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Diagnosis and classification in autism

Lynn Waterhouse, Carl Feinstein

Journal of Autism and Developmental Disorders

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Journal of Autism and Developmental Disorders, Vol. 26, No. 1, 1996

Diagnosis and Classification in Autism 1

Lynn Waterhouse 2
Trenton State College

Robin M o r r i s
Georgia State University

Doris Mien and Michelle Dnnn

Albert Einstein College of Medicine

Deborah Fein
University of Connecticut

Carl Feinstein
Kennedy Krieger Institute and The Johns Hopkins Medical School

Isabelle Rapin
Albert Einstein College of Medicine

L o r n a Wing
Centre for Social and Communication D/sorders, Bromley Ken~ England

This study compared four systems for the diagnosis of autism (DSM-III,
DSM-III-R, DSM-I~, and ICD-IO) with two empirically derived taxa of
autism, and with three social subgroups of autism (Aloof, Passive, and

IThis study was supported in part by National Institutes of Health grant NS 20489 to the
Autism and Language Disorders Collaborative Project: Preschool Study Group. The authors
gratefully acknowledge the contributions of Robert Golden, Dorothy Aram, and Barbara
Wilson to this study. The authors thank Dolores Drake and Maura McGovern Graber for
assistance in the preparation of this paper, and thank Cathy Lord and several anonymous
reviewers for their help in developing the structure of this paper.
2Address all correspondence to Lynn Waterhouse, 226 Bray Hall, Trenton State College,
Trenton, New Jersey 08650-4700.

59
0162-3257/96/02004)059509.50/0O 1996 Plenum PublishingCorporation
60 Waterhouse et al.

Active-but-Odd) in 194 preschool children with salient social impairment.

There were significant behavior and IQ differences between autistic and
other-PDD groups for all four diagnostic systems, and a significant association
was found (a) for Taxon B, diagnoses of autism, and the Aloof subgroup, and
(b) for Taxon A, other-PDD, and the Active-but-Odd subgroup. Findings offer
support for two major overlapping continua within idiopathic Pervasive
Developmental Disorder.

Autism is found in association with many different levels of language im-

pairment and social impairment, with variant neural deficits and mental
ages, and with a range of etiologies. This heterogeneity has been attributed
to the structure of the diagnostic systems (Parks, 1983), and to the incorrect
use of diagnostic systems (Cohen, Paul, & Volkmar, 1986; Meehl, 1986).
Identifying more homogeneous behavioral subgroups would increase the
inferential power of developmental, genetic, imaging, neuroanatomic, and
neurophysiological studies of autism (Dahl, Cohen, & Provence, 1986;
Eaves, Ho, & Eaves, 1994; Horowitz & Rumsey, 1994; Piven & Folstein,
1994; Rapin, 1991; Reichler & Lee, 1987; Tsai & Ghaziuddin, 1992; Wa-
terhouse, 1994).
Efforts to limit heterogeneity have included the creation of sub-
groups (a) by clinical consensus and field trials (DSM-III, American Psy-
chiatric Association [APA], 1980; DSM-III-R, APA, 1987; DSM-II(, APA,
1994; ICD-IO World Health Organization [WHO], 1993); (b) by IQ (Co-
hen, Paul, & Volkmar, 1987; Freeman et al., 1981; Tsai, 1992); (c) by
social functioning--Aloof, Passive, Active-but-Odd (Borden & Ollendick,
1994; Castelloe & Dawson, 1993; Volkmar, Cohen, Bregman, Hooks, &
Stevenson, 1989; Wing, 1988; Wing & Gould, 1979); (d) by cognitive pro-
files (Fein, Waterhouse, Lucci, & Snyder, 1985); (e) by presence of or-
ganic features (Cohen et al., 1987); (f) by cluster analysis of sets of
variables (Eaves et al., 1994; Siegel, Anders, Ciarenello, Bienenstock, &
Kraemer, 1986); and, (g) by cluster and taxometric analysis together
(Golden & Mayer, 1995; Rapin, in press).
Formal diagnostic systems have assumed there is a core syndrome--
Infantile Autism, DSM-III (1980); Childhood Autism, ICD-IO (1993); Autis-
tic Disorder, DSM-III-R (1987), DSM-1V (1994)--and other noncore
autistic-like groups. Developmental research, however, has suggested an
autistic continuum rather than a sharp boundary between core autism and
noncore groups (Dalai et al., 1986; Provence & Dalai, 1987; Waterhouse,
Wing, & Fein, 1989; Wing, 1988; Wing & Attwood, 1988). Furthermore,
researchers reviewing clinical studies have proposed that there may be two
Diagnosis and Classification in Autism 61

major forms of the autistic syndrome: high functioning and low functioning
(Cohen et al., 1987; Tsai, 1992).
To compare these three proposals--1. An autism core group; 2. An
autistic continuum; 3. High and low functioning autism--we have explored
associations between four diagnostic systems for autism--DSM-III, DSM-
Ili-R, DSM-II(, and ICD-lO--with two statistically derived taxa of autism
(Golden & Mayer, 1995; Rapin, in press), and with three social subgroups
of autism (Aloof, Passive, and Active-but-Odd) (Wing, 1988) in a multisite
preschool sample of 194 children diagnosed as having Pervasive Develop-
mental Disorder (PDD). Findings presented in the Results section suggest
support for a fourth proposal, two major overlapping autistic subgroups of
differential severity whose behavioral continua together form a larger con-
tinuum.

METHOD

Subjects

Preschool Study Sample

For a longitudinal study of children with communication disorders we

recruited more than 700 children ages 3 to 7 in three groups by prior clini-
cal diagnosis: developmental language disorder (DLD), autistic disorder
(AD), and nonautistic mental retardation (NAMR). A sample of 46 normal
children provided normative data for nonstandardized measures of spon-
taneous language, sociability, and play.
Children were recruited by clinical referral and by solicited participa-
tion of special schools and programs in Atlanta, Boston, Bronx NY, Cleve-
land, Manhasset NY, and Trenton. The project was not designed as an
epidemiological study: Complete sampling in discrete geographic regions
was not conducted.
Inclusionary and exclusionary criteria were (a) age 3-7 years; (b) Eng-
lish speaking; (c) normal hearing (25 Db or better); (d) no known brain
lesions or neural disease; (e) no known genetic disorder; (f) no frequent
seizures; (g) no significant motor or sensory handicaps; (h) not on high
doses of anticonvulsants or behavior-altering medications. Six hundred
thirty-three children met these criteria; 36 children did not complete all
core measures and 41 dropped out of the study. These 77 did not differ
significantly from the remaining 556 children (Rapin, in press).
62 Waterhouse et al.

Autistic Sample

Two-Phase Screeningfor Social Impairment. Two hundred fifty-three chil-

dren recruited for the autistic sample had been screened by a clinician as
having significant impairment in social relatedness and social communica-
tion. For a second level screening the child's mother or teacher was inter-
viewed with the three-section 21-item Wing Autistic Disorder Interview
(WADIC, Wing, 1985). Interrater kappas computed for each of the 21
WADIC items during the field trials of DSM-IIIR ranged from a low of .51
for C5 to a high of .92 for A1 (see Appendix A; Waterhouse, 1986; Water-
house, W'mg, Spitzer, & Siegel, 1992). A child was included in the study if
the child's mother or teacher endorsed two of nine items in section A, or
one item for each of the three sections-- (A) social impairment, (B) impair-
ment in social communication, (C) repetitive or restricted activities. Of the
253 children recruited 221 were included by this second level screening.
Psychiatric Evaluation. All 221 screened children were evaluated by a
child psychiatrist who (a) determined a DSM-II1 PDD (1980) diagnosis with
endorsement of a detailed DSM-111 feature/symptom checklist; (b) deter-
mined a DSM-II1-R PDD (1987) diagnosis with endorsement of a detailed
DSM-III-R feature/symptom checklist; (c) completed two checklists of social
abnormalities; and (d) coded the child's level of social relatedness--Aloof,
Passive, Active-but-Odd--by means of Wing and Gould's (1979) description
of each group (see Rapin, in press, for details). Of the 221 children 194
were diagnosed by child psychiatrists as having some form of PDD. Inter-
rater agreement (Fleiss, Spitzer, Endicott, & Cohen, 1972; Krippendorff,
1970) between the site child psychiatrists and research clinician (N = 8)
was computed for a representative subsample of 65 PDD children (52 boys;
13 girls) with a mental age of 18 to 106 months: for DSM-111 Infantile
Autism versus other-PDD, the kappa was .88; for DSM-1I-R Autistic Dis-
order versus other-PDD the kappa was .91.
Diagnostic Algorithm Classification. Using DSM-III and DSM-III-R
symptom endorsements from the original psychiatric interviews, the abnor-
malities checklists from the psychiatric interview, and symptom endorse-
ments from a developmental history interview with parents, we constructed
diagnostic algorithms to determine both an ICD-IO (1993) and a DSM-1V
(1994) PDD classification for each of the 194 children originally evaluated
in 1986. Appendix B provides exemplars of algorithm equivalencies. Com-
plete algorithms are published elsewhere (Rapin, in press; Waterhouse,
Feinstein, Allen, & Morris, 1993).
In the sample of 194 PDD children, child psychiatrists diagnosed 51%
with DSM-III Infantile Autism and 91% with DSM-III-R (1987) Autistic
Disorder. The diagnostic algorithm identified 59% with DSM-IV Autistic
Diagnosis and Classification in Autism 63

Table I. Overlap of Four Systems of Diagnosis of Autism in a Sample of 194 Preschool

Children
DSM-III DSM-III-R DSM-IV ICD-IO
Infantile Autistic Autistic Childhood
Autism by Disorder by Disorder by Autism by
psychiatric psychiatric diagnostic diagnostic
evaluation evaluation algorithm algorithm
Distribution by sex
Boys 85 147 92 103
Girls 13 29 23 22
Ratio 6.5/1 5.1/1 4/1 4.7/1
Chronological age (months) 60.5 59.6 59.4 60.1
No. of children in each group
DSM-II1 Infantile Autism 98 98 68 81
DSM-IlI-R Autistic Disorder 176 112 123
DSM-IV Autistic Disorder 115 98
ICD-IO Childhood Autism 125

Disorder, and 64% with ICD-IO Childhood Autism. The same relative dif-
ferences in coverage have been identified previously (Rutter & Schopler,
1992; Szatmari, 1992; Volkmar, Cicchetti, Bregman, & Cohen, 1992). The
overlapping relationship between these four classifications can be seen on
Table I.
Social Subtypes Clinical Classification. Psychiatrists determined the chil-
dren's Wing Social subtype by descriptive checklist during a complete clini-
cal evaluation of the child: (a) Aloof (n = 59), (b) Passive (n = 96), or
(c) Active-but-Odd (n = 22). Teachers also made the same determination
as Item 22 of the MRC Handicap Schedule. The interrater kappa between
psychiatrists and teachers (n = 6), computed on the representative sub-
sample of 65 PDD subjects, was .82.
Cluster and Taxometric Classification. Hierarchic cluster analysis and
taxometric analysis (Erlenmeyer-Kimling, Golden, & Cornblatt, 1989;
Golden, 1991; Golden, Campbell, & Perry, 1987; Golden & Mayer, 1995;
Golden & Sliwinski, 1996) both yielded two major groups within the sam-
ple of 194 children. Using the Vineland domain scores, Verbal IQ, Non-
verbal IQ, the WADIC items, MRC Handicap Schedule items, and
Neurological examination scores as variables, cluster analysis identified
two large groups of subjects (Rapin, in press). Using the same set of vari-
ables as indicators taxometric analysis also identified two groups: Taxon
A with 92 subjects; Taxon B with 102 subjects (Rapin, in press). Taxometric
analysis is based on a regression-mixture model. This method analyzes the
regression of each possible candidate indicator on each of the other in-
dicators for a sample of individuals in order to detect the presence of
natural underlying subgroups or latent taxa. Indicator variable measure-
64 Waterhouse et al.

ments are assumed to be determined by a wide range of causal factors.

Unlike cluster analysis, which will always form groups in a dataset,
taxometric analysis yields three possible outcomes: (a) evidence for no la-
tent groups, i.e., suggesting a continuum; or (b) evidence identifying one
taxonic group and a remainder; or, (c) evidence suggesting two taxonic
groups. Taxometric analysis in the sample of 194 suggested two possible
taxonie groups with partially overlapping distributions of variance. The
dearest contributor to the two taxa was developmental status. Taxon A
children are older (A, mean age = 62.9 months; B, mean age = 55.0
months), and better functioning (A, mean verbal IQ = 55.2; B, mean ver-
bal IQ = 24.6) than Taxon B children. The empirically derived taxa, how-
ever, are not equivalent to high and low functioning in terms of IQ.
Making an IQ cut at 70 in the sample of 194 will wrongly group 42 indi-
viduals: approximately 21% of Taxon A have IQs below 70, and 23% of
Taxon B have IQs above 70 (Waterhouse et al., 1993).

Contrast Sample

In addition to the 194 PDD children, we tested 252 children with clini-
cally diagnosed developmental language disorder (mean age 49 months)
and 110 nonautistic mentally retarded children with IQs below 80 (mean
age 56 months). While data from these clinical study populations are re-
ported elsewhere (Rapin, in press), data from the 362 children on the
WADIC screening instrument are reported here for comparison.

Measures

Interview Schedules

After the WADIC interview, mothers of children who passed the

screen were interviewed with the Vineland Adaptive Behavior Scales
(VABS; Sparrow, BaUa, & Cicchetti, 1984) to assess communication, daily
living, socialization, and motor skills. Teachers of the 194 children were
interviewed with the Medical Research Council Handicaps, Behaviour and
Skills schedule (Wing & Gould, 1978) to assess language, play, abnormal
sensory and motor behavior, daily living skills, behavior problems, attention,
and social skills.
Diagnosis and Classification in Autism 65

IQ Measures

Because of the wide range of functioning of the sample of 194 PDD

children, we employed two measures for nonverbal IQ--the Stanford-Binet
Intelligence Test--4th Edition (S-B, Thomdike, Hagen, & Satfler, 1986) and
the Bayley Scales of Infant Development--Mental Scale (Bayley, 1969), and
two measures to determine a verbal IQ--The Test of Early Language De-
velopment (TELD; (Hresko, Reid, & Hammill, 1981) or Sequenced Inven-
tory of Communication Development--Revised (SICD-R; Hedrick, Prather,
& Tobin, 1984). The exact procedures by which we determined verbal and
nonverbal IQ are provided in Rapin (in press, Chap. 4). (We also adminis-
tered an extensive battery of tests of language and cognitive skills to the
194 children. The findings are reported in Rapin, in press.)

RESULTS

Diagnostic Classifications

All four diagnostic systems yielded significant differences between

autistic and other-PDD groups in endorsements of WADIC items: A 1-9,
Social Impairment; B 1-5, Communication Impairment; C 1-7, Ritual or
Repetitive Activity. For DSM-III (Infantile Autism = 98; other-PDD = 96),
only section A was significant (F = 21.65, p = .0001). For DSM-III-R
(Autistic Disorder = 176; PDDNOS = 18), A (F = 9.31, p = .002), and
C (F = 5.20, p = .01) were significant. For DSM-IV (Autistic Disorder =
115; other-PDD = 79), and 1CD-IO (Childhood Autism = 125; other-PDD
= 69) all three sections showed significant differences: DSM-II( section A
(F = 54.76, p = .0001), section B (F = 8.82, p = .01), section C (F =
52.74, p = .0001), ICD-IO, section A (F = 59.39, p = .0001); section B (F
= 6.18, p = .02), section C (F = 83.36, p = .0001).
Figure 1 shows the WADIC A, B, and C endorsement profiles of the
four diagnostic groups and the contrast sample of 362 preschool children
(252 developmental language disorder; 110 nonautistic mentally retarded).
All chi-square comparisons of item frequencies for the DSM-III, DSM-III-R,
DSM-11(and ICD-IO autism groups with the contrast sample were significant
at the p = .001 level or lower. (Tests of significance cannot be run to com-
pare endorsement frequencies of the four groups of children classified as
autistic because the four groups contain subsets of the same individuals.)
Figure 2 shows DSM-IV Autistic Disorder and other-PDD endorse-
ment frequencies on the WADIC A, B, and C items. ICD-IO, DSM-III-R,
and DSM-1V showed nearly identical endorsement frequencies. DSM-IH
 Waterhouse et aL

1oo
90-
0 80-
uJ . 9~ . / " ~,
70. DSM III IA

OSM III R AD
Z
'" 50" DSM IV AD
I-,-
4o
~ICD.
m m .10 CA
tlJ NON - PDD
O. 20" ~176 ~ ~.* "~, CLINICAL
CONTRAST
10-" " ""~'.. .~ ........ --"" " "" "" SAMPLE

0/~1 A2 A3 A4 A5 A6 A7 A8 A9

DIAGNOSTIC GROUPS
NINE SOCIAL IMPAIRMENT BEHAVIORS

100:
90
r~ 80
uJ
70 DSM III IA
0
0 60 DSM III R AO
Z
LU 50
I--
DSM IV AD
40
ICD - 10 CA
30
Q. 20 ~o~ ~176o~ ~ 1 7 6 1 7 6 NON o PDD
o,~~176176 CLINICAL
10 CONTRAST
SAMPLE

B1 132 133 B4 B5

DIAGNOSTIC GROUPS
FIVE COMMUNICATION IMPAIRMENT BEHAVIORS

lOG
90
80'
uJ
70.
' * ~ ~ DsM I[I iA
~.
Z DSM ul R A~
W 50 . . . . .
~. os.__My_Ao
3 o - ~ ,c_.o-_,o_cA
W
20' NON - PDD
CLINICAL
10- CONTRