Research in Developmental Disabilities 35 (2014) 3416–3422

Contents lists available at ScienceDirect

Research in Developmental Disabilities

Socialization and nonverbal communication in atypically

developing infants and toddlers
Matthew J. Konst *, Johnny L. Matson, Rachel L. Goldin, Lindsey W. Williams
Louisiana State University, United States

A R T I C L E I N F O A B S T R A C T

Article history: Emphasis on early identification of atypical development has increased as evidence
Received 12 July 2014 supporting the efficacy of intervention has grown. These increases have also directly
Accepted 19 August 2014 affected the availability of funding and providers of early intervention services. A majority
Available online 7 September 2014
of research has focused on interventions specific to an individual’s primary diagnoses. For
example, interventions for those with cerebral palsy (CP) have traditionally focused on
Keywords:
physiological symptoms, while intervention for individuals with Autism Spectrum
Atypical development
Disorder (ASD) focus on socialization, communication, and restricted interests and
Cerebral Palsy
Down’s syndrome repetitive behaviors. However deficits in areas other than those related to their primary
Autism Spectrum Disorder diagnoses (e.g., communication, adaptive behaviors, and social skills) are prevalent in
Social skills atypically developing populations and are significant predictors of quality of life.
Nonverbal communication Therefore, the purpose of the current study was to examine impairments in socialization
and nonverbal communication in individuals with Down’s syndrome (DS), CP, and those
with CP and comorbid ASD. Individuals with comorbid CP and ASD exhibited significantly
greater impairments than any diagnostic group alone. However, individuals with CP also
exhibited significantly greater impairments than those with DS. The implications of these
results are discussed.
ß 2014 Elsevier Ltd. All rights reserved.

As a class of disorders, cerebral palsy (CP) is a neurodevelopmental condition resulting in non-progressive impairment
caused by damage to the fetal or infant brain (Bult, Verschuren, Jongmans, Lindeman, & Ketelaar, 2011; Rosenbaum et al.,
2007). The worldwide incidence is approximately 2.5 per 1000 live births (Rosen & Dickinson, 1992). Historically, CP has
been defined as a set of conditions affecting movement and posture, though the degree and nature of impairment may vary
widely (Østensjø, Brogren Carlberg, & Vøllestad, 2003). In 2004, clinicians and researchers attending the International
Workshop on Definition and Classification of Cerebral Palsy in Bethesda, Maryland (USA) concluded that previous definitions
of CP were insufficient, because impaired motor development is frequently associated with other disabilities (Rosenbaum
et al., 2007). Himmelmann, Beckung, Hagberg, and Uvebrant (2006) found that approximately half of individuals with CP
exhibited major impairment in at least one developmental domain other than motor skills, further impacting overall
functioning and quality of life. Though motor impairment is a hallmark of CP and is often the initial cause for medical
attention, researchers and clinicians are increasingly cognizant of the non-motor neurodevelopmental issues that often
accompany CP including problems with cognition, expressive and/or receptive communication, social skills, and psychiatric
or comorbid conditions such as Autism Spectrum Disorder (ASD), epilepsy, intellectual disability (ID), sleep disturbances,

* Corresponding author at: Clinical Psychology, Department of Psychology, Louisiana State University, Baton Rouge, LA 70803, United States.
Tel.: +1 225 578 1494.
E-mail address: mkonst1@tigers.lsu.edu (M.J. Konst).

http://dx.doi.org/10.1016/j.ridd.2014.08.024
0891-4222/ß 2014 Elsevier Ltd. All rights reserved.
 M.J. Konst et al. / Research in Developmental Disabilities 35 (2014) 3416–3422 3417

