Age Of First Words Predicts Cognitive Ability And Adaptive .
J Autism Dev Disord (2013) 43:253–264DOI 10.1007/s10803-012-1558-0ORIGINAL PAPERAge of First Words Predicts Cognitive Ability and Adaptive Skillsin Children with ASDJessica Mayo Colby Chlebowski Deborah A. FeinInge-Marie Eigsti Published online: 7 June 2012Ó Springer Science Business Media, LLC 2012Abstract Acquiring useful language by age 5 has beenidentified as a strong predictor of positive outcomes inindividuals with Autism Spectrum Disorders (ASD). Thisstudy examined the relationship between age of languageacquisition and later functioning in children with ASD(n 119). First word acquisition at a range of ages wasprobed for its relationship to cognitive ability and adaptivebehaviors at 52 months. Results indicated that althoughproducing first words predicted better outcome at every ageexamined, producing first words by 24 months was a particularly strong predictor of better outcomes. This findingsuggests that the historic criterion for positive prognosis(i.e., ‘‘useful language by age 5’’) can be updated to a morespecific criterion with an earlier developmental time point.Keywords Autism Autism spectrum disorders Language acquisition Language delay Developmental milestones PrognosisIntroductionDeficits in language and communication are core featuresof Autism Spectrum Disorders (ASD) that are often evidentearly in life (American Psychiatric Association 2000). Forinstance, toddlers with ASD produce significantly fewerThe present study was conducted by Jessica D. Mayo, University ofConnecticut; Colby Chlebowski, University of Connecticut; DeborahA. Fein, University of Connecticut, and Inge-Marie Eigsti, Universityof Connecticut.J. Mayo (&) C. Chlebowski D. A. Fein I.-M. EigstiDepartment of Psychology, University of Connecticut,406 Babbidge Road, U-1020, Storrs, CT 06269, USAe-mail: jessica.mayo@uconn.educommunicative acts and demonstrate significantly less jointattention than typically developing children or childrenwith developmental delays (Shumway and Wetherby2009). Young children with ASD display fewer gaze shifts,conventional gestures, and gestures coordinated withvocalizations and eye gaze than children with developmental delays (Stone et al. 1997). In addition to atypicalsocial communication, many individuals with ASD struggle to acquire basic expressive language skills; for a reviewof language development in ASD see Frith and Happé(1994) and Rapin and Dunn (1997, 2003). Approximatelyone quarter of individuals with ASD remain non-verbalover the course of their lives (Lord et al. 2004). Childrenwith ASD who do learn verbal communication, generallyachieve language milestones later than children with typical development (Howlin 2003). Although typicallydeveloping children generally produce their first wordsbetween 12 and 18 months old (Tager-Flusberg et al. 2009;Zubrick et al. 2007), children with ASD are reported to doso at an average age of 36 months (Howlin 2003).Age of language acquisition is an important indicator ofpositive prognosis and social functioning. Very earlyreports noted that having language by age 5–6 was animportant discriminator of higher versus lower functioningindividuals with ASD (Rutter 1970), as it related to bettersocial functioning in adulthood (Eisenberg 1956; Kanneret al. 1972). The importance of language by age 5 wasconfirmed in a more recent report that found that adultswith ASD who had acquired ‘‘useful speech’’ by age 5 weremore social and required fewer residential support servicesthan those who had not (Howlin et al. 2004). The observedassociations between delayed language acquisition andpoorer prognosis have prompted many to avoid the ‘‘waitand see’’ approach to late language development in youngchildren (Buschmann et al. 2008), and instead to adopt a123
