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104 Chapter 6 Intellectual Developmental Disorder and Learning Disorders
and, on an untimed test involving math problems, he
was reluctant to use a paper and pencil to work on the
problems, preferring to do them in his head. Test results
showed Ethan’s general cognitive abilities to be in the high
average range, with processing speed (measured by timed
tests with pencil and paper) to be the one area of relative
weakness.
Ethan’s executive function skills are generally typical
for his age. Achievement testing showed that Ethan
has strong math reasoning ability and good reading
comprehension scores. However, his writing skills are
more problematic. Ethan needs considerably more time
than average on writing tasks. He appears to struggle as
he thinks about how to form each letter as he writes it.
He shows below average visual–motor control, but his fine
motor speed and coordination are not delayed.
On standardized tests, Ethan scored below age
expectations in terms of his ability to write conventionally
(e.g., use of paragraphs and punctuation) and had even
more difficulty with his contextual language skills (e.g.,
with fragmentary sentences, run-on sentences, absence
of compound sentences). However, with a topic of his
choosing, Ethan was able to show good story construction,
with sequence and plot, and sc ored in t he average range. The
neuropsychologist concluded that Ethan meets the criteria
for Learning Disorder of Written Expression, as evidenced
by his difficulties with handwriting, conventional writing
skills, and clarity of written expression.
With this diagnosis, Ethan’s teachers worked with
his parents to develop a plan that included limiting
the amount of written work required of Ethan while at
the same time providing him with greater instruction
and support to improve his writing skills, increase his
confidence in his writing, and decrease his feelings of
frustration and inadequacy. Additional strategies, such as
reducing unnecessary copying, providing additional time
for tasks requiring written work, and increasing the use of
keyboarding and dictation for longer assignments, were
also recommended.
The importance of learning, academic progress, and academic
achievement is difficult to overstate. Indeed, learning is
so essential that “modern societies have institutionalized
strong, directional social scaffolds, e.g., formal education, for
continuous and sustained learning over nearly the entirety
of infant, child, and adolescent development” (Briley &
Tucker-Drob, 2017, p. 53). Many children who struggle
with learning are formally diagnosed with a developmental
disorder such as IDD or learning disorders. Others who
struggle may do so quietly and not receive a diagnosis or
educational intervention. Some may struggle so loudly and
with so many additional behavioral and mental health issues
that they are removed from classrooms and schools (or they
remove themselves). Parents, teachers, school psychologists,
and special education professionals must work together
to identify children and adolescents who have difficulty
learning and provide opportunities and supports that
enhance learning outcomes.
Children, adolescents, and adults with learning
disorders display persistent difficulties in the acquisition
and application of academic skills. These difficulties are
associated with significant impairment in school, work,
and/or everyday living. Deficits in academic skills have long
been linked to cognitive functioning, and there are many
cognitive models of learning disorders. Several key findings
have received significant empirical support. (1) Learning
disorders are linked to components of cognitive skills rather
than to overall or below average intellectual functioning.
(2) Cognitive component skills are dimensional and
normally distributed. That means that knowledge about
how typical children learn provides useful information
about how atypical children learn; understanding how
atypical processes unfold provides information about the
development of typical processes. (3) Genetic and brainrelated factors include distinctive and overlapping inf luences
on academic and cognitive components. (4) Overlapping
processes help explain the comorbidity observed for
different learning disorders. (5) Deficits in cognitive and
academic skills persist over time, especially in the absence
of intervention (Grigorenko et al., 2020).
The Individuals with Disabilities Education Act (IDEA,
U.S. Department of Education, 2004) identifies learning
disorders in youth when they do not meet age- or gradelevel standards in one or more learning domains: oral
expression, written expression, listening comprehension,
reading skills, reading fluency, reading comprehension,
mathematics calculation, and mathematics problem solving.
The description and assessment of learning disorders varies
by state and by other countries (Benson et al., 2020;
Grigorenko et al., 2020).
DSM-5-TR describes three domains of specific
learning disorder (SLD): reading, written expression,
and mathematics. A diagnosis of SLD is not made if
exclusionary factors that might compromise learning are
present (e.g., problems involving sensory or perceptual
skills, emotional and behavioral difficulties, economic
disadvantage, inadequate instruction). Descriptions of
SLDs overlap somewhat with the related constructs of verbal
learning disabilities and nonverbal learning disabilities.
Verbal learning disabilities are similar to language-based
reading and writing learning disorders. Nonverbal learning
disabilities include atypical difficulties involving motor
skills, visual–spatial skills, and social skills.
