Continuity and change in the social competence of children with autism, Down syndrome, and developmental delays

Challenges in evaluating psychosocial interventions for Autistic Spectrum Disorders

In 2002, the National Institutes of Health sponsored a meeting concerning methodological challenges of research in psychosocial interventions in Autism Spectrum Disorders. This paper provides a summary of the presentations and the discussions that occurred during this meeting. Recommendations to federal and private agencies included the need for randomized clinical trials of comprehensive interventions for autism as the highest, but not the sole priority. Ongoing working groups were proposed to address psychosocial interventions with a focus on relevant statistics, standardized documentation and methods of diagnosis, development of outcome measures, establishment of standards in research; and the need for innovative treatment designs, including application of designs from other research areas to the study of interventions in ASD.

Relations among joint attention, amount of intervention and language gain in autism

The purpose of the present study was to investigate the unconditional and conditional relations between amount of intervention and language development in children with autism. Joint attention skills were proposed as child characteristics that might moderate this relation. The results replicated previous findings that better joint attention skills were associated with greater language development. The results further indicated that the relation between amount of intervention and gain in language age was conditional; it depended upon the child's ability to respond to bids for joint attention from others and initial language skills. The current study demonstrated the utility of employing characteristics of children as moderators of relations between interventions and developmental outcomes.

Outcome at 7 years of children diagnosed with autism at age 2: predictive validity of assessments conducted at 2 and 3 years of age and pattern of symptom change over time

OBJECTIVE

To examine the predictive validity of symptom severity, cognitive and language measures taken at ages 2 and 3 years to outcome at age 7 in a sample of children diagnosed with autism at age 2.

METHOD

Twenty-six children diagnosed with autism at age 2 were re-assessed at ages 3 and 7 years. At each age symptom severity, cognitive and language assessments were completed.

RESULTS

The pattern of autistic symptom severity varied over time by domain. Across time, children moved across diagnostic boundaries both in terms of clinical diagnosis and in terms of instrument diagnosis on the Autism Diagnostic Interview-Revised (ADI-R). On all measures group variability in scores increased with age. Although non-verbal IQ (NVIQ) for the group as a whole was stable across the 3 assessments, this masked considerable individual instability. Standard assessments at age 2 did not predict outcome at age 7 even within the same domain of functioning. In contrast, standard assessments at age 3 did predict outcome. However, a measure of rate of non-verbal communicative acts taken from an interactive play-based assessment at age 2 was significantly associated with language, communication and social outcomes at age 7.

CONCLUSIONS

The trajectory of autism symptoms over time differed in different domains, suggesting that they may be, at least in part, separable. Variability in language, NVIQ and symptom severity increased over time. Caution is required when interpreting the findings from assessments of children with autism at age 2 years. At this age measures of rate of non-verbal communication might be more informative than scores on standard psychometric tests. Predictive validity of assessments at age 3 years was greater.

Autism in infancy and early childhood

Although initially described as an inborn disorder of affective contact, information on autism as it exists in infants has been limited. Delays in diagnosis, lack of information about the condition, and reliance on retrospective research strategies have been problematic. An awareness of the increased risk for siblings is now allowing the development of new, prospective approaches. Consistent with Kanner's original hypothesis, the available information strongly suggests a fundamental difficulty in the earliest social processes, which, in turn, impacts many other areas of development. New approaches to screening have lowered the age of initial diagnosis; this presents new challenges for early intervention. Directions for future research are highlighted.

Continuity and change from early childhood to adolescence in autism

BACKGROUND

This longitudinal study of 48 children diagnosed with autism at 2-5 years of age was designed to test the hypothesis that diagnosis would remain stable for most of the sample but that there would be improvements in symptom severity, adaptive behavior, and emotional responsiveness in adolescence.

METHODS

A sample of children with autism assessed in both early and middle childhood were observed in late adolescence with the Autism Diagnostic Observation Scale (ADOS) and their parents were administered the Autism Diagnostic Interview-Revised (ADI-R) and the Vineland Adaptive Behavior Scale.

RESULTS

All but 2 adolescents (46 of 48) met lifetime criteria for autism according to the ADI-R, and all but 4 adolescents (40 of 44) met criteria for autism spectrum disorder on the ADOS. In contrast to the continuity in diagnosis, parents described improvements in social interactions, repetitive/stereotyped behaviors, adaptive behaviors, and emotional responsiveness to others' distress in adolescence compared to middle childhood. High-functioning adolescents with autism showed more improvement in these domains than low-functioning adolescents with autism. The extent to which the adolescents were observed to be socially engaged with their peers in school in middle childhood predicted adaptive behavior skills even when intelligence level was statistically constrained.