254more active ‘‘watch and see’’ approach by monitoringdevelopment over short periods of time (3–6 months) (Paul1996, 2000) or to implement specific interventions as soonas delayed language onset is observed (Ellis Weismer2000; Girolametto et al. 1996).In recent years, children can be reliably diagnosed withASD as early as the toddler years, which allows for aninvestigation of the relationship between earlier aspects oflanguage acquisition and later development (Charman et al.2005; Lord et al. 2005; Stone et al. 2000). Studies of therelationship between standardized language scores andlater functioning in ASD have clearly established anassociation between early language skills and later skills(Gillespie-Lynch et al. 2012; Venter et al. 1992). However,most children do not receive a comprehensive evaluation oflanguage skills using standardized formal assessments at anearly age, limiting the wide-spread use of standardizedmeasures as a source for prognostic information.There is a simple marker of language development, parentreport of the timing of first words, that could offer valuableprognostic information. Delay in the onset of spoken language is often the most pressing concern expressed by parents of children with ASD (De Giacomo and Fombonne1998; Howlin and Asgharian 1999; Short and Schopler1988), indicating that this aspect of early language development is highly salient. The current study examines therelationship between early language acquisition and laterfunctioning in children with ASD by investigating thequestion: does the age of a child’s first word productionpredict later cognitive ability, adaptive behavior skills, orsymptoms of ASD severity and if so, is there a particularlypotent predictive age of language onset?J Autism Dev Disord (2013) 43:253–264approximately 2 years later. The first-stage M-CHAT datahave been described elsewhere (Kleinman et al. 2008;Robins et al. 2001); the current study focuses on dataobtained from the follow up evaluation for children whowent on to receive diagnoses of ASD.All children in the current study received ASD diagnoses at the follow up evaluation based on parent interview,the Autism Diagnostic Observation Schedule (ADOS; Lordet al. 2000), the Autism Diagnostic Interview, Revised(ADI-R; Lord et al. 1994), the Childhood Autism RatingScale (CARS; Schopler et al. 1980; Schopler et al. 1988)and clinical judgment. Diagnoses were made by a clinicalpsychologist or a developmental pediatrician with experience with ASD using DSM-IV-TR criteria (AmericanPsychiatric Association 2000).Children with reported language regression were excluded from the study because of the difficulty of accuratelyjudging onset of first words. Language regression, identifiedfrom the ADI-R, was defined as the regular communicativeuse of at least five words (other than ‘dada’ or ‘mama’) for atleast three months followed by the loss of those languageskills for three or more months (Lord et al. 1994).The sample consisted of 119 children; 75 children(63 %) with diagnoses of Autistic Disorder (AD) and 44(37 %) with diagnoses of Pervasive Developmental Disorder, Not Otherwise Specified (PDD-NOS). The samplewas primarily male (83.2 %) and White (82.4 %). Childrenranged in age at the time of the evaluation from 45 to72 months, with a mean age of 52.22 months (SD 6.09).Table 1 presents the sample characteristics.MeasuresAssessment of First WordsMethodParticipantsThe participants in this study were 119 children who participated in a larger ASD screening study using the Modified Checklist for Autism in Toddlers (M-CHAT; Robinset al. 1999a), a parent report autism-specific screeninginstrument, at the University of Connecticut. Detailedinformation about the M-CHAT is available elsewhere(Kleinman et al. 2008; Robins 2008; Robins et al. 2001;Robins and Dumont-Mathieu 2006). All children in thecurrent study were screened with the M-CHAT between 16and 30 months of age at the office of a pediatrician or EarlyIntervention provider. Children who screened positive onthe instrument and the M-CHAT Follow Up (M-CHATFollow Up; Robins et al. 1999b), an interview designed toverify screening responses, were offered a comprehensivedevelopmental evaluation, and a follow up evaluation123Age of first words was defined as the age (in months) atwhich the child first produced single words, other than‘‘mama’’ and ‘‘dada,’’ in a consistent and meaningful wayfor the purposes of communication. This information wasobtained from the caregiver during a clinical interviewusing the ADI-R. Following ADI-R administration protocol, parents were asked to give examples of first words;follow up questions helped clarify that words were usedmeaningfully, a process which has been found to promotemore accurate parent recall (Hus et al. 2011).Cognitive DevelopmentThe Mullen Scales of Early Learning (MSEL; Mullen1997) assesses cognitive development in five domains:Gross Motor, Visual Reception, Fine Motor, ReceptiveLanguage, and Expressive Language. The Gross Motorscale was not administered in this study. The reliability and
J Autism Dev Disord (2013) 43:253–264255Table 1 Sample characteristics for the Autistic Disorder, PDD-NOS, and combined (full) ASD sampleAutisticDisorder(n 75)PDD-NOS(n 44)v2Male (% of sample)n 62 (82.7 %)n 37 (84.1 %)0.04White:Non-white:Not reported62:7:636:5:30.525Age in months at evaluation (SD)52.75 (6.46)51.32 (5.36)Age in months at initial diagnosis (SD)26.04 (4.28)Age in months at first words (SD)MSEL Visual ReceptiontpdCombined ASDSample (n 119)–0.84–n 99 (83.2 %)–0.97–98:12:9–1.240.220.2452.2 (6.1)26 (4.18)–0.0510.960.0126 (4.2)23.48 (11.44)22.20 (9.0)–0.6260.530.1223 (10.5)31.2 (15.8; 20–74)36.6 (16.4; 20–63)–0.100.3433.2 (16.2; 20–74)-1.67MSEL Fine Motor27.9 (11.6; 20–69)31.6 (15.3; 20–74)–-1.30.200.2829.3 (13.2; 20–74)MSEL Receptive Language30.0 (13.9; 20–69)34.1 (15.5; 20-70)–-1.380.170.2831.6 (14.6; 20–70)MSEL Expressive Language28.4 (11.6; 20–69)31.5 (12.1; 20–58)–-1.260.210.2629.6 (11.9; 20–69)VABS Communication68.83 (19.0; 44–116)73.29 (20.4; 45–126)–-1.160.250.2370.5 (19.6; 44–126)VABS Daily Living Skills59.3 (10.1; 42–89)63.4 (12.8; 38–95)–-1.880.060.3760.8 (11.3; 38–95)VABS Socialization64.8 (12.1; 49–96)67.8 (10.9; 50–94)–-1.330.190.2665.9 (11.7; 49–96)VABS Motor Skills65.9 (13.9; 43–105)73.3 (20.3; 33–116)–-2.080.040.4568.7 (16.9; 33–116)CARS Total31.74 (5.86; 21.5–45.5)29.25 (5.54; 19.5–42)–2.230.030.4330.8 (5.84; 19.5–45.5)ADOS Severity Score6.48 (2.41; 1–10)6.03 (2.39; 1–10)–0.950.340.196.31 (2.40; 1–10)Number of DSM-IV Symptoms6.49 (1.84; 2–11)6.12 (1.98; 2–10)–1.000.320.206.35 (1.89; 2–11)Scores are presented as M (SD, range). All MSEL scores are T scores, with mean 50, SD 10. All VABS scores are standard scores, withmean 100, SD 15MSEL Mullen Scales of Early Learning, VABS Vineland Adaptive Behavior Scales, ADOS Autism Diagnostic Interview Schedule, CARS ChildhoodAutism Rating Scalevalidity of the measure are well established, and the MullenScales of Early Learning has been identified as an appropriate measure for cognitive testing for children with ASD(Filipek et al. 1999; Mullen 1997). The Mullen Scales ofEarly Learning was administered by doctoral students inclinical psychology familiar with early autism assessmentunder the supervision of a licensed psychologist.Adaptive FunctioningThe Vineland Adaptive Behavior Scales (VABS; Sparrowet al. 1984) is a standardized semi-structured caregiverinterview that evaluates the adaptive functioning forCommunication, Daily Living Skills, Socialization, andMotor Skill domains. The psychometrics of the measureare well established and the Vineland Adaptive BehaviorScales is a frequently used measure in clinical and researchsettings (Sparrow et al. 1984). In this study, the