Specific learning disorders involving reading include
difficulties related to word recognition, reading fluency, and
reading comprehension. Each of these difficulties is associated
with an academic skill deficit (word decoding, reading
speed, extracting meaning from text) and a core cognitive
process (phonological awareness, rapid naming, language
skills). For SLDs related to mathematics, the academic skill
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Etiology 105
deficits include computation and problem solving. Core
cognitive processes include working memory, attention, and
executive function. For SLDs related to written expression,
academic skill deficits include handwriting, spelling, and
composition. Core cognitive processes include fine motor
skills (Grigorenko et al., 2020).
Estimates of prevalence vary widely. The most common
SLDs in children and adolescents involve reading,
spelling, and comprehension (between 5%–17%). The
prevalence of SLDs involving mathematics ranges between
4%–8%. SLDs involving writing are less-well studied;
prevalence rates appear between 6%–22%. Comorbidity
is very common, with one-third to one-half of children
diagnosed with more than one SLD. ADHD, anxiety,
conduct problems, and depression are also frequently
observed (Grigorenko et al., 2020; Peterson et al., 2021).
Approximately one-third of the youth who receive special
education services in schools in the United States have an
SLD diagnosis (Benson et al., 2020).
Developmental Course
Even when special education efforts are taken into account,
learning disorders often involve persistent difficulties rather
than developmental delays in the acquisition and use of
academic skills. With a developmental progression from
oral language skills at 3 ½ years, to word literacy skills at
5 ½ years, to reading comprehension at 8 ½ years, the early
identification of at-risk children is critical (Hulme et al.,
2015). Indeed, the learning and achievement gaps between
typically developing children and children with learning
disorders often widen over time, although some children
with learning disorders do display compensatory cycles of
growth (Peterson & Pennington, 2012).
Learning difficulties are associated with many negative
outcomes, including below average school achievement,
lower graduation rates, poorer vocational pathways
and outcomes, mental health difficulties, and greater
iStock.com/Shellphoto
Specific learning disorders in areas such as written expression
may contribute to academic underachievement.
involvement with the criminal justice system (Grigorenko
et al., 2020). Identifying individual, familial, and
sociocultural factors that decrease negative learning
experiences and alter problematic pathways is essential.
With respect to motivation, it is important to address
intelligence mindsets and the beliefs of children, parents,
and teachers about intelligence (i.e., whether intelligence
is fixed or malleable), success, and failure (Haimovitz &
Dweck, 2016). Understanding the motivation to learn
also requires an appreciation of the impact of genetics,
environments, and culture (Kovas et al., 2015).
The role of parents in influencing children’s
developmental pathways of achievement and adjustment
is noteworthy. Related to special education efforts, parents
are involved in the identification of learning problems,
collaborations with school professionals, and issues related
to equity and advocacy (Valle, 2011). The role of classroom
teachers, special education professionals, schools and school
systems are critical to ensure high-quality instruction and
support for all children (refer to Box 6.1).
Keep in mind, of course, that many, many children
and adolescents diagnosed with learning disorders are
successful in both school and life. A holistic appreciation
of academic strengths and weaknesses must be balanced by
an appreciation of non-academic characteristics and skills.
Etiology
A model of multiple influences on the development of
learning disorders is illustrated in Figure 6.6 (Fletcher
et al., 2007). These influences include genetic factors,
neurobiological factors, child factors, and environmental
factors. With respect to genetic factors, there is evidence
for a strong heritable component. Children whose parents
have dyslexia are at much higher risk for the development
of a learning disorder, especially when both parents have
learning disorders (Grigorenko et al., 2020).
Differences in brain structure and function have been
described, involving multiple regions and network activation.
Multiple regions of the genome have been identified that
are associated with SLDs (Fletcher et al., 2007; Grigorenko
et al., 2020). A review of the cross-cultural research in this
area emphasizes the universality of genetic and physiological
processes (Peterson & Pennington, 2012).
Environmental factors also influence the development of
learning disorders and how learning disorders play out over
time. As noted, children with learning disorders often have
parents with learning disorders. Parents who are poor readers
are less likely to read to their children, so they provide lessfrequent and lower-quality reading experiences (Fletcher
et al., 2007). Families of low SES backgrounds and families
experiencing significant stressors are also less likely to provide
and support learning-related activities. Combinations of
family factors and cultural factors also affect school readiness
(Iruk a et al., 2012). School factors such as teacher expectations,
teaching practices, and class size are also important.
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106 Chapter 6 Intellectual Developmental Disorder and Learning Disorders
Figure 6.6 Different sources of variability influence academic outcomes
Neurobiology
• Genetic factors
• Brain structure and function
Core Cognitive
(e.g., phonemic awareness)
Behavioral/Psychosocial
(e.g., attention, anxiety,
motivation)
Environment
• SES background
• Schooling
• Intervention
Processes
Academic Skill
Deficits
(e.g., word recognition)
Factors
Source: From Fletcher et al. (2007). Learning disabilities: From identification to intervention.
Gene-by-environment-by-time interactions are also
evident, with worse outcomes for children with both
genetic and environmental risks (Docherty et al., 2011).