CONCLUSIONS

The developmental trajectory of children with autism appears to show both continuity and change. In this sample, most individuals continued to be diagnosed in the autism spectrum but parents reported improvements in adolescence. The results suggest that social involvement with peers improves adaptive behavior skills, and this argues for focusing intervention programs in this area. In addition, it is clear that high-functioning adolescents improve more than low-functioning individuals not only in cognitive abilities but also in social interaction skills. Thus, any early intervention that impacts the cognitive abilities of young children with autism is likely to have a parallel influence on their social skills as they mature into late adolescence and early adulthood.

Improvement in cognitive and language skills from preschool to adolescence in autism

This paper reports on the developmental progression of a sample of 48 adolescents and young adults with autism who were previously assessed at preschool age and again in the mid-school period. In contrast to the earlier period when about one-third of the children made dramatic gains, cognitive and language skills tended to remain stable or decline over this time span. The gain in mental and language age of the non-retarded adolescents with autism was less than half the change in their chronological age. The mentally retarded adolescents with autism showed some gain in mental age over time but this was far less than their change in chronological age, and they showed almost no gain in language age. Early childhood predictors of language skills in adolescence were functional play skills, responsiveness to others' bids for joint attention, and the frequency of requesting behaviors.

Essential versus complex autism: Definition of fundamental prognostic subtypes

Heterogeneity within the autism diagnosis obscures the genetic basis of the disorder and impedes our ability to develop effective treatments. We found that by using two readily available tests, autism can be divided into two subgroups, "essential autism" and "complex autism," with different outcomes and recurrence risks. Complex autism consists of individuals in whom there is evidence of some abnormality of early morphogenesis, manifested by either significant dysmorphology or microcephaly. The remainder have "essential autism." From 1995 to 2001, 260 individuals who met DSM-IV criteria for autistic disorder were examined. Five percent (13/260) were microcephalic and 16% (41/260) had significant physical anomalies. Individually, each trait predicted a poorer outcome. Together they define the "complex autism" subgroup, comprising 20% (46/233) of the total autism population. Individuals with complex autism have lower IQs (P=0.006), more seizures (P=0.0008), more abnormal EEGs (46% vs. 30%), more brain abnormalities by MRI (28% vs. 13%). Everyone with an identifiable syndrome was in the complex group. Essential autism defines the more heritable group with higher sib recurrence (4% vs. 0%), more relatives with autism (20% vs. 9%), and higher male to female ratio (6.5:1 vs. 3.2:1). Their outcome was better with higher IQs (P=0.02) and fewer seizures (P=0.0008). They were more apt to develop autism with a regressive onset (43% vs. 23%, P=0.02). Analysis of the features predictive of poor outcome (IQ<55, functionally non-verbal) showed that microcephaly was 100% specific but only 14% sensitive; the presence of physical anomalies was 86% specific and 34% sensitive. The two tests combined yielded 87% specificity, 47% sensitivity, and an odds ratio of 4.8:1 for poor outcome. Separating essential from complex autism should be the first diagnostic step for children with autism spectrum disorders as it allows better prognostication and counseling. Definition of more homogeneous populations should increase power of research analyses.

Applying the Emotional Availability Scales to children with disabilities

In this article, we describe issues regarding emotional availability and its application to children with disabilities. We then apply this approach to the scoring of emotional availability for caregiver-child interactions of children with disabilities, with information based on children with genetic mental retardation syndromes, children with autism, and children with hearing impairments.

Peer relationships and social and recreational activities among adolescents and adults with autism

In this study, we investigate peer relationships and participation in social and recreational activities among 235 adolescents and adults with autism who live at home. The prevalence of having friendships, peer relationships, and participating in social and recreational activities were all low and comparable to previous research. Both individual and environmental factors were investigated as predictors of having peer relationships and participation in social and recreational activities. Having peer relationships was predicted by individual characteristics (younger age, and less impairment in social interaction skills), but not by characteristics of the environment. Greater participation in social and recreational activities was predicted by characteristics of the individual with autism (greater functional independence, less impairment in social interaction skills, higher levels of internalizing behaviors) and characteristics of the environment (greater maternal participation in social and recreational activities, greater number of services received, and inclusion in integrated settings while in school).