VinelandAdaptive Behavior Scales were completed by a licensedpsychologist or developmental pediatrician with experience in autism assessment.Diagnostic EvaluationThe Autism Diagnostic Observation Schedule (ADOS;Lord et al. 2000) is a semi-structured standardizedassessment of communication, social interaction and playused to diagnose autism spectrum disorders. The psychometrics of the instrument are strong (Lord et al. 2000).ADOS modules one and two were used in this study. TheADOS was administered by doctoral students in clinicalpsychology familiar with early autism assessment underthe supervision of a licensed psychologist. Autism severitywas calculated from raw scores (Gotham et al. 2009).The Autism Diagnostic Interview-Revised (ADI-R;Lord et al. 1994) is a standardized semi-structured caregiver interview that assesses communication, socialdevelopment, and play, and the presence of repetitive orrestricted behaviors. The ADI-R has strong reliability andvalidity (Lord et al. 1994). Information regarding the age atwhich the child produced his or her first words and language regression was obtained using this measure. TheADI-R was completed by a licensed psychologist ordevelopmental pediatrician with experience in autismassessment.The Childhood Autism Rating Scale (CARS; Schopleret al. 1980, 1988) is a behavioral rating scale assessing thepresence and severity of symptoms of ASD. The CARS itemsaddress related features of autism and an overall categoryrating of ‘‘general impressions’’ of autism. Acceptable psychometric properties have been reported for the CARS(Schopler et al. 1988). The CARS was completed by a123
256licensed psychologist or developmental pediatrician and adoctoral student. CARS reliability assessed by the currentauthors in previous analyses found agreement for CARS totalscores to be very high (r 0.94) and excellent agreement inregards to the overall CARS classification (e.g., autism ornon-autism) (j 0.90; p \ 0.001) (Chlebowski et al.2010).Data Analytic PlanIn order to determine the relationship between early language acquisition and later functioning in children withASD, parents of children with ASD reported the age oftheir child’s first word production. Examination of therelationship between age of first words and later cognitiveability, adaptive behavior, and ASD severity was conducted using the following data analytic strategies. t testand Chi square analyses were used to compare the diagnostic groups (Autistic Disorder vs. PDD-NOS) on demographic characteristics and clinical variables. OmnibusMANOVA, and subsequent ANOVAs were used to compare children grouped as a function of age of first words(i.e., first words by 12, 18, 24, 30, 36 months) on outcomemeasures of cognition, language, and autism symptomatology with post hoc analyses to examine specific groupcontrasts. t tests were used to examine cognitive andadaptive skills from children with versus without firstwords by salient benchmark ages (i.e., by 18, 24, 30,36 months). Levene’s test for the equality of variances wascalculated for each statistic and if the error variance wasnot assumed to be similar across groups, the Dunnett’s T3post hoc test was performed. All other post hoc analyseswere completed using Tukey’s test. Effect sizes arereported using Cohen’s d and classified as small(d 0.20), medium (d 0.50), or large (d 0.80; Cohen1988).ResultsComparison Between Diagnostic Groups: AutisticDisorder Versus PDD-NOSTo examine diagnostic group differences at the time ofevaluation, the AD and PDD-NOS groups were compared.There were no differences in gender, v2 (1, N 119) 0.04, p 0.84, ethnicity, v2 (4, N 119) 0.53,p 0.97, age of initial diagnosis, t(103) 0.05, p 0.96,or age at current evaluation, t(117) 1.24, p 0.22. Dataare presented in Table 1. There was no difference betweendiagnostic groups in age of first words, t(95) 