Combinations of genetic risk, child and parent factors
related to learning, and environmental factors related to
education access and quality, under-resourced schools,
and lack of teacher support may lead to a cascade
of negative experiences and outcomes (Grigorenko
et al., 2020).
typical classroom teaching. Tier 2 includes supplemental
interventions, usually in small groups. Tier 3 involves
individualized interventions, often provided by special
education professionals. RTI identifies learning disorders
as a combination of underachievement with inadequate
response to instr uction (Bens on et al., 2020; Grigorenko et a l.,
2020; Kranzler et al., 2016).
School psychologists report using different assessments
depending on federal and state regulations as well as
current practices in school districts (Benson et al., 2020).
Following the identification of SLDs, various school-
Assessment, Diagnosis,
andIntervention
There are many approaches to the assessment and diagnosis
of specific learning disorders. One approach focuses on
the discrepancy between aptitude (usually measured by
an intelligence test) and school achievement. Although
well-known and frequently used, the aptitude-achievement
(or intelligence-achievement) discrepancy approach has not
received a lot of empirical support. The lack of research
support led to the de-emphasis of this approach in IDEA
2004 and its exclusion in DSM-5. Another approach is
focused on uneven patterns of strengths and weaknesses so that
specific cognitive deficits can be identified and addressed.
A newer approach is the response to intervention (RTI)
model. RTI (also referred to as the multitiered systems of
support (MTSS) model) is based on screening children for
academic achievement and difficulties and then monitoring
progress following instruction. Tier 1 instruction is
based interventions may be employed. In the United
States, special education and remediation efforts are
often based on individualized education plans (IEPs)
designed for students with learning disorders. Individual
and small-group lessons are often components of an IEP
and are focused on specific academic skills and cognitive
deficits.
Effective interventions for learning disorders include
the following: Interventions need to be explicit. That is,
the targets of intervention need to be clearly described
and the instructional support matched to those targets.
Interventions need to be both comprehensive and
differentiated. They should address multiple components
of cognitive skill deficits in an integrated set of supports.
Interventions need to be individualized for specific
children and adolescents, each of whom displays their
own set of SLDs and associated difficulties. The intensity
of interventions can be adjusted over time, depending on
a child’s progress (Grigorenko et al., 2020).
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Assessment, Diagnosis, and Intervention 107
Early intervention is critical, and the instructional
supports must include actual reading, writing, and
mathematics. Treatments that focus on optometric
training with special glasses or lenses or brain exercises
are ineffective (Grigorenko et al., 2020). With advances
Key Terms
Cognitive development (88)
Intellectual development (88)
Intellectual developmental disorder (91)
Intellectual functioning (91)
Adaptive functioning (91)
Quality of life (QOL) (92)
Chapter Summary
●
Our understanding of intellectual developmental
disorder is influenced by models of intelligence: the
development of cognitive and intellectual functioning
over time; the ways in which factors related to genes, the
brain, and the environment influence intelligence; and
the measurement of intelligence.
●
Intellectual developmental disorders involve significant
deficits in both intellectual functioning and adaptive
functioning.
●
The classification levels of mild, moderate, severe, and
profound intellectual developmental disorder describe
the degree of compromise in intellectual and adaptive
functioning in an individual diagnosed with IDD.
These correspond to intermittent, limited, extensive,
and pervasive levels of support needed to maximize
well-being.
●
Adaptive behavior refers to the ability to master age-
appropriate tasks of daily living.
in educational neuroscience, it is important to be
cautious when translating neuroscience research to SLD
interventions (Thomas et al., 2019). Given the high stakes,
the interventions provided to children and adolescents
must be the best available.
Genotypes (93)
Neurobehavioral phenotypes (93)
Down syndrome (94)
Williams syndrome (94)
Fragile X syndrome (94)
Fetal alcohol spectrum disorder (95)
Specific learning disorder (104)
Individualized education plan (IEP) (106)
●
An alternative classification approach focuses on the
relation between genotypes and neurobehavioral
phenotypes. Examples of this approach include Down
syndrome, Williams syndrome, fragile X syndrome, and
fetal alcohol spectrum disorder.
●
In addition to careful consideration of all relevant
medical and developmental background information,
standardized assessment of both intellectual and adaptive
functioning is critical to the valid and reliable diagnosis
of intellectual developmental disorder.
●
A variety of preventive strategies and interventions are
associated with improvements in outcomes across the
lifespan
●
Specific learning disorders are diagnosed in many
children and adolescents with significant impacts on
educational and related developmental pathways.
●
Early assessment and treatment of learning disorders
improves youth and adult outcomes.