Deficits in Social Attribution Ability in Prader?Willi Syndrome

Prader-Willi syndrome (PWS), a genetic form of mental retardation, involves a myriad of physical and behavioral problems. Poor social adjustment has been reported, but the origin of this difficulty is unknown. The Social Attribution Task, a measure of one's ability to make appropriate social attributions from an ambiguous visual display [Klin (2000) Journal of Child Psychology and Psychiatry, 33(5) [861-876] was administered to study participants with PWS, participants with pervasive developmental disorder and an IQ matched comparison group with no known syndrome. The participants with PWS performed significantly more poorly than participants with comparable intellectual ability, and not significantly differently from the group of participants with a pervasive developmental disorder. Poor performance on this task by the PWS participants suggests an underlying difficulty interpreting social information that is presented visually, which may be a critical factor in the impairment in social functioning in this population.

Peer interaction and loneliness in high-functioning children with autism

Social interaction with peers and the understanding and feelings of loneliness were examined in 18 high-functioning children with autism and 17 typically developing children matched for IQ, chronological age, gender, and maternal education. Observations were conducted on children's spontaneous social initiations and responses to their peers in natural settings such as recess and snack time, and children reported on their understanding and feelings of loneliness and social interaction. Overall, children with autism revealed a good understanding of both social interaction and loneliness, and they demonstrated a high level of social initiation. However, they spent only half the time in social interactions with peers compared with their matched counterparts, and they interacted more often with a typically developing child than with another special education child. Despite the intergroup differences in frequency of interaction, a similar distribution of interactions emerged for both groups, who presented mostly positive social behaviors, fewer low-level behaviors, and very infrequent negative behaviors. Children with autism reported higher degrees of loneliness than their typical age-mates, as well as a lower association between social interaction and loneliness, suggesting their poorer understanding of the relations between loneliness and social interaction. Research and practice implications of these findings are discussed.

Play and language in children with autism

It is well established that the play and language skills of children with autism are impaired. The article considers the relationship between these developments in typically developing children and children with autism. First, the evidence for a relationship between these two areas in typically developing children is reviewed. Despite many methodological differences between studies, this evidence supports a relationship, with specific developments emerging first in play and subsequently in language. Second, evidence for a relationship between play and language in children with autism is reviewed. From published and some previously unpublished data it is concluded that if there is a relationship between play and language in children with autism it is weak, if it exists at all. Finally, the implications of these findings are discussed and it is suggested that any relationship between play and language may be mediated by how children and their parents interact when they are playing.

Autism

Autism is a disorder characterised by severe difficulties in social interaction and communication, and with unusual behaviours. Once thought of as rare, autism is now recognised as being common. The role of CNS factors in pathogenesis is suggested by high rates of seizure disorder; research has highlighted the role of several specific brain regions in syndrome pathogenesis. Autism is a strongly genetic disorder and probably arises because of multiple genes; recurrence rates in families with one child are high. Early intervention with various techniques is helpful in many cases. Some pharmacological agents may help with certain problematic behaviours but do not address the underlying cause of the disorder.

Annotation: the neural basis of social impairments in autism: the role of the dorsal medial-frontal cortex and anterior cingulate system

BACKGROUND

The fundamental social disturbance of autism is characterized, in part, by problems in the acquisition of joint attention skills in the first years of life, followed by impairments in the development of social cognition, as assessed on theory of mind (ToM) measures. Recently, studies have indicated that a system involving the dorsal medial-frontal cortex (DMFC), and the anterior cingulate (AC), may contribute to the development of the tendency to initiate joint attention in infancy. Similarly, research has implicated the DMFC/AC system in ToM performance in typical and atypical individuals. These data suggest it may be useful to consider the functions associated with this system in the developmental psychopathology of autism.

METHOD

A review of the studies of the connections between the DMFC/AC system, joint attention and ToM task performance.

RESULTS AND CONCLUSIONS

This review raises the hypothesis that the DMFC/AC may be involved in the basic disturbance in social orienting in autism. The DMFAC/AC may also play a role in the capacity to monitor proprioceptive information concerning self-action and integrate this self-related information with exteroceptive perceptual information about the behavior of other people. A disturbance in these functions of the DMFC/ AC may contribute to the atypical development of intersubjectivity, joint attention and social cognition that may impair the lives of people with autism. Thus, impairment in the development of this system may constitute a neural substrate for socio-cognitive deficits in autism.