and mood disorders (Rosenbaum et al., 2007). Intellectual disability occurs in about 60% of CP cases, and is correlated with
increased risk for receptive and expressive language deficits (Cherry, Matson, & Paclawskyj, 1997; Matson & Smiroldo, 1997;
Matson, Smiroldo, Hamilton, & Baglio, 1997; Paclawskyj, Matson, Bamburg, & Baglio, 1997; Sankar & Mundkur, 2005). Social
skill deficits are also common in individuals with comorbid ID as are a variety of different psychopathologies (Smith &
Matson, 2010).
In CP, motor difficulties including apraxia may impede verbal communication, leading more severely affected individuals
to rely more heavily on non-verbal communication (Shevell, Dagenais, & Hall, 2009). However, ID may further inhibit the
development of verbal and nonverbal communication, leading to difficulty interpreting nonverbal social cues of others and
negatively impacting socialization (Grove, Bunning, Porter, & Olsson, 1999; Matson et al., 1997; Matson, Kiely, & Bamburg,
1997; Matson, Smiroldo, et al., 1997). In a study of 9- to 13-year old children with CP, Voorman and colleagues (2006) found
that co-occurring cognitive impairment was a major factor associated with both social life and communication skills.
Children with decreased social communication skills are at significantly increased risk of decreased academic achievement,
depression, and other mood or conduct disorders (Gilmour, Hill, Place, & Skuse, 2004; Matson, Carlisle, & Bamburg, 1998;
Matson, Smiroldo, & Bamburg, 1998; Matson, Leblanc, & Weinheimer, 1999; McClelland, Morrison, & Holmes, 2000; Segrin,
2000), suggesting a need for intervention applied earlier, rather than later, in development. Communication and social
deficits in CP may be affected by motor difficulties or other commonly co-occurring conditions including ASD and ID
(Matson, Leblanc, et al., 1999; Njardvik, Matson, & Cherry, 1999).
The prevalence of concomitant ASD in CP populations is variable with estimates ranging from 1% to 10.5% (Kirby et al.,
2011; Nordin & Gillberg, 1996; Surén et al., 2012). ASD is a neurodevelopmental disorder, by definition marked by significant
impairments in socialization and communication in addition to restricted and repetitive behaviors and interests (Gabriels,
Cuccaro, Hill, Ivers, & Goldson, 2005; Hattier, Matson, Tureck, & Horovitz, 2011; Horovitz & Matson, 2010; Matson, Dempsey,
& Fodstad, 2009; Matson, Boisjoli, Hess, & Wilkins, 2010; Matson et al., 2011). Social and communication deficits in
individuals with ASD are often major targets of intervention. Early intensive behavior intervention (EIBI) uses applied
behavior analysis methods and has been found effective in improving deficits in multiple developmental domains, including
social, nonverbal, and verbal communication for children with ASD (Eikeseth, 2011), particularly when intervention begins
early in development, addresses multiple developmental domains in a normal developmental sequence using behavior
analytic procedures, and involving parents as co-therapists across environments to promote generalization (Eikeseth, 2011;
Matson, Mahan, & LoVullo, 2009). EIBI has proven effective for children with ASD both with and without concomitant ID. EIBI
is often initiated in toddlerhood, and has also been found effective in improving adaptive behaviors for children with ID
without ASD (Eldevik, Jahr, Eikeseth, Hastings, & Hughes, 2010; Smith, Eikeseth, Klevstrand, & Lovaas, 1997). Researchers
investigating the efficacy of EIBI interventions in ASD populations have observed that earlier intervention (e.g., begining at
age 3) had a significantly greater effect than interventions begun after age 5 (Woods & Wetherby, 2003).
Down syndrome (DS) is a chromosomal disorder typically resulting in mild to moderate ID, characteristic facial features,
and hypotonia (Korenberg et al., 1994). The disorder does not typically involve the motor difficulties of CP or the severe
difficulty with comprehending social information found in ASD, though social and communication skills are impacted by ID.
Individuals with DS have been found to have both relative strengths and weaknesses in nonverbal communication when
compared to children of matched mental age. Mundy, Sigman, Kasari, and Yirmiya (1988) found children with DS were
skilled in nonverbal social interaction skills, but displayed deficits in certain nonverbal skills such as nonverbal object-
requesting skills, related to overall deficits in expressive communication. Other researchers have found that individuals with
DS often exhibit significant delays in nonverbal cognitive development, though they often have fewer social problems and
challenging behaviors than individuals with other cognitive disabilities (Chapman & Hesketh, 2000). These tendencies may
be evident as early as toddlerhood (Fidler, Hepburn, & Rogers, 2006).
Both social skills and communication skills are closely linked to quality of life (Cummins & Lau, 2003; Verdugo, Schalock,
Keith, & Stancliffe, 2005). Multiple researchers have also previously demonstrated the positive correlation between the
presence of communication deficits and challenging behaviors in developmentally disabled populations (Chadwick, Walker,
Bernard, & Taylor, 2000; Durand, 1993; Matson & Boisjoli, 2007; Matson et al., 2005; Matson, Minshawi, Gonzalez, &
Mayville, 2006; Matson, Boisjoli, & Mahan, 2009). These skills are impacted by many factors, including the presence of
intellectual and/or neurodevelopmental disorders (Matson, Dempsey, & LoVullo, 2009). Deficits in motor skills can also
negatively impact quality of life and participation in normative experiences and opportunities important to development in
other areas; accordingly motor skills are often the primary focus of treatment for individuals with CP. However, given the
high frequency of co-occurring disorders or deficits in the context of both CP and DS, it is important to assess for the presence
of deficits in other domains such as communication and social skills that may benefit from intervention early in
development.
The focus of the current manuscript centered upon the Socialization/Nonverbal Communication domain of the BISCUIT-
Part 1. This domain consists of items that examine non-verbal communication skills and socialization deficits (Matson et al.,
2010). Although items in this domain are consistent with symptoms commonly observed in ASD populations, these
impairments are not unique to those with ASD. Researchers have previously observed communication (e.g., dysarthria) and
social deficits in individuals with CP and DS (Chapman & Hesketh, 2000; Clement & Twitchell, 1959; Kennes et al., 2002;
Mundy et al., 1988; Pennington, 2008). The authors utilized the Socialization and Non-Verbal Communication domain of the
BISCUIT-Part 1 to compare the degree of impairment across diagnostic groups (i.e., DS, CP, and CP/ASD). It was hypothesized
that individuals with CP and comorbid ASD would be significantly more impaired than the remaining groups. Further, the
3418 M.J. Konst et al. / Research in Developmental Disabilities 35 (2014) 3416–3422