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7
Autism Spectrum Disorder
Chapter Outline
The Case of Noah
The Case of Luca
Historical and Current Conceptualizations of Autism
Spectrum Disorder 109
Developmental Tasks and Challenges Related to the
Coordination of Social, Emotional, and Cognitive
Domains 110
Social Cognition
Theory of Mind
Affective Social Competence
Autism Spectrum Disorder 112
Social and Communication Deficits
Box 7.1 Emerging Science: Eyes, Faces, and Social
Engagement Processes
Restricted, Repetitive Behaviors and Fixated Interests
Associated Difficulties and Comorbid Conditions
Prevalence and Sex/Gender Information
Developmental Course 118
Infancy and Childhood
Adolescent and Adult Outcomes
Family Roles and Culture
Resilience Pathways
Etiology 123
Early Hypotheses
Genes and Heredity
Physiological Factors
Social and Cognitive Factors
Environmental Factors
Assessment and Diagnosis 126
Interviews, Questionnaires, and Rating Scales
Sociocultural Factors and Adult Diagnoses
Intervention 128
Prevention Efforts
Pharmacological Treatment
Psychological Treatment and Support
School-Based Programs
Long-Term Treatment and Support
Box 7.2 Clinical Perspectives:
Intervention
The TEACCH Model of
Learning Objectives
1. Summarize the ways in which the conceptualization of
autism spectrum disorder has changed over time.
2. Explain the impact of the neurodiversity framework on our
understanding of autism and autistic individuals.
3. Describe the constructs of social cognition, theory of mind,
and affective social competence and their roles in typical
development.
108
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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
4. Summarize the criteria for the diagnosis of autism spectrum
disorder.
5. Explain the dimensional approach to understanding social
and communication difficulties and restricted, repetitive
behaviors.
6. Summarize the data on the prevalence of autism spectrum
disorder.
Historical and Current Conceptualizations of Autism Spectrum Disorder 109
Learning Objectives (continued)
7. Compare and contrast several developmental trajectories for
youth with autism spectrum disorder.
8. Summarize the research on genetic factors, physiological
factors, social and cognitive factors, and environmental
factors in autism spectrum disorder.
9. Summarize the components of a comprehensive assessment
for autism spectrum disorder.
10. Explain the ethical and clinical issues related to intervention
for autism spectrum disorder.
11. Summarize the evidence-based treatments for autism
spectrum disorder.
The Case of Noah
Four-year-old Noah was referred for a psychological
evaluation two years ago after his parents and
pediatrician became concerned about his significantly
delayed language development. Noah’s parents described
him as an extremely fussy baby who was hard to settle.
Unlike his older sister, he was not very cuddly and, much
to his parents’ dismay, actually seemed to become more
distressed when he was held. Although Noah’s motor
milestones were all achieved at the expected times, his
language and communications skills lagged far behind.
Not only did he speak much later than expected,
he also seemed to show little interest in any kind of
communication. For example, he did not respond to his
name and did not seek his parents’ attention.
Noah is very dependent on fixed and predictable
routines. He plays with only a few toys and always in the
same order. When playing, he often uses toys in unusual
ways that do not fit their intended purpose, such as using
a doll to hammer in a peg or repeatedly spinning a horse
on its side. He becomes extremely upset if these favorite
toys are moved or rearranged on the shelf in his room
where he keeps them. Noah also has difficulty engaging
in imaginative or pretend play. Even on Halloween, he had
difficulty with the idea of pretending to be a character,
finding the idea confusing and upsetting.
When Noah speaks, which isn’t often, his speech is
atypical in rhythm and volume, and he frequently reverses
his pronouns (saying, for example, “Would you like the
ball?” when he wants someone to give him a ball). When
his parents or the evaluators attempt to speak directly
to Noah, he quickly looks away and sometimes even
turns his back on them. Noah has always been extremely
active and easily frustrated; at times, when he is upset,
he bangs his head against the wall. He is described as
being generally fearful and anxious in new situations and
settings and has been observed engaging in lots of handflapping and other self-stimulating behaviors. Noah’s
parents are quite worried about him starting kindergarten
in a few months, knowing that he will be reluctant to be
away from home and does not seem at all interested in
the school setting or in meeting or playing with other
children.
The Case of Luca
Luca is nine years old and having considerable difficulty
at school. Although Luca’s early motor and cognitive
development were typical, he began to show both
communication and social disturbances as a preschooler. For
instance, Luca can be very affectionate and engaging, but he
can also be intrusive and overwhelming when interacting
with other children. Although quite talkative from an early
age, Luca often talks at length about his own interests and is
quite resistant to sharing in the interests or responding to the
questions of others. By the time he entered elementary school,
Luca had developed clear, specific, and obsessive interests.
This characteristic first manifested itself in his keen interest
in weather and meteorology, which now includes weather
radar equipment. All his reading and nearly all conversations
that he initiates with others are on these topics. Although
his parents, teachers, and older siblings have all explained
to him that his intensity and relentless focus make others
uncomfortable, he has not modified this behavior at all.