0.63,p 0.53 and the number of children who had not yetacquired their first words was equally distributed between123J Autism Dev Disord (2013) 43:253–264the two groups, v2 (1, N 119) 2.46, p 0.12 (seeTable 1). Across all measures of cognitive and languageability, adaptive behavior, and ASD characteristics, thegroups differed on only two measures: Vineland MotorSkills domain, with the PDD-NOS group scoring significantly higher than the AD group, t(62) -2.08, p 0.04,d 0.45 and CARS total score, with the AD groupobtaining a higher (i.e., more severe) score t(110) 2.22,p 0.03, d 0.43. Although the difference was statistically significant, the difference in CARS scores betweenthe two groups differed by only 2.5 points (on a scaleranging from 0 to 60) suggesting little meaningful clinicaldifference between the samples.Because the groups were similar on demographic andclinical characteristics, PDD and AD samples were combined for all subsequent analyses into a single ASD sample.The mean age of first words for the full ASD sample of 119children was 23.0 months (SD 10.5); 19 children (16 %)had not yet produced first words at time of evaluation.Clinical characteristics are presented in Table 1. All children in the ASD sample received a thorough clinicalevaluation in which they received standardized clinicalmeasures that were assessed as ‘‘outcomes’’ that werepotentially different depending upon the age at which eachchild began to produce meaningful, communicative firstwords.Comparison of Outcomes: Children with VersusWithout First Words by Benchmark AgesTo assess the importance of reaching the first word milestone by salient age markers, children with versus withoutfirst words by specific ‘‘benchmark’’ ages (i.e., by 18, 24,30, 36 months) were compared on measures of cognitiveability, adaptive behavior, and ASD characteristics. t testsindicate that children without first words by the 18 monthbenchmark scored significantly lower than children whohad produced first words by 18 months on four cognitive/language measures [MSEL Visual Reception (30.5 vs.37.6, t 2.09, p 0.04, d 0.45); MSEL ReceptiveLanguage (28.7 vs. 36.4, t 2.5, p 0.015, d 0.54);MSEL Expressive Language (27.5 vs. 32.9, t 2.14,p 0.036, d 0.46) and VABS Communication domain(67.9 vs. 75.5, t 1.99, p 0.049, d 0.4)], all withmedium effect sizes, as shown in Table 2.Comparison of children who did versus did not producetheir first words by the later benchmark ages (i.e., 24, 30, or36 months) revealed a similar pattern of results. In allcases, children who had not produced their first words bythe given age scored significantly lower on all MSEL andVABS domains, and had significantly higher (more severe)CARS scores, than children who had met this milestone.There were no differences between groups for total number
J Autism Dev Disord (2013) 43:253–264257Table 2 Children with versus without first words by 18 months: a comparison of outcomes at 52 monthsFirst words by 18 monthsNo words by18 monthsnnMean (SD)tpd0.45Mean (SD)MSEL Visual Reception4037.6 (18.4)6530.5 (14.5)2.090.04MSEL Fine Motor3831.1 (12.8)6628.2 (13.3)1.060.290.22MSEL Receptive Language3836.4 (16.2)6528.7 (12.9)2.50.020.54MSEL Eexpressive Language3933.0 (13.4)6527.5 (10.5)2.140.040.46VABS Communication3875.5 (20.3)7367.9 (18.8)1.990.050.40VABS Daily Living Skills3863.0 (11.7)7359.6 (10.9)1.530.130.30VABS SocializationVABS Motor Skills383868.2 (10.4)70.8 (16.92)737264.7 (12.2)67.5 (16.8)1.490.9800.140.330.300.20CARS Total4229.88 (5.05)7031.36 (6.24)0.200.25ADOS Severity Score396.46 (2.4)676.22 (2.42)-1.30.4890.630.10Number of DSM-IV Symptoms406.48 (2.03)746.28 (1.83)0.5140.610.11MSEL Mullen Scales of Early Learning, VABS Vineland Adaptive Behavior Scales, ADOS Autism Diagnostic Interview Schedule, CARSChildhood Autism Rating ScaleAll MSEL scores are T scores, with mean 50, SD 10. All VABS