authors hypothesized that individuals with CP would be significantly more impaired than individuals with DS due to the
underlying physical impairments associated with CP.

1. Method

1.1. Participants

Children included in the current study were selected from a larger database of children receiving services through
EarlySteps, Louisiana’s early intervention system. EarlySteps provides services to children with developmental delays and
their families from birth to 36 months of age, under the Individuals with Disabilities Education Improvement Act, Part C. The
sample of participants used in the study consisted of 211 children between the ages of 17 and 35 months (M = 26). Of the 211
participants, 127 were male and 83 were female. Regarding ethnicity, 50.3% of the participants identified as Caucasian, 34.2%
as African American, 3.1% as Hispanic, and 12.4% as of other or unspecified ethnicity.
Participants were split into three groups: Cerebral Palsy (CP; n = 89), Down’s syndrome (DS; n = 96) or CP + Autism Spectrum
Disorder (ASD; n = 26). Placement into the CP or DS group was based on parent/caregiver reported diagnoses. Participants were
placed in the CP + ASD group if they held a diagnosis of both CP and ASD. Inclusion in this group was based off parent/caregiver
report for diagnoses of CP, while diagnoses of ASD were determined by a licensed psychologist with over 30 years of experience
in the field of developmental disabilities. See Table 1 for more detailed demographics separated by diagnostic group.

2. Measure

2.1. Baby and infant screen for children with aUtIsm Traits-Part 1 (BISCUIT-Part 1; Matson et al., 2010)

The BISCUIT-Part 1 is one component of a larger assessment battery used to screen for ASD, comorbid psychopathology
and challenging behaviors in infants and toddlers 17–37 months of age. Part 1 of the BISCUIT consists of 62-items which
screens specifically for symptoms of ASD. Items are rated by parents or caregivers to the degree which the child’s current
behavior is different/impaired compared to same-aged peers of typical development. Items are rated along a 3-point Likert-
type scale (0 = ‘‘not different; no impairment;’’ 1 = ‘‘different; mild impairment;’’ 2 = ‘‘very different; severe impairment’’).
The normative sample for the BISCUIT battery contained individuals with ASD as well as atypically developing infants and
toddlers (e.g., CP, DS, epilepsy).
Psychometrically the BISCUIT-Part 1 demonstrates excellent internal reliability (.97; Matson, Boisjoli, et al., 2009; Matson,
Dempsey, & Fodstad, 2009; Matson, Dempsey, & LoVullo, 2009; Matson, Mahan, & LoVullo, 2009; Matson el al., 2009), and an
exploratory factor analysis identified a three factor structure: socialization/non-verbal communication, repetitive
behaviors/restricted interests, and communication (Matson, Boisjoli, et al., 2009; Matson, Dempsey, & Fodstad, 2009;
Matson, Dempsey, & LoVullo, 2009; Matson, Mahan, & LoVullo, 2009; Matson el al., 2009). Additionally, the measure has
excellent sensitivity and specificity, .844 and .833 respectively (Alfonso, Rentz, & Chung, 2010).

