Research in Autism Spectrum Disorders 4 (2010) 626632

Contents lists available at ScienceDirect

Research in Autism Spectrum Disorders

Journal homepage: http://ees.elsevier.com/RASD/default.asp

Differentiating communication disorders and autism in children

Johnny L. Matson *, Daniene Neal
Louisiana State University, United States

A R T I C L E I N F O

A B S T R A C T

Keywords:
Autism
PDD-NOS
Children
Communication disorders
Differential diagnosis
Assessment

The diagnosis of autism and Pervasive Developmental Disorder Not Otherwise Specied
(PDD-NOS), particularly in young children has become a top priority in the elds of mental
health and education. Core symptoms include rituals and stereotypies, social skills decits,
and problems in communication. Considerable overlap exists in symptoms for autism
spectrum disorders and communication disorders. As a result, distinguishing between
these two conditions is one of the most difcult aspects of the assessment enterprise.
However, being able to differentially diagnose these two disorders has important
implications for the treatment and management of these conditions. This paper provides
an overview and critical analysis of these disorders, how they are differentiated, and the
specic impact correct diagnosis can have on the selection and efcacy of interventions.
2009 Elsevier Ltd. All rights reserved.

Autism Spectrum Disorders (ASD) are neurodevelopmental conditions which commonly occur in children and have a
lifetime course (Heiman & Berger, 2008; Matson, 2007a, 2007b; Matson et al., 1996; Matson, Nebel-Schwalm, & Matson,
2007; Matson, Wilkins, Biosjoli, & Smith, 2008; Morton & Campbell, 2008). A great deal of overlap exists with intellectual
disability (ID), which further exacerbates core symptoms of ASD (Agaliotis & Kalyva, 2008; Ben Itzchak, Lahat, Burgin, &
Zachor, 2008; Matson, Dempsey, LoVullo, & Wilkins, 2008). These ASD present with common decits in communication,
social skills, and rituals and stereotypies (Matson & Boisjoli, 2007; Matson, Mayville, Lott, Bielecki, & Logan, 2003; Mitchell et
al., 2006; Packlawskyj, Matson, Rush, Smalls, & Vollmer, 2001). The core features of ASD are major barriers to normal
development and adjustment, and do not improve without effective treatment (Matson et al., 1997; Matson, Kiely, &
Bamburg, 1997; Matson & Nebel-Schwalm, 2007; Murphy et al., 2005). Additionally, the more severe the core symptoms of
ASD, the greater the risk for challenging behaviors and psychopathology (Dixon, Kurtz, & Chin, 2008; Matson & LoVullo,
2008; Matson, LoVullo, Boisjoli, & Gonzalez, 2008; Matson et al., 2005; Matson & Rivet, 2008; Ringdahl, Call, Mews, Boeltery,
& Christensen, 2008; Rojahn, Aman, Matson, & Mayville, 2003; Rojahn, Matson, Naglieri, & Mayville, 2004).
1. Differential diagnosis
One of the major problems in accurate diagnosis is being able to reliably differentiate ASD from similar problems,
particularly at young ages. Given that the 3 core features include impairments in social behavior, rituals, and
communication, communication disorders constitute an important disorder to consider (Chiang & Lin, 2008; Prizant, 1983;
Rapin & Dunn, 1997). Researchers have speculated about the overlap in these two groups of disorders for some time
(Churchill, 1972; Mayes, Volkmar, Hooks, & Cicchetti, 1993; Rojahn et al., 2004).
Ensuring an accurate diagnosis increases the likelihood that the most effective treatments will be put in place. Core
symptoms of ASD can and do overlap with other conditions, making differential diagnosis more difcult. One of the most

* Corresponding author at: Department of Psychology, Louisiana State University, Baton Rouge, LA 70803, United States.
E-mail address: johnmatson@aol.com (J.L. Matson).
1750-9467/$ see front matter 2009 Elsevier Ltd. All rights reserved.
doi:10.1016/j.rasd.2009.12.006