scores are standard scores, with mean 100, SD 15. Due to occasionalnon-compliance in testing, not all children completed all the evaluation subtests; sample sizes for each subtest have been included in the table.Bold values indicates significance with a small to medium effect size; normal values indicates p [ 0.05Table 3 Children with versus without first words by 24 months: A comparison of outcomes at 52 monthsFirst words by 24 monthsNo words by 24 monthstpdnMean (SD)nMean (SD)MSEL Visual Reception5737.7 (17.1)4827.9 (13.2)3.290.0010.63MSEL Fine Motor5531.7 (12.9)4926.6 (13.1)2.030.050.40MSEL Receptive Language5537.5 (16.1)4824.8 (8.8)5.03 0.0010.96MSEL Expressive Language5534.0 (12.8)4924.6 (8.4)4.46 0.0010.86VABS Communication5678 (20.0)5562.8 (15.9)4.42 0.0010.84VABS Daily Living Skills5663.3 (11.0)5558.2 (11.1)2.440.020.46VABS SocializationVABS Motor Skills565669.7 (11.5)71.8 (16.8)555462.1 (10.8)65.4 (16.5)3.592.010.0010.050.680.38CARS Total6129.3 (4.9)5132.6 (6.37)23.030.0030.59ADOS Severity Score566.18 (2.32)506.46 (2.51)-0.60.550.12Number of DSM-IV Symptoms596.39 (1.97)506.31 (1.82)0.820.040.227All MSEL scores are T scores, with mean 50, SD 10. All VABS scores are standard scores, with mean 100, SD 15. Due to occasionaltesting non-compliance, not all children completed all the evaluation subtests; sample sizes for each subtest have been included in the table.Bolditalic values indicates significance with a large effect size; bold values indicates significance with a small to medium effect size; normalvalues indicates p [ 0.05MSEL Mullen Scales of Early Learning, VABS Vineland Adaptive Behavior Scales, ADOS Autism Diagnostic Interview Schedule, CARSChildhood Autism Rating Scaleof DSM-IV symptoms or ADOS severity score at anybenchmark age, see Tables 3, 4, 5.Because of the potential clinical relevance of these data,the patterns of group differences were further examined. Theeffect sizes of the group differences grow larger as the age ofcomparison increases from 18 to 36 months (see Tables 2, 3,4, 5). Group differences between children who were verbalversus non-verbal at 18 months show medium effect sizes.Similarly, the majority of group differences between verbaland non-verbal children at 24 months show medium effectsizes; however, language measures show large effect sizes(i.e., MSEL Receptive Language, d 0.96; MSELExpressive Language, d 0.86; and VABS Communication, d 0.84). By 30 months, group differences on measures of language skills continue to show large effect sizes(MSEL Receptive Language, d 1.08; MSEL Expressive123
258J Autism Dev Disord (2013) 43:253–264Table 4 Children with versus without first words by 30 months: a comparison of outcomes at 52 monthsFirst words by 30 monthsNo words by 30 monthsnnMean (SD)tpdMean (SD)MSEL Visual Reception7136.6 (16.6)3426.3 (12.8)3.490.001MSEL Fine Motor6931.5 (13.6)3524.9 (11.3)2.640.0100.52MSEL Receptive Language6836.3 (15.4)3522.3 (6.1)6.59 0.0011.08MSEL Expressive Language6933.4 (12.4)3522.0 (5.7)6.38 0.0011.07VABS Communication7176.2 (19.3)4060.4 (15.7)4.4 0.0010.87VABS Daily Living Skills7163.3 (10.9)4056.3 (10.6)3.30.0010.65VABS SocializationVABS Motor Skills717168.7 (11.1)71.5 (17.1)403960.9 (11.3)63.5 (12.3)3.562.430.0010.020.700.490.67CARS Total7529.29 (5.08)3733.87 (6.15)24.17 0.0010.84ADOS Severity Score716.14 (2.35)356.66 (2.51)-1.040.300.22Number of DSM-IV Symptoms746.32 (2.08)406.40 (1.52)-0.220.820.04All MSEL scores are T scores, with mean 50, SD 10.All VABS scores are standard scores, with mean 100, SD 15. Due to occasionaltesting non-compliance, not all children completed all the evaluation subtests; sample sizes for each subtest have been included in the table.Bolditalic values indicates significance with a large effect size; bold values indicates significance with a small to medium effect size; normalvalues indicates p [ 0.05MSEL Mullen Scales of Early Learning, VABS Vineland Adaptive Behavior Scales, ADOS Autism Diagnostic Interview Schedule, CARSChildhood Autism Rating ScaleTable 5 Children with versus without first words by 36 months: a comparison of outcomes at 52 monthsFirst words by 36 monthsNo words by 36 monthstpdnMean (SD)nMSEL Visual Reception8435.2 (16.4)2125.3 (12.7)2.99MSEL Fine Motor8231.0 (13.7)2222.8 (8.1)3.590.0010.65MSEL Receptive Language8134.3 (15.1)2221.4 (5.0)6.48 0.0010.95MSEL Expressive Language8231.8 (12.2)2221.3 (5.3)5.94 0.0010.94VABS CommunicationVABS Daily Living Skills858574.7 (19.2)62.7 (11.0)262656.9 (13.9)54.5 (7.8)5.193.42 0.0010.0010.980.80VABS Socialization8568.1 (11.4)2658.9 (10.2)3.67 0.0010.82VABS Motor Skills8471.1 (16.3)2660.9 (16.7)2.790.0060.63CARS Total8829.6 (5.1)2435.06 (6.67)24.34 0.0011.00ADOS Severity Score846.3 (2.3)226.27 (2.91)0.070.940.01Number of DSM-IV Symptoms886.2 (2.0)266.73 (1.34)-1.450.150.28Mean (SD)0.0050.63All MSEL scores are T scores, with mean 50, SD 10.All VABS scores are standard scores, with mean 100, SD 15. Due to occasionaltesting non-compliance, not all children completed all the evaluation subtests; sample sizes for each subtest have been included in the table.Bolditalic values shading indicates significance with a large effect size; bold values indicates significance with a small to medium effect size;normal values indicates p [ 0.05MSEL Mullen Scales of Early Learning, VABS Vineland Adaptive Behavior Scales, ADOS Autism Diagnostic Interview Schedule, CARSChildhood Autism Rating ScaleLanguage, d 1.07; and VABS Communication, d 0.87)and the difference between CARS scores increases to a largeeffect (d 0.84). All other significant group differencescontinue to have medium effects. By age 36 months, allsignificant group differences have large effect sizes, with theexception of medium effect sizes for the MSEL VisualReception, and MSEL and VABS motor domains.123Analyses to this point indicated that, when comparingchildren who had versus had not produced first words by fourdifferent benchmark ages, the verbal children consistentlyscored higher on cognitive assessments (e.g., MSEL VisualReception, Expressive and Receptive Language), and as thebenchmark age increased, they also scored higher on communicative skills (e.g., VABS Communication domain) and
J Autism Dev Disord (2013) 43:253–264259lower on autism severity (e.g., CARS total score). The effectsizes also increased as the benchmark comparison pointincreased. In no comparisons did the groups differ in numberof DSM-IV symptoms or ADOS severity score.Comparison of Outcomes Among First Word GroupsIn order to more directly examine the association betweenage of first words and later functioning, children weregrouped according to age of their first words by 6 monthincrements centered at 12, 18, 24, 30, or 36 months; anadditional group was created for those who remainednonverbal at 40 months (B15, 16–21, 22–27, 28–33,34–39, C40 months). One way ANOVAs comparing thesesix first word groups indicated that the average intervalbetween initial ASD diagnosis and current evaluation wassimilar across the six first word groups, F(5, 99) 0.25,p 0.94, and that age at the current evaluation was notsignificantly different across groups, F(5, 113) 0.78,p 0.57. Omnibus MANOVA suggested significant differences among the groups when compared across outcomemeasures of cognition, language, and ASD severity, F(5,45) 1.69, p 0.006, Wilk’s k 0.377. AdditionalANOVAs were used to compare the six first word groupson these measures.One way ANOVAs comparing the six first word groupsrevealed significant differences for CARS total score andall of the MSEL and VABS domains (all p’s \ 0.03), withthe exception of the MSEL Fine Motor and VABS Motordomains (which trended towards significance), indicatingsignificantly different