In the primary grades, the major concerns expressed
by his teachers were his poor attention, impulsivity, and
poor work completion. Although these problems have
continued, his poor social skills are currently causing the
most difficulty. Luca was mostly ignored and somewhat
isolated in his early school years, but now he has become
the target of teasing and rejection. Recently a classmate
has goaded him into doing things that have gotten him
into trouble and resulted in being ridiculed by others.
Luca is quite sensitive to the trouble he is having regarding
schoolwork and friendships, but he shows little insight into
either the causes or the solutions to these problems.
Historical and Current Conceptualizations of Autism Spectrum Disorder
Both Noah and Luca exhibit a pattern of emotional,
cognitive, and behavioral characteristics that reflect
atypical development associated with clinically significant
impairment. What we call these patterns is important
because the names of disorders facilitate research on
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110 Chapter 7 Autism Spectrum Disorder
causes and treatments, allow mental health professionals
to communicate with parents and teachers, and help
children and adolescents make sense of their challenges
and strengths. The disorders displayed by Noah and Luca
have, at various times, been called autistic disorder, Asperger
syndrome, high-functioning autism, atypical autism, and
pervasive developmental disorder; they are now called autism
spectrum disorder (ASD). The change in nomenclature
in the DSM-5 and continued in the DSM-5-TR should be
understood in the context of continuing work focused on
the complex etiology of autism, the varied developmental
pathways, and the best interventions for Noah and Luca and
children like them.
The current conceptualizations of autism spectrum
disorder are based on decades of work following the clinical
summaries provided by Leo Kanner (1943) and Hans
Asperger (1944/1991) (Rosen et al., 2021; Tager-Flusberg,
2014). Both Kanner, in his descriptions of children with
“early infantile autism,” and Asperger, in his portrayals of
boys with “autistic psychopathy,” emphasized the children’s
profound lack of social awareness. Asperger, however,
described better language skills and more social interest in
his small sample. Much of the theory and research on autism
in the United States, at least until the 1990s, was based on
Kanner’s work. A picture of autism emerged that highlighted
three areas of deviance: social isolation, impaired language
and communication, and stereotypical behaviors. Some
children, of course, did not fit the classic presentation. These
children usually had better cognitive and language skills
and were believed to have “high-functioning autism.” Over
time, clinicians and researchers hypothesized that some of
the children diagnosed with high-functioning autism might
be better understood (and better treated) if their symptoms
and struggles were conceptualized as a related but distinct
disorder: Asperger syndrome. Asperger syndrome was
included as a separate diagnosis in the DSM-IV. After more
than two decades of research, clinical work, and discussion
and debate, the overwhelming evidence is that autism
and Asperger syndrome are best understood as part of a
continuum (i.e., a spectrum) of disorder, and that is how
these disorders are presented in the DSM-5-TR.
A summary of the important ways in which the
conceptualization of autism has changed over time provides
additional perspective (Happé & Frith, 2020; Rosen et al.,
2021). One way in which our understanding of autism
has changed involves a shift in definition from a relatively
narrow syndrome to a much broader spectrum disorder.
Another way in which our understanding has changed
involves a shift from viewing autism as a rare disorder (with
early estimates of prevalence of 3 in 10,000) to viewing it
as a common disorder (with current estimates of 1 in 100).
Yet another change involves expanding our focus from early
childhood to a lifespan perspective. The conceptualization
of autism has also changed from a categorical approach to a
dimensional approach. With a dimensional approach, there
is also an appreciation for the display of subclinical autistic
traits, or the broad autism phenotype (discussed in more
detail later in the chapter). Our understanding of autism
now also includes the heterogeneity of clinical presentations
and etiologies. In addition, we recognize that autism is
frequently accompanied by other psychological and medical
challenges. Finally, there has been a shift from understanding
autism as a developmental disorder to understanding autism
as an example of neurodiversity.
Thinking about autism within a neurodiversity
framework means that we explore the ways in which
autism may reflect individual difference rather than
psychopathology. It means that instead of focusing only on
deficits, dysfunction, and impairments, we also consider
holistic assessments that identify strengths and talents. A
neurodiversity framework includes and highlights autistic
people’s descriptions of their own experiences and partners
with the autistic community to identify important
research topics, priorities, and goals (Baron-Cohen, 2017;
Fletcher-Watson et al., 2017; Pellicano & den Houting,
2021). A neurodiversity approach leads to important ethical
and clinical questions about treatments to normalize or
cure autism. Instead of interventions that are focused on
making individuals less autistic, positive outcomes are
reframed to emphasize autonomy, purpose, social inclusion,
and the well-being of individuals across the spectrum of
autism severity (Baron-Cohen, 2017; Vivanti & Messinger,
2021).