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627

obvious of these potential diagnostic difculties involves communication problems, since it is at once a core feature of
autism, but also a distinct disorder in its own right (Botting & Conti-Ramsden, 2003; Conti-Ramsden, Botting, & Faragher,
2001; Wray, Silove, & Knott, 2005). Reviewing representative studies aimed at teasing out the differences in ASD versus
communication disorders will therefore serve as the focus of this paper.
Language is unique to humans and consists of socially agreed upon words and sentences to convey meaning (Feldman,
2005). These utterances can vary from very concrete to highly abstract thoughts. Because language plays such an important role
in socialization and adjustment, decits can lead to a host of difculties. Specic Language Impairment (SLI) has a prevalence
gure of about 7% of the population (Law, Boyle, Harris, Harkness, & Nye, 1998; Tomblin et al., 1997) and recent gures suggest
that ASD may occur in up to 1% of the population. Both disorders are marked by major decits in communication. Additionally,
the conditions can overlap (Matson, Fodstad, & Mahan, 2009; Miniscalco & Gillberg, 2009). Conti-Ramsden, Simkin, and Botting
(2006), for example, report a 3.9% overlap in the disorders or about 10 times what would be expected in the general population.
Added to the concern for early diagnosis and intervention is the recognition that both conditions evince a chronic course
(Feldman, 2005; LoVullo & Matson, 2009; Matson, Rivet, Fodstad, Dempsey, & Boisjoli, 2008).
Verbal communication problems can be divided into two broad categories. Language disorders involve poorly developed
grammatical patterns, odd conversational patterns, misuse of words with respect to their meaning, difculty in expressing or
following ideas and an inability to follow directions. Speech disorders, on the other hand, involve articulation problems such
as the production of speech sounds, disrupted speech patterns, and difculties with pitch, volume, and quality in voice
modulation.
Psychological markers for various communication disorders, such as SLI have been established. SLI is a disorder
characterized by slow, abnormal language development (Botting & Conti-Ramsden, 1999). SLI typically is not associated
with cognitive or neurological decitis and is an overarching term for developmental verbal dyspraxia, linguistic dysphagia
and pragmatic language impairment (Parisse & Maillart, 2009). Conti-Ramsden et al. (2001) report on markers for SLI in 160
11-year-olds diagnosed with the condition. Three particularly prominent characteristics were sentence completion, nonword repetition, and linguistic tense marking.
Botting and Conti-Ramsden (2003) have also looked at specic markers to differentiate SLI from autism. In their study, 13
children averaging 10 years and 10 months of age with ASD were compared to 29 children average age 10 years, 10 months,
an age matched control group of 100 children, and 25 children with pragmatic language impairment (PLI). The SLI group
could be distinguished from the other groups in the recalling sentence task. The Childrens Autism Rating Scales (CARS;
Schopler, Reichler, Devellis, & Dah, 1980) proved most useful in discriminating the ASD group from typically developing and
language impaired groups.
A host of other psychometrically sound measures are also available for differential diagnosis of autism, but few have been
