al., 2005; Sigman & McGovern, 2005; Siller & Sigman,
2002; Stone & Yoder, 2001; Szatmari, Bryson, Boyle,
Streiner, & Duku, 2003), follow-up studies are needed to
examine the predictive relationships found here in a larger
group of participants. Second, the timeline of 2 years for
this investigation was relatively short for a longitudinal
design. Follow-up at 5 years and beyond for this group of
children would be optimal, in order to ascertain the stability of the findings.
Third, the data were originally collected for a purpose other than that for which they were used in this investigation. This resulted in several limitations. First,
information was not available about the extent to which
each childs treatment specifically targeted the problem
behaviors examined in this study. Second, items included
within each child behavior variable were limited to only
those items available in the existing measures in the data
set. Thus, none of the predictor variables incorporated all
possible behavioral manifestations of the behavior constructs. For example, the IS variable contained only six
items and did not include behaviors such as circumscribed
interests, which have been found to be related to child
development in other studies (e.g., Bishop et al., 2006).
Third, all of the items used to construct the predictor
variables originated from parent-report measures, and
none of the behaviors were directly observed by an experienced professional. Finally, even though care was taken
in the construction of the predictor variables with regard to psychometric and content validity, none of the

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variables were taken directly from existing valid and

reliable standardized measures of child behavior. In
addition, the coefficient alpha for inattentive behavior
was slightly lower (.56) than the .60 value that is typically used to reflect adequate internal consistency. In
preliminary analyses, we attempted to increase the alpha
by systematically removing one inattentive behavior item
at a time from the variable, but this did not improve
the outcome. We decided to use the variable in the analysis regardless, as the 10 behaviors that comprise it
were identified as relevant by 80% or more of the expert
panel members. In the end, this appears to have been a
reasonable decision, as this variable was found to be a
significant predictor of language development despite
the reduced power associated with lower alpha scores.

Future Directions
The results of this research provide a preliminary
understanding of some of the child problem behaviors
that may be related to language development in young
children with ASD. Identifying such predictive relationships may provide guidance for the development of treatments that result in optimal outcomes (Koegel et al.,
1992). For example, many intervention programs target early socio-communicative behaviors such as imitation (Ingersoll, Schreibman, & Quy, 2003; Schreibman &
Ingersoll, 2005), an approach supported by recent research demonstrating predictive relationships between
imitation skills and development in other areas (e.g.,
V. Smith et al., 2007; Toth et al., 2006). The results of
the present study suggest that children who are more attentive and socially responsive are likely to make greater
gains in vocabulary and/or language development. These
findings support the theory that children with autism
learn language much like typical children do, through forms
of joint social engagement (e.g., Abbeduto & Boudreau,
2004; Luyster et al., 2007). If future research supports
this finding, specific approaches aimed at improving attentiveness and socially responsive behavior would appear to be critical as key components of early treatment
packages. In addition, research is needed to examine the
extent to which the predictive relationships found in
this investigation are common across young children
with ASD who receive various types of early intervention. This will add to our current, limited understanding of the influence of problem behaviors on the widely
heterogeneous outcomes observed in young children
with ASD (Schreibman, 2000).
In conclusion, this exploratory investigation opens
the door to future examinations of predictive relationships between specific child behaviors and changes in
child vocabulary and language development over time,
using analytic techniques that take advantage of multiwave data. This type of research has potential for adding

substantially to our current understanding of these complex relationships and for assisting service providers,
families, and policy makers to make more informed decisions about how to maximize the effectiveness of their
early intervention efforts.

Acknowledgments
This research was completed by the first author in partial
fulfillment of the requirements for a doctoral degree at the
University of British Columbia. Portions of this research were
presented at the International Meeting for Autism Research
in Seattle, May 2007; the American Speech-Language-Hearing
Association conference in Chicago, November 2008; and on a
public webcast at http://breeze.setbc.org/p65709571/. We are
grateful to the children and families who participated in this
study and to the many evaluators who were involved in data
collection. Partial funding was provided by the Human Early
Learning Partnership, the BC Ministry for Children and Family
Development, and the National Alliance for Autism Research /
Autism Speaks postdoctoral fellowship program.

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DOI: 10.1044/1092-4388(2009/07-0262)
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