Autism advocacy groups, first organized by parents of
youth with autism and now broadly inclusive of autistic
individuals themselves, help to keep the research, clinical,
and community focus on appropriate and adequate services
for individuals and families. One concrete example of
advocacy efforts that prioritize the experience of autistic
individuals is respect for a preference for identity-first (rather
than person-first) language (i.e., autistic individual rather
than individual with autism). Because this preference is not
universal, we will alternate between terms such as autistic
youth and youth with autism spectrum disorder throughout
the chapter.
Developmental Tasks and Challenges Related to the Coordination of Social, Emotional, and Cognitive Domains
The sections on typical development in the previous chapters
have summarized physiological functioning, temperament,
attachment, and intellectual functioning to provide
useful comparisons and contrasts for specific disorders. In
this chapter, rather than focusing on a single domain of
functioning, we emphasize the interdependent, coordinated
nature of early development.
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Developmental Tasks and Challenges Related to Social, Emotional, and Cognitive Domains 111
Social Cognition
This more integrative overview begins with a focus on social
cognition, a construct at the intersections of self and other,
emotion and cognition, and language and meaning. Social
cognition refers to the many ways that people think about
themselves, about others, and about their social worlds.
We are especially concerned with the ways in which young
children take in and process socially relevant information
from the vast amounts of information available to them. An
appreciation of social cognition in the typically developing
child is essential to understand what about social cognition
is similar and what is different for children with autism
spectrum disorder.
Two of the most important features of social cognition
are the distinctions between what is more and less
important, and what is social and nonsocial. According to
Landa (2000, p. 133), almost all children “pay attention to
what is important. This awareness of salience is reflected
in children’s first words, which typically represent a salient
person, place, thing, or action such as ‘ball, kitty, cookie’
rather than inanimate objects having little relevance in their
lives such as ‘wall.’” Among salient people, salient places,
and salient things, people receive the most attention. The
people in young children’s lives and environments are key
participants in social learning processes and outcomes.
Social learning tasks include learning from others (e.g.,
imitation of action, mirroring of emotion) as well as learning
about others (e.g., others’ desires, beliefs, intentions).
Learning from others means that young children seek out
and look to others for meaningful information. Almost all
typically-developing children, for example, recognize that the
caregiver is worthy of notice and behave as if emotional and
social engagement with the caregiver is special, pleasant, and
informative. Almost all young children look to others to help
them make sense of new or unusual situations, and almost
all young children share their own experiences of delight,
confusion, or fear with others. These types of experiences
involve joint attention, which is the social coordination of
attention, pairing one’s own attention to another person’s to
share information (Mundy, 2018).
Learning about others means that young children can
gather and use information about emotions, beliefs, and
intentions. This learning is ref lected in social mirroring, social
representations, and social comparisons. Early and ongoing
knowledge about others’ mental states and the ability to use
different types of social information influence a variety of
social processes and outcomes. These include perspective
taking, empathy, pretend play, an appreciation of humor, and
making and keeping friends (Deschrijver & Palmer, 2020;
Wellman, 2018). Social learning begins early in development
and extends throughout childhood and adulthood (Frith &
Frith, 2012; Meltzoff, 2007; Wellman, 2018).
There are numerous investigations of the role of brain
structure and function related to social cognition. The
research on “building a social brain” is focused on identif ying
various brain regions implicated in the processing of
important social stimuli (e.g., faces, human movement)
and describing the development of increasingly organized
networks of activity (National Scientific Council on the
Developing Child, 2020; Tottenham, 2020). Much of the
empirical study of social cognition examines the tempoparietal junction and the medial prefrontal cortex, each with
activity and connections to multiple networks (Deschrijver
& Palmer, 2020; Mundy, 2018; Wellman, 2018).
Theory of Mind
One of the most important and well-researched
developmental constructs contributing to social cognition
and successful social interaction is the child’s theory of
mind. Theory of mind (ToM) refers to an ability to
recognize and represent the mental states of others (BaronCohen, 2001; Wellman, 2018). ToM is a complex construct,
similar to the mentalizing construct discussed in previous
chapters. ToM may be studied during experimental tasks
as well as during real-life experiences such as “children’s
everyday conversations about people and minds through
the use of terms like think, want, feel, and guess” (Wellman,
2018, p. 730). ToM displays a developmental progression
of appreciation of potential differences in desires, beliefs,
knowledge access, false beliefs, and hidden emotions (refer
to Figure 7.1). ToM is reflected in the child’s understanding
not only of typical minds, but also of “extraordinary minds,”
such as the minds of God, Santa Claus, and superheroes
(Wellman, 2018).
Figure 7.1 Developmental sequence of
children’s understanding of different mentalstate contrasts
Diverse desire:
Diverse belief:
Knowledge-
access:
False belief:
Hidden emotion:
Source: Wellman (2018). Theory of mind: The state of the art.