tested with respect to their viability in the differential diagnosis of ASD and language disorders (Matson et al., 2007). This
area of research certainly warrants further consideration given pragmatic issues. For example, Overton, Fielding, and Garcia
deAlba (2007) who tested 28 Hispanic children, found high rates of comorbid conditions for those identied with ASD and at
risk children who did not meet ASD criteria. In addition, Noterdaeme, Sitter, Mildenberger, and Amorosa (2000) used the
Autism Diagnostic Observation Schedule (ADOS) to distinguish 11 children with autism from 20 children with a specic
language disorder and 18 children with an expressive language disorder.
Mayes and Calhoun (2001) make an interesting point between early speech delays in autistic children and those with
Aspergers syndrome. They compared 23 children with a speech delay and 24 children with ASD, some of whom were autistic
and some of whom had Aspergers syndrome. They detected no difference on this dimension in the two ASD groups and
concluded that the distinguishing criteria of speech delay in DSM-IV between Aspergers syndrome and autism should be
dropped. Furthermore, they concluded that early speech delays may be irrelevant to later functioning in children with ASD
and normal IQ. Similar results have also been reported by Howlin (2003) and Bennett et al. (2008).
Rapin, Dunn, Allen, Stevens, and Fein (2009) provide somewhat different ndings. In the 79 years olds with autism that they
tested, four symptom clusters emerged. Eleven children evinced low phonology and near average comprehension, 40 children
had average phonology and low to average comprehension, and 7 children were average or better on both of these criteria.
Broadly speaking, differences in language impairments have not been identied across types of ASD when IQ is held
constant. Conversely, differences in language impairments can be differentiated among various language disorders. Those
with language disorders versus ASD tend to have impairments specic to only the communication domain, and language
decits are qualitatively different. Additionally, the other core decits in ASD (i.e., social skills and rituals and stereotypies)
are much more common in the ASD group.
Pinborough-Zimmerman et al. (2007) identied 1667 8-year-old children who met criteria for a communication
disorder. Four percent of the communication disorder cases had intellectual disability and 3.7% had ASD. Other high rate cooccurring conditions included attention decit/hyperactivity disorder, anxiety, and conduct disorder. These ndings are not
inconsequential given that prevalence rates of SLI, which is a subset of communication disorder, have been reported in 7.4%
of a stratied sample of 7218 midwestern children (boys at 8% and girls at 6%; Tomblin et al., 1997). Fundudis, Kolvin, and
Garside (1979) reported on 3300 British children. They noted that SLI was present in 4% of their 3-year-olds and 3% of their 7year-olds. Finally, Law, Boyle, Harris, Harkness, and Nye (2000), reviewed 16 prevalence estimates of SLI from 21 published
studies. They noted that the overall prevalence of speech and language impairments was roughly 6%. This coupled with the
high rates of ASD, and a degree of comorbid overlap, suggests that ASD researchers should have at least a passing knowledge
of language disorders.