Cognitive underpinnings of pretend play in autism

This article examines the cognitive underpinnings of spontaneous and prompted pretend play in 28 young children with autism, 24 children with other developmental disorders, and 26 typical children. The article compares theories that consider either theory of mind (ToM) or executive function (EF) to be causally important deficits in the development of pretend play in autism and important factors in pretend play. Each of these two theories posits a cognitive precursor to pretense, which would need to be present in typical development, and the absence of which could explain pretend play deficits in children with developmental disabilities such as autism. We tested which of these theories better predicts a child's production of pretend play. Children with autism were significantly delayed on pretend play scores. They also had significant deficits in our ToM measure, but not our EF measures. Regression analyses suggested a role for our measure of generativity, one of the EF measures.

The importance of eyes: how infants interpret adult looking behavior

Two studies assessed the gaze following of 12-, 14-, and 18-month-old infants. The experimental manipulation was whether an adult could see the targets. In Experiment 1, the adult turned to targets with either open or closed eyes. Infants at all ages looked at the adult's target more in the open- versus closed-eyes condition. In Experiment 2, an inanimate occluder, a blindfold, was compared with a headband control. Infants 14- and 18-months-old looked more at the adult's target in the headband condition. Infants were not simply responding to adult head turning, which was controlled, but were sensitive to the status of the adult's eyes. In the 2nd year, infants interpreted adult looking as object-directed--an act connecting the gazer and the object.

Responses and sustained interactions in children with mental retardation and autism

Sustained interactions and responses to social bids made by children with autism and verbal-age-matched children with mental retardation were recorded in two naturalistic settings. Children with autism produced fewer positive responses and more "no responses" than children with mental retardation; both groups were more likely to make positive responses to adults and not to respond to other children. Furthermore, although the frequency of conversations was not different for the two groups, children with autism were significantly less likely to engage in sustained play compared to children with mental retardation. Results suggest that children with autism are able to master the more rote and need-oriented social skills, such as simple conversation, but may not develop other forms of social interactions, like play.

Why is joint attention a pivotal skill in autism?

Joint attention abilities play a crucial role in the development of autism. Impairments in joint attention are among the earliest signs of the disorder and joint attention skills relate to outcome, both in the 'natural course' of autism and through being targeted in early intervention programmes. In the current study, concurrent and longitudinal associations between joint attention and other social communication abilities measured in a sample of infants with autism and related pervasive developmental disorders at age 20 months, and language and symptom severity at age 42 months, were examined. Extending the findings from previous studies, joint attention ability was positively associated with language gains and (lower) social and communication symptoms, and imitation ability was also positively associated with later language. Some specificity in the association between different aspects of joint attention behaviours and outcome was found: declarative, triadic gaze switching predicted language and symptom severity but imperative, dyadic eye contact behaviours did not. Further, although joint attention was associated with later social and language symptoms it was unrelated to repetitive and stereotyped symptoms, suggesting the latter may have a separate developmental trajectory. Possible deficits in psychological and neurological processes that might underlie the impaired development of joint attention in autism are discussed.

Assessing change in early intervention programs for children with autism

Assessing the efficacy of any intervention can be a difficult task. In the case of children with autism who require comprehensive and long-lasting interventions, the task becomes even more difficult. In this paper, intervention studies based on comprehensive interventions for young children with autism are reviewed and examined in reference to elements that are essential to a well-designed treatment study, e.g., randomization/matching procedures, and outcome measures. Given the complexity of these comprehensive intervention programs, and the few data available on interventions with clear empirical validation, a plea is made for studies to consider the active ingredients or component parts of an intervention, e.g., number of hours, type of setting, and teaching approach. Suggestions are further made for improving future studies, including more rigorous designs, and measuring change.