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112 Chapter 7 Autism Spectrum Disorder
With respect to developmental timetables, a lot of what
happens in ToM occurs over the preschool years, but there
is variation depending on culture and on exposure to
language and social experiences. With less exposure to the
“free-flowing, turn-taking, perspective-shifting interchange
of social interactions and communication,” deaf children
of hearing parents, for example, are delayed in ToM tasks
(Wellman, 2018, p. 737). Still, they display ToM achievements
by age 11 or 12 (compared to typically developing children
who display similar achievements by age 6). ToM can also be
significantly sped up with training. Indeed, Wellman asserts
that ToM mechanisms and outcomes are “seriously plastic”
processes.
The complexity of the ToM construct is further explored
in comparisons related to inferring another’s internal state
(i.e., mentalizing) and monitoring agreement or conflict
between a nother’s internal state a nd one’s own (Deschrijver &
Palmer, 2020). To date, ToM has primarily focused on one’s
representation of others’ views (what others think, feel, or
know) but might be usefully expanded (or reframed) to
emphasize the important relational information that others
may think, feel, or know differently from oneself. This
expansion or reframing of ToM leads to important questions
about how children understand and respond to conflicting
social perspectives. With such conflicts, for instance, do
children seek more information, provide more information,
and/or adjust their behavior? An emphasis on relational
ToM provides meaningful information about children and
their social worlds (Deschrijver & Palmer, 2020).
Affective Social Competence
The development of social cognition over the early years
also depends on increasingly complex emotion skills.
Affective social competence involves the coordination
of the capacities to experience emotion, communicate
emotion, and understand emotion. The experience of
emotion involves knowing what one is feeling (including
the possibility that one may feel more than one emotion at
a time). The experience of emotion also involves emotion
regulation and developing skills to monitor and modulate
feelings. The communication of emotion involves sending
and reading emotions. Understanding emotion involves the
recognition of feelings and knowledge about the sources
and outcomes of feelings in oneself and others (Halberstadt
et al., 2001; Camras & Halberstadt, 2017). The dynamic
interaction of these types of emotion abilities with emerging
cognitive abilities provides yet another way that children
can glean essential information from their social partners.
Overall, then, the developmental transition from the
sensorimotor experiences of infancy to the symbolic
experiences of toddlerhood and later years is marked by
ever-increasing coordination among various developmental
domains. The multiple and overlapping processes related to
children’s social cognition, theory of mind, and affective social
competence help explain some of the pathways and outcomes
of children with and without autism spectrum disorder.
Autism Spectrum Disorder
Autism spectrum disorder (ASD) is characterized by deficits
and significant impairment in two domains: (1) social and
communication deficits and (2) repetitive behaviors and fixated
interests. For a diagnosis of autism spectrum disorder, children,
adolescents, or adults must display three kinds of social and
communication deficits: deficits in social– emotional reciprocity,
deficits in nonverbal communication during social interactions,
and deficits in developing and maintaining relationships. Each
of these deficits is evaluated against developmental norms. In
addition to these social and communication deficits, children
must display at least two types of repetitive behaviors and
fixated interests. These might include stereotyped or repetitive
speech, motor movements, or use of objects; excessive adherence
to routines or ritualized patterns or resistance to change; highly
restricted interests that are atypical with respect to intensity or
focus; or atypical sensitivity to sensory stimulation or atypical
interest in aspects of the sensory environment (refer to Table 7.1).
The level of severity of the symptom picture is also noted,
ranging from requiring support, to requiring substantial support,
to requiring very substantial support. This severity index reflects
the dimensional conceptualization of autism spectrum disorder.
Table 7.1 Autism Spectrum Disorder:
Summary of DSM-5-TR Diagnostic Criteria
A. Deficits in social communication and social
interaction across multiple contexts
1. Deficits in social–emotional reciprocity
2. Deficits in nonverbal communicative
behaviors used for social interaction
3. Deficits in developing and maintaining
relationships, appropriate to developmental
level
B. Restricted, repetitive patterns of behavior,
interests, or activities
1. Stereotyped or repetitive speech, motor
movements, or use of objects
2. Excessive adherence to routines, ritualized
patterns of verbal or nonverbal behavior, or
excessive resistance to change
3. Highly restricted, fixated interests that are
abnormal in intensity or focus
4. Hyper- or hypo-reactivity to sensory input
or unusual interest in sensory aspects of
environment
C. Symptoms must be present in early childhood
(but may not become fully manifest until social
demands exceed limited capacities)
D. Symptoms cause clinically significant
impairment in current functioning
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Autism Spectrum Disorder 113
The validity of the DSM-5 criteria (continued with DSM5-TR) has been the subject of much research and debate.
The key issues include (a) sensitivity: do the criteria capture
all children who struggle with ASD? (b) specificity: do the
criteria differentiate children with ASD from children with
other disorders and from typically developing children?