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2. Developmental issues
Language is formulated at very early ages. Researchers have been studying the potential underlying symbolic function
that is tied to skills such as language (Thal & Bates, 1988). Normal language only develops after 2575 words have been
developed and are codied in the childs vocabulary. Thus, decits in symbolic function can markedly delay this process.
Additionally, joint attention, a common problem in children with ASD, has also proven to be a signicant predictor of
receptive language (Mundy & Gomes, 1998). Thus, core decits of ASD may be linked in some instances, and can adversely
affect core features of the disorder.
Developmental course of language problems can also be fairly persistent. For example, approximately 1/3 to 1/2 of
children showing language delays at 2 years of age continue to show delays at age three. Furthermore, 5080% of
preschoolers with language problems continue to display these symptoms into early adulthood (Grizzle & Simms, 2005).
3. Assessment instruments
In an effort to improve differential diagnosis between ASD and communication disorders, many measures have been
developed and studied to determine if specic differences in language impairment can be identied between the
aforementioned disorders. Differences in the topography, extent, and severity of decits may be useful in distinguishing
between disorders if detected by reliable assessment techniques. In addition, given the high degree of comorbidity with ASD,
assessment tools may help to determine whether the child evinces symptoms of one or both of the disorders with an
understanding of what is unique to and similar in each.
3.1. MacArthur communicative developmental inventories (CDI)
The CDI is comprised of two parent report measures, an infant version and a toddler version, used to assess language
development (Fenson et al., 1993). The CDI/Words and Gestures form is for children ages 818 months and consists of 396
vocabulary words for parents to indicate whether their child understands and/or produces the word. Parents also record any
gestures that their child uses for communication. The CDI/Words and Sentences form is for children ages 1630 months and
consists of 680 vocabulary words for parents to indicate whether their child produces the word. Parents also answer
questions regarding their childs understanding and use of phrases and sentences. Two alternate versions of the toddler form
are available for ongoing assessment. While Fenson, Bates, et al. (2000) warn that the CDI may not be able to adequately
assess intervention effectiveness as it demonstrates high variability across administrations, Feldman et al. (2000) argue that
this variability is an expression of typical changes in development and not a product of the measure itself. In addition to
being cost effective and easy to administer, the use of a parent checklist has the added benet of getting a comprehensive
assessment of communication skills across many observations and settings without the potential confounds of a clinical
observation (e.g., shyness or noncompliance with testing in young child; Feldman et al., 2000)
The CDI has been widely used, not only in studies of typically developing children, but also in studies of children with
developmental delays, including ASD. Charman, Drew, Baird, and Baird (2003) studied language development in children
ages 17 years with ASD using the CDI infant form. They found that, compared to typically developing children, children with
ASD evinced a greater number of language delays in both understanding and production. There were some patterns of
impairment unique to the children with ASD. Word production was greater than word and phrase comprehension in children
with ASD, which is contrary to what is developmentally expected. In addition, decits in gesture production for children with
ASD were more often in socially related gestures (e.g., reaching out to caregiver, waving hello). These qualitative differences
may be helpful in differentiating language impairments observed in ASD from those in communication disorders.
Short-form versions of the CDI are also available (Fenson, Pethick, Renda, & Cox, 2000). Items were derived from the long
form with 89 and 100 vocabulary words for the infant and toddler forms, respectively. The short versions contain only items
from the vocabulary list of the original CDI; however, scores are highly correlated with those obtained from the full CDI. The
short-form versions can be used in both research and practice and have demonstrated reliable measures of vocabulary
development (Cronbachs alpha of .95 and above for each form; Fenson, Bates, et al., 2000).
3.2. Childrens communication checklist (CCC)
The CCC is a 70 item parent/teacher completed measure designed to assess for differences in language impairments (i.e.,
pragmatic versus problems with language structure; Bishop, 1998). Items are a series of statements to which parents
respond does not apply, applies somewhat, or denitely applies. The CCC is comprised of nine scales, two of which
assess for social relationships and restricted interests in order to assist in differential diagnosis of autism and communication
disorders. The other seven scales include measures of pragmatic language use, speech production, and syntax (Bishop, 1998).
Research has supported the reliability of the CCC in children with a broad range of impairments (e.g. autism, ADHD, and
communication disorders; Bishop, 1998; Bishop & Baird, 2001; Botting & Conti-Ramsden, 1999; Geurts et al., 2008) and has
been used in different countries (Helland, Biringer, Helland, & Heimann, 2009; Verte et al., 2006).
In a validation study of the CCC, Bishop (1998) found that children with pragmatic language impairments did not exhibit
impairments on the restricted interests and social relationships subscales; however, their sample did not include children