Interventions to facilitate social interaction for young children with autism: review of available research and recommendations for educational intervention and future research

The purpose of this paper is to review the knowledge available from aggregated research (primarily through 2000) on the characteristics of social interactions and social relationships among young children with autism, with special attention to strategies and tactics that promote competence or improved performance in this area. In its commissioning letter for the initial version of this paper, the Committee on Educational Interventions for Children with Autism of the National Research Council requested "a critical, scholarly review of the empirical research on interventions to facilitate the social interactions of children with autism, considering adult-child interactions (where information is available) as well as child-child interactions, and including treatment of [one specific question]: What is the empirical evidence that social irregularities of children with autism are amenable to remediation?" To do this, the paper (a) reviews the extent and quality of empirical literature on social interaction for young children with autism; (b) reviews existing descriptive and experimental research that may inform us of relations between autism and characteristics that support social development, and efforts to promote improved social outcomes (including claims for effectiveness for several specific types of intervention); (c) highlights some possible directions for future research; and (d) summarizes recommendations for educational practices that can be drawn from this research.

The facilitation of social-emotional understanding and social interaction in high-functioning children with autism: intervention outcomes

This study evaluated the effectiveness of a 7-month cognitive behavioral intervention for the facilitation of the social-emotional understanding and social interaction of 15 high-functioning children (8 to 17 years old) with autism. Intervention focused on teaching interpersonal problem solving, affective knowledge, and social interaction. Preintervention and postintervention measures included observations of social interaction, measures of problem solving and of emotion understanding, and teacher-rated social skills. Results demonstrated progress in three areas of intervention. Children were more likely to initiate positive social interaction with peers after treatment; in particular, they improved eye contact and their ability to share experiences with peers and to show interest in peers. In problem solving after treatment, children provided more relevant solutions and fewer nonsocial solutions to different social situations. In emotional knowledge, after treatment, children provided more examples of complex emotions, supplied more specific rather then general examples, and included an audience more often in the different emotions. Children also obtained higher teacher-rated social skills scores in assertion and cooperation after treatment. The implications of these findings are discussed in terms of the effectiveness of the current model of intervention for high-functioning children with autism.

Perception of human and nonhuman facial age by developmentally disabled children

Human and nonhuman faces were shown to clinical controls, autistic, mentally retarded, and language-disordered children to assess their ability to detect and draw inferences about facial age. Children were asked to select from sets of three faces the one that appeared youthful or to select faces that would be associated with some age-related characteristic. In two studies, it was found that, relative to other children, autistic children had more difficulty perceiving youthfulness in nonhuman faces compared with human faces. These data are discussed with respect to differences in mechanisms and processes that may underlie facial information processing in autistic and nonautistic children.

Longitudinal changes in cognitive and adaptive behavior scores in children and adolescents with the fragile X mutation or autism

Studies of the relationship between the fragile X (FRAXA) mutation and autism have been controversial. Although there are differences between the two populations, individuals with FRAXA and autism exhibit remarkably similar aberrant behavior patterns. We examined comparably aged children and adolescents with FRAXA or autism to determine whether longitudinal changes in cognitive ability and adaptive behavior were similar in the two groups. We found decreases in IQ scores in young children with FRAXA as well as in those with autism. Declines in IQ scores were steeper among children with FRAXA. Older children and adolescents with autism exhibit stable test-retest scores, whereas older children with FRAXA continue to show decreases. Comparable declines in adaptive behavior composite scores were observed in both groups, at all ages tested, and across all adaptive behavior domains.

Interrelations among social-cognitive skills in young children with autism

Typically developing infants show a reliable developmental sequence of emergence of early social-cognitive skills, such as joint attention, communicative gestures, gaze and point following, imitation, and referential language. First infants share others' attention, then they follow others' attention and then behavior, and then they direct others' attention and then behavior. The current study used a series of tests from a study of typically developing infants (Carpenter, Nagell, & Tomasello, 1998) to investigate interrelations among these social-cognitive skills in young children with autism and children with other developmental delays. Tests of object permanence, spatial relations, facial and manual imitation, and executive function also were included. We found that for most children with autism, unlike other children, tests involving others' attention were more difficult than tests involving others' behavior. However, within the domains of attention and behavior, the typical pattern of sharing, then following, and then directing was evident. There were several positive intercorrelations among the social-cognitive skills (as there were for typically developing infants), but there also was some evidence of individual differences in patterns. Implications for theories of social-cognitive and language development are discussed.