(c) service eligibility: do the criteria make it more difficult
for children who struggle with significant impairment to
continue to receive mental health and education services?
A number of large-scale studies of the criteria suggest
that the two-factor model (social and communication
difficulties + repetitive behaviors and fixated interests)
exhibits superior specificity (compared to DSM-IV) in
distinguishing children with ASD from other children.
The criteria also better reflect the ways in which ASD is
observed in individuals across age, intellectual functioning,
and language ability (Lord & Bishop, 2015; Wiggins et al.,
2019). The revised criteria do not appear to have led to a
significant reduction in the number of children diagnosed
with ASD (Lord & Bishop, 2015; Tager-Flusberg, 2014).
Social and Communication Deficits
Autistic children display a varied set of social and
communication deficits. Their socioemotional development
is both quantitatively and qualitatively different from
typically developing children and children with other
disorders. Atypical behaviors related to social perception,
social motivation, and/or social cognition include a lack of
social orienting; a failure to respond to social sounds and
signals, such as the parent’s voice or clapping hands; a lack
of social reciprocity, or the turn taking of social interactions;
and fewer and more deviant social behaviors. Each of these
atypical behaviors reflects a relative lack of differentiation
between social and nonsocial stimuli. For autistic children,
“the striking imbalance between their lack of engagement
with people and enhanced engagement with things is at
the heart of what differentiates toddlers with ASD from
both typically developing toddlers and toddlers with other
neurodevelopmental disorders” (Tager-Flusberg, 2014,
p. 658).
Ongoing research is focused on identifying the specific
social mechanisms that underlie complex social behaviors.
Investigations of infants’ atypical patterns of social attention
and engagement highlight the ways in which multiple
behaviors contribute to a “derailment of processes” that
underlie typical social and language development (Klin et al.,
2015). Autistic children display basic social-communication
impairments (related to, for example, attention to faces and
perception of biological motion) as well as impairments in
more complex aspects of social interaction (refer to Box 7.1).
Autistic youth (and adults) are often described as having
mindblindness (deficits in ToM or impaired mind-reading
ability). This description is increasingly understood as
inaccurate. Early studies of autistic children focused on
experimenta l tasks involving matc hes a nd mismatches between
self and others’ perceptions. These matches or mismatches are
an important piece of social information, but they are not the
only piece of social information. Some of the building blocks
of social cognition, such as the ability to represent the mental
states of others, are displayed by many autistic individuals.
“People on the autism spectrum may be well able to grasp
what others think, in contrast to popular and scientific belief,
while they may experience more subtle issues after this with
monitoring the extent to which others are thinking differently
from themselves. Throughout life, an adequate processing of
the extent to which others are on the same page may be more
fundamental to navigating the social world than inferring the
mental states of others” (Deschrijver & Palmer, 2020, p. 941).
Keep in mind as well that non-autistic individuals are not
very good at mind-reading the minds of autistic people (Edey
et al., 2016; Sheppard et al., 2016).
There may be other ways in which some social and
communication patterns may be better understood as
differences rather than deficits (Happé, 2015). Although
social interactions and communication with typicallydeveloping individuals are often challenging for autistic
youth, research suggests that information transfer from one
autistic peer to another autistic peer (compared to transfer
from one autistic peer to another non-autistic peer) is more
successful. Autistic peers also report good social rapport
with other autistic peers and less rapport with non-autistic
peers (Crompton et al., 2020).
In addition to social and communication challenges,
there are difficulties related to the experience, perception,
and processing of emotion. In contrast to long-held beliefs
that autistic children and adolescents lack emotion or
emotion skills, many studies provide compelling evidence
of emotional experiences, and autistic youth describe a wide
range of emotion experiences (Losh & Capps, 2006; Macari
et al., 2018). Autistic individuals recognize and express
basic emotions such as happiness, anger, and sadness,
although they often have difficulties with more complex
emotions such as embarrassment, pride, and guilt (Jones
et al., 2011; Keating et al., 2022; Uljarevic & Hamilton,
2013). Emotional language difficulties are frequently noted,
with young children having problems acquiring and using
emotion concepts (Lartseva et al., 2015).
Autistic youth are sometimes viewed as less empathic
than typically-developing youth. Empathy is a multistep socioemotional phenomenon, and we need to think
carefully about what may be different about autistic youth’s
experience that leads to apparent lack of empathy (FletcherWatson & Bird, 2020). The first step involves noticing
another’s emotion. The second step involves interpreting
emotion correctly. The third step involves feeling/mirroring/
appreciating the other’s emotion. The fourth step involves
the expression of empathy. The first two steps are challenging
for autistic youth. The third step, feeling what another is
feeling, may not be as problematic. The communication of
a social emotion may also be complicated. Understanding
which aspects of a complex experience are more or less
difficult helps us better support autistic youth in their
everyday lives.
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