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629

with ASD for comparison. Bishop and Norbury (2002) compared scores on the CCC to scores on the Autism Diagnostic
Observation Schedule-Generic (ADOS-G; Lord et al., 2000), Autism Diagnostic Interview-Revised (ADI-R; Lord, Rutter, & Le
Couteur, 1994), and the Social Communication Questionnaire (SCQ; Berument, Rutter, Lord, Pickles, & Bailey, 1999). The SCQ
is a 40 item parent completed screening measure used to assess for symptoms of autistic disorder. They found that children
with pragmatic language decits are not merely misdiagnosed children with ASD. That is, there were children with decits in
pragmatic language without endorsed symptoms of ASD. This implies that although there is overlap of symptoms in some
cases, communication disorders and ASD are distinct.
Geurts et al. used the CCC to differentiate between autism, ADHD, and typically developing children between the ages of
514 years. They found that children with autism exhibited the greatest impairments, followed by children with ADHD, and
then the control group. Decits in both children with autism and ADHD were primarily pragmatic or involving social
communication. Both parent and teacher reports were consistent and indicated the correct diagnosis in 7378% of the cases.
Verte et al. (2006) further explored the utility of the CCC by attempting to differentiate among the subtypes of ASD in 160
children ages 613 years. Parents of children receiving diagnoses of an ASD using the ADI-R completed the CCC via mail-in
questionnaires. While children with any ASD evinced greater impairments in communication compared to typically
developing controls, there were few differences among high functioning autism, Aspergers syndrome, and PDD-NOS. Based
on these studies, researchers have suggested that the CCC is a reliable and valid measure for assessing pragmatic language
decits in children and differentiating between children with ASD and other disorders. However, the ability to differentiate
among subtypes of ASD is questionable at this time.
3.3. Miscellaneous techniques
There are several methods used for assessment and differential diagnosis of impairments in communication that have
received less attention than the ones discussed above. One such method is the Diagnostic Interview for Social and
Communication Disorders (DISCO). The DISCO is a semi-structured interview which obtains developmental history and
clinical presentation of the child (Wing, Leekham, Libby, Gould, & Larcombe, 2002). It assess across a broad range of disorders
including psychiatric disorders, ASD, and developmental disabilities. While many diagnostic interviews are based primarily
on DSM or ICD diagnostic criteria, the DISCO takes a dimensional approach, aimed at obtaining a wealth of information for
the clinician to consider in making a diagnosis. However, diagnostic algorithms have been developed for diagnosing autism
(Leekam, Libby, Wing, Gould, & Taylor, 2002). While, the DISCO is not specically designed to diagnostically differentiate
between ASD and communication disorders, it can be useful for collecting information regarding communication problems
and the presence of symptoms unique to ASD
Doherty and Rosenfeld (1984) assessed play behavior in children with autistic disorder and communication disorders as a
potential distinguishing factor between ASD and communication disorder. They hypothesized that children with autism lack
symbolic, or make-believe, play, a skill which children with language disorders retain. They had parents of 15 children ages
615 years complete questionnaires regarding different types of play (i.e., sensory, functional, and symbolic) and also
conducted a 20 min observation during a structured play session. While some children with autism exhibited sensory and
functional play, all lacked symbolic play. This nding is in contrast to children with communication disorder alone, who
exhibited all types of play. These ndings emphasize the importance of assessing all core symptoms of ASD when considering
differential diagnoses.
Camaioni, Castelli, Longobardi, and Volterra (1991) developed a parent report instrument similar to the CDI for assessing
language development containing a checklist of vocabulary words and a series of questions assessing functional
communication (e.g., what does the child do when he/she is hungry). Parents of 24 children residing in Rome completed
the measure at ages 12, 16, and 20 months. Their ndings indicated that the parent measure resulted in reliable assessments
of language development. In addition, they found that language production at earlier ages predicted language performance
at 20 months of age. The implications of the study are important in extending ndings from American samples, to more
universal groups of children.
Automatic speech recognition (ASR) is a technology typically used to transcribe speech into text on a computer. More
recently, it has been considered for use in the assessment and treatment of speech problems (Kitzing, Maier, & Ahlander,
2009). However, this is a very new development and further research is needed to determine if and how it may assist in the
diagnosis of communication disorders and differentiating between ASD and communication disorders.
The above sections have reviewed various measures and methods used to assess for and differentiate ASD and
communication disorders. While many of these measures show promise, differential diagnosis continues to require a degree
of clinical judgment in addition to knowledge regarding the similar and unique characteristics of each disorder. As is
standard for achieving accurate diagnoses of any type, a comprehensive assessment including interviews, standardized
measures, and observation should be conducted when considering a diagnosis of ASD, communication disorder, or both.
4. Co-occurring problems
In addition to decits in communication skills associated with ASD, commonly co-occurring conditions may also
exacerbate the impairments exhibited. Challenging behaviors are common in children with ASD and have been strongly
correlated with the degree of communication decits (Sigafoos, 2000). That is, children with greater impairments in