The behaviors of parents of children with autism predict the subsequent development of their children's communication

The present study focused on behaviors that caregivers of children with autism show during play interactions, particularly the extent to which the caregiver's behavior is synchronized with the child's focus of attention and ongoing activity. The study had two major findings. First, caregivers of children with autism synchronized their behaviors to their children's attention and activities as much as did caregivers of children with developmental delay and caregivers of typically developing children, matched on language capacities. Second, caregivers of children with autism who showed higher levels of synchronization during initial play interactions had children who developed superior joint attention and language over a period of 1, 10, and 16 years than did children of caregivers who showed lower levels of synchronization initially. These findings suggest a developmental link between parental sensitivity and the child's subsequent development of communication skills in children with autism. Implications for parent training interventions are discussed.

Practitioner review: Diagnosis of autism spectrum disorder in 2- and 3-year-old children

BACKGROUND

Progress has recently been made in the earlier identification of children with autism spectrum disorder (ASD). Whilst being welcome, this progress to earlier referral and diagnosis presents new challenges to clinical practice, including the accuracy and stability of early diagnosis, the utility of standardised assessment instruments with young pre-schoolers and the ability to indicate prognosis.

METHOD

A selective review of recent research literature on the characteristic features of ASD in preschool children.

RESULTS

Multidisciplinary diagnostic assessment should include detailed information on developmental history, parents' descriptions of the everyday behaviour and activities of the child, direct assessment of the child's social interaction style, including where possible with age peers, and formal assessment of communicative, intellectual and adaptive function. Clinical assessments need to concentrate on the identification of impairments in early non-verbal social communication behaviours that characterise children with ASD from the second year of life, including social orienting, joint attention, imitation, play and reciprocal affective behaviour. The particular pattern of symptoms that presents in a 2-year-old with ASD may differ from that seen at the more prototypic age of 4 or 5 years. In particular, overt repetitive and stereotyped behaviours may be less notable, although where these are seen alongside the social and communicative impairments they are highly indicative of ASD. The use of standardised assessment instruments and the strict application of the DSM and ICD diagnostic criteria need to be employed with caution, as an expert clinical view has been shown to be more accurate. An important aspect of early diagnostic consultation is an open and straightforward approach to the negotiation of the diagnostic view with parents over time.

CONCLUSIONS

Earlier diagnosis and rising recognition of ASD have significant implications for primary healthcare and specialist diagnostic and therapeutic services.

Predictors of treatment outcome in young children with autism: a retrospective study

This study examined predictors of developmental outcomes in 17 children diagnosed with autism or PDD-NOS, who received generic treatment over a mean period of 37 months. Pre-treatment evaluations occurred at a mean age of 31 months with follow-up evaluations at a mean age of 69 months. Significantly different developmental trajectories were observed among the participants at follow-up, separating the participants into two distinct groups (high and low outcome). However, groups did not differ significantly in treatment intensity or other outcome prediction measures. Pre-treatment developmental intelligence levels between the two groups approached significance. The results raise questions regarding the effect of treatment intensity and type, family stress factors, and intelligence ability in very early childhood on, outcome.

Links between social understanding and social behavior in verbally able children with autism

This study investigated the relations between various measures of social understanding and social interaction competence in verbally able children with autism. Measures of social understanding included measures of verbalizable knowledge (false belief understanding, affective perspective taking), as well as measures of more intuitive forms of social responsiveness (empathy, concern to distress, and initiating joint attention). Two measures of social interaction competence were employed: level of engagement with peers on the playground, and prosocial behavior in a structured laboratory task. For children with autism, initiating joint attention and empathy were strongly related to both measures of social interaction competence. No understanding-behavior links were identified for a language-age matched comparison sample of developmentally delayed children. Several accounts of these understanding-behavior links are considered, including the possibility that for children with autism, more impaired forms of understanding are more closely linked to behavior because they serve as limits on competence.

"The frog ate the bug and made his mouth sad": narrative competence in children with autism

This study compares the narrative abilities of 13 children with autism, 13 children with developmental delays, and 13 typically developing children matched on language ability. Although groups did not differ in their use of causal language or internal state terms, children with autism and children with developmental delays were less likely than typical children to identify the causes of characters' internal states. Rather, they tended simply to label emotions and explain actions. Children with autism and children with developmental delays also relied on a more restricted range of evaluative devices, which both convey point of view and maintain listener involvement. In addition, the narrative abilities of children with autism were linked to performance on measures of theory of mind and an index of conversational competence, whereas this was not the case among children with developmental delays. Findings are discussed in relation to the social, cognitive, and emotional underpinnings and consequences of narrative activity.