cognitive and adaptive skills acrossgroups. Consistent with prior findings, there were no groupdifferences in ADOS severity score or number of DSM-IVsymptoms. Results are presented in Table 6 and Figs. 1(MSEL) and 2 (VABS).Post hoc comparisons revealed similar performanceamong children in the 12, 18, and 24 month first wordgroups on MSEL language domains (i.e. Receptive andExpressive Language), VABS Communication and Socialdomains, and CARS total score. In contrast, for each ofthese measures, children in the 12, 18, and 24 month firstword groups performed significantly better than childrenwho spoke their first words after 24 months. Dunnett’s T3post hoc comparisons indicate that children in the24 month first word group scored significantly higher onMSEL language domains than children in the 30, 36, orC40 month first word groups (see Table 6 for groupmeans). Additionally, Tukey’s post hoc comparisons indicate that children in the 24 month first word group scoredhigher on the VABS Communication and Social domainsand significantly lower (less impaired) on the CARS thanthe group of children who produced first words after40 months (see Table 6 for group means).In sum, results from t tests indicate that, for language,cognitive, and symptom severity domains, the group ofchildren producing communicative meaningful words by agiven age (i.e., 18, 24, 30, 36 months) performed significantly better than the group of children who remained nonverbal at that benchmark. This difference was present asearly as 18 months. Furthermore, as the age of comparisonincreased, more comparisons yielded significant results,and effect sizes became larger. All comparisons, (exceptfor ADOS severity score and DSM-IV total symptoms,which were not significantly different at any comparisonTable 6 Comparison of performance between children with varying first word acquisition age, assessed at mean age 52 monthsAge at first wordsB15 monthsMean (SD)16–21 monthsMean (SD)22–27 monthsMean (SD)28–33 monthsMean (SD)34–39 monthsMean (SD)C40 monthsMean (SD)FpSample Sizen 27n 24n 15n 16n 11n 26MSEL Visual Reception39.8 (18.7)35.6 (16.2)37.8 (14.6)32.1 (15.2)23.5 (7.2)MSEL Fine Motor34.4 (13.6)28.0 (12.4)33.8 (12.3)30.3 (15.5)26.6 (15.6)25.3 (13.0)3.130.0122.9 (8.3)2.25MSEL Receptive Language39.4 (17.1)35.2 (15.5)38.5 (13.8)29.4 (11.3)0.0621.2 (4.2)21.5 (5.1)6.67\0.001MSEL Expressive LanguageVABS Communication33.6 (12.9)75.9 (19.9)33.3 (13.8)78.9 (20.2)35.3 (10.3)78.4 (20.2)29.7 (10.7)71.1 (16.4)21.4 (4.6)63.1 (16.2)21.4 (5.4)56.9 (14.2)5.55.08\0.001\0.001VABS Daily Living Skills64.1 (12.6)61.6 (7.9)63.5 (11.7)63.8 (11.5)58.5 (11.0)54.4 (9.9)2.780.02VABS Socialization68.0 (9.9)70.1 (11.7)72.1 (13.2)66.3 (11.8)62.6 (9.9)58.4 (10.0)4.190.002VABS Motor Skills72.0 (15.4)69.4 (18.1)72.7 (18.0)72.9 (18.0)68.3
Adaptive Functioning The Vineland Adaptive Behavior Scales (VABS; Sparrow et al. 1984) is a standardized semi-structured caregiver interview that evaluates the adaptive functioning for Communication, Daily Living Skills, Socialization, and Motor Skill domains. The psychometrics of the measure are well established and the Vineland Adaptive Behavior
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The Fry 1000 Instant Words are a list of the most common words used for teaching reading, writing, and spelling. These high frequency words should be recognized instantly by readers. Dr. Edward B. Fry's Instant Words (which are often referred to as the "Fry Words") are the most common words used in
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Core Vocabulary words are in bold. Multiple Meaning Word Activity word is underlined. Vocabulary Instructional Activity words have an asterisk (*). Suggested words to pre-teach are in italics. Type of Words Tier 3 Domain-Specific Words Tier 2 General Academic Words Tier 1 Everyday-Speech Words Underst