3. Procedure

Prior to data collection, the current study was approved by the Louisiana State University Institutional Review Board and
Louisiana’s Office for Citizens with Developmental Disabilities. Informed consent was provided by the parents/caregivers of
the participants before the assessment was conducted. The BISCUIT-Part 1 was administered by trained interviewers
employed through the state of Louisiana as part of a larger battery of assessments for EarlySteps.
All interviewers received training regarding ASDs and appropriate administrations techniques before they were deemed
qualified to conduct assessments by the State of Louisiana’s EarlySteps program. Interviewers specialized in fields such as

Table 1
Participant demographics.

Diagnostic category

DS (n = 96) CP (n = 89) CP + ASD (n = 26)

Age M = 26.63 (5.2) M = 27.11 (4.99) M = 26.38 (4.62)

Gender
Female 40 36 7
Male 55 53 19

Ethnicity
African-American 30 34 12
Caucasian 52 40 12
Hispanic 8 5 0
Other 6 10 2

Note: Standard deviations are provided in parentheses directly beside the mean.
 M.J. Konst et al. / Research in Developmental Disabilities 35 (2014) 3416–3422 3419

Table 2
Post hoc analysis of the Socialization/Nonverbal Communication subscale of the BISCUIT-Part 1.

Diagnostic category

CP + ASD (n = 26)/CP(n = 89) CP + ASD(n = 26)/DS(n = 96) CP(n = 89)/DS(n = 96)

Games-Howell M/D = 20.83** M/D 24.56** M/D = 3.73*

Note: M/D indicates mean difference between two diagnostic groups.

* Significant at .05 level.
** Significant at .01 level.

social work, education, speech-language pathology, physical therapy, occupational therapy, and psychology. Assessment
measures, including the BISCUIT-Part 1, were administered in person and parents/caregivers were permitted to ask questions
or express concerns at any time during the assessment.

4. Statistical analyses

Prior to carrying out the main analysis various a priori statistics were used to evaluate the database and verify that the
current sample was normally distributed. A Chi-square test revealed that the diagnostic groups were not significantly
different based upon informant reported ethnicity, x2 (6) = 6.01, p = .42. Gender differences were also not observed to be
significantly between groups x2 (2) = 2.02, p = .36. An analysis of variance (ANOVA) was conducted to determine if there were
significant differences between diagnostic groups based upon age. No significant difference was observed (F (2, 201) = 0.31,
p = .73).

5. Results

A one-way between subjects ANOVA was carried out with diagnostic category (i.e., CP/ASD, CP, and DS) as the
independent variable and the participant’s cumulative score on the Socialization and NonVerbal Communication factor of
the BISCUIT-Part 1 as the dependent variable. Levene’s test was significant, F (2, 208) = 11.34, p = .00 indicating that the
assumption of homogeneity of variance was not upheld. In order to be conservative and retain power the Brown-Forsythe F
test was selected for analysis (Field, 2009). The one-way ANOVA of symptom endorsement on a measure of inattention-
impulsivity revealed a statistically significant main effect Brown-Forsythe F (2, 76) = 76.24, p = .00. Post hoc analyses were
carried out to determine which groups significantly differed from one-another. Results of the Games-Howell post hoc
procedure are presented in Table 2. Overall, individuals with CP and ASD (M = 30.11, SD = 11.89) exhibited significantly
greater deficits on the socialization and non-verbal communication subscale than individuals with CP (M = 9.28, SD = 11.24)
and DS alone (M = 5.55, SD = 7.63), p = .00. The difference between the CP and DS groups was also significant (p = .03). (Fig. 1)

Fig. 1. Estimated marginal mean of Socialization/Communication impairment for each diagnostic category.
3420 M.J. Konst et al. / Research in Developmental Disabilities 35 (2014) 3416–3422