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communication tend to exhibit more challenging behaviors. The nature of this relationship may be complex and multifaceted; however, researchers have suggested that improvements in communication skills (e.g., functional communication
training) have decreased challenging behaviors.
Deafness and hearing impairments may also co-occur with ASD and have adverse effects on prognosis. Konstantareas and
Homatidis (1987) found that children with autism had signicantly more ear infections and resulting hearing loss than
typically developing children. They also found that increased ear infections were correlated with lower cognitive
functioning, increased severity of ASD symptoms, and greater impairments in communication. Many children who are deaf
are diagnosed with an ASD later in life than children who are able to hear (Vernon & Rhodes, 2009). This delays the onset of
early intervention strategies, which have been implicated in better outcomes. In addition, many of the diagnostic
instruments used in assessing for ASD are not appropriate for children with deafness. Treatment techniques aimed at
teaching functional communication skills (e.g., sign language, picture communication) are effective for individuals with both
disorders; however, the improvements may not be as great as those in a child with only one of the disorders. In a study of
children of children with cochlear implants, both with and without additional disabilities (including autistic disorder),
Nikolopuulos, Archbold, Wever, and Lloyd (2008) found that after 5 years children with additional disabilities were less
likely to develop increased intelligible speech.
Children with psychiatric disorders may also have an increased risk for impairments in language. Cohen, Davine,
Horodezky, Lipsett, and Isaacson (1993) found that in a group of 399 children ages 412 years, approximately 30% of the
children evinced impairments in language. These impairments may be greater in the general population, but are easily
overlooked compared to the external behavioral issues of these children. Psychiatric disorders are commonly comorbid in
ASD and may place these children at an increased risk for more severe communication problems.
The presence of seizures and epilepsy are high in ASD and often result in lower IQ, less adaptive behavior, more emotional
problems, and higher psychiatric drug use (Hara, 2007). Turk et al. (2009) conducted a study comparing children with ASD
and epilepsy to children with ASD only. As with children with hearing impairments, children with epilepsy often received an
ASD diagnosis later in life. Children with ASD and epilepsy also differed from children with ASD alone in that they evinced
greater impairments in social, adaptive, and communication skills.
These overlapping conditions further complicate the ability of the clinician to make an accurate diagnosis and treatment
recommendations for children with ASD. As indicated above, many times, comorbid conditions are masked by the obtrusive
and challenging symptoms of another disorder. However, this can have important implications for treatment and prognosis.
It is imperative that the clinician not only consider alternate diagnoses during the comprehensive assessment, but also the
possibility of multiple co-occurring conditions.
5. Conclusions
Language decits have been looked at in this paper primarily from the perspective of those involved in the diagnosis of
ASD. Ruling out a language disorder requires some knowledge of the speaking and communication process. However,
language disorder is a separate and highly complex eld in and of itself. Thus, researchers and clinicians who are primarily
involved in ASD will, in most instances, not be experts in language disorders as well. Thus, the primary role of these ASD
professionals would be to determine whether ASD was present, and to obtain assistance or make a referral to an expert in
communication where a language disorder appeared to be the diagnosis, or to gain assistance for communication issues
where a language disorder was comorbid with ASD. Of course, assistance for communication problems specic to ASD might
also be sought, but this is a separate issue that appears in a different context.
What seems clear is that an initial ASD assessment may need to include tests designed more specically to assess
language decits in some cases. This latter approach to evaluation would be a second step, and would follow upon the
conclusion that a language disorder might be present in the child being evaluated. However, differentiation of disorders is
possible. Pervasive decits across all three core symptoms areas (i.e., social functioning, communication, and rituals and
stereotypies) is more typical of ASD. Furthermore, types of speech anomalies can be a key marker for differentiating ASD and
language disorders.
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