6. Discussion

The increased emphasis of early identification of atypical development has been largely spurred by a growing amount of
research surrounding ASD populations. This is largely related to the positive effects of early intervention practices in ASD
populations. Results of our analyses confirmed our hypothesis that participants with CP and ASD exhibited significantly
greater deficits in socialization and nonverbal communication than other atypically developing groups. The current
results also indicated that elevated levels of impairment surrounding social skills and non-verbal communication are
present in infants and toddlers with CP. Although these deficits are not as great as those observed in the CP/ASD group
they are significantly greater than those observed in the DS group. Researchers have previously estimated that 20% of
children with CP do not utilize intelligible speech (Andersen, Mjøen, & Vik, 2010a,b; Chan, Lau, Fong, Poon, & Lam, 2005;
Pennington, Goldbart, & Marshall, 2005; Sigurdardottir & Vik, 2011). Further, even when verbal communication abilities
are present, nearly half of those with CP evidence some form of communication deficit (Bax, Tydeman, & Flodmark, 2006;
Pennington et al., 2005). For these individuals, concurrent deficits in non-verbal communication may further
impair their ability to communicate and interact with their environment. Similar to children with ASD, individuals with
CP would likely benefit from early interventions targeting these specific deficits given their association with overall
quality of life.
Unlike those with ASD, communication deficits in CP populations are often associated with impaired motor skills
(Pennington, 2008; Sigurdardottir & Vik, 2011). Researchers have reported that the severity of motor impairment (GMFCS,
Gross Motor Function Classification System) was positively associated with decreased verbal communication skills
(Sigurdardottir & Vik, 2011). Those motor impairments associated with CP affect multiple factors necessary for
communication to include the production of nonverbal (e.g., facial expression and gesture use) and verbal communication
(e.g., speech regulation; Pennington, Goldbart, & Marshall, 2004). In addition to impaired motor and communication
abilities, individuals with CP are also at risk for additional comorbid conditions (e.g., epilepsy, ID, impaired hearing, and
visual impairments; Sankar & Mundkur, 2005). These specific comorbid conditions are also associated with communication
deficits (Pennington, 2008).
Researchers have previously advocated for the need of early communication intervention in CP populations (Pennington,
2008). The development of early communication abilities is necessary in facilitating the development of later
communication skills which directly impact social interactions (Bates, Benigni, Bretherton, Camaioni, & Volterra, 1979;
Bruner, 1973, 1975; Snow, 1984). Falkman, Sandberg, and Hjelmquist (2002) suggested that decreased opportunities for
interaction in CP populations due to physical disabilities may negatively affect the later development and advancement of
communication capabilities. Communication deficits have been previously demonstrated to be strongly related to increases
in challenging behaviors (Chadwick et al., 2000; Durand, 1993; Matson, Boisjoli, & Mahan, 2009) and an overall decrease in
quality of life (Cummins & Lau, 2003; Dickinson et al., 2007; Livingston, Rosenbaum, Russell, & Palisano, 2007; Tuzun, Eker, &
Daskapan, 2004; Verdugo et al., 2005). In addition to a focus on improving verbal communication skills, intervention may
also incorporate the introduction of alternative communication means (Andersen, Mjøen, & Vik, 2010a,b; Ganz et al., 2012;
Schlosser & Sigafoos, 2006). Despite the differences underlying their communication deficits, the introduction of alternative
means of communication is common in intervention approaches for individuals with ASD, ID, and/or CP (Banda, Hart, and
Liu-Gitz, 2010; Marchant, McAuliffe, and Huckabee, 2008). Hagen, Porter, and Brink (1973) previously demonstrated the
benefit of utilizing augmented communication devices in CP populations, despite the presence of severe ID and motor
disabilities. It is important to note that the use of alternative forms of communication should be supplemental to ongoing
communication interventions.
Previous researchers have also demonstrated the negative impact that lower levels of gross motor functioning has upon
the development of social skills in CP populations (Østensjø, Carlberg, and Vøllestad, 2004). Although not every individual
with CP has a comorbid disorder of ASD (Kirby et al., 2011; Nordin & Gillberg, 1996) results of the current research
demonstrate that individuals with CP exhibit significantly greater social skill impairments when compared to atypically
developing peers. Individuals with CP would likely benefit from similar early interventions provided to ASD children to
improve social skills and provide increased opportunity and positive reinforcement for social interactions. The increasing
availability of early intervention resources for ASD populations may facilitate the delivery of similar interventions for young
children with CP.
However, at present research surrounding CP, especially young children with CP focuses heavily on treating the physical
disabilities associated with CP with little research investigating the efficacy of intervention for factors such as
communication and social skills. Although speech and language interventions are utilized in CP populations, a recent review
discussed concerns surrounding methodological design in the studies used to analyze the efficacy of these interventions in
CP populations (Pennington, Goldbart, & Marshall, 2003). Although positive evidence is available for early communication
interventions (e.g., Pennington, Smallman, & Farrier, 2006) large-scale research is needed to demonstrate their efficacy and
to provide a systematic and detailed outline of intervention components (Pennington, 2008).

Conflict of interests

The authors report no conflicts of interests and are solely responsible for the content and writing of this paper.
 M.J. Konst et al. / Research in Developmental Disabilities 35 (2014) 3416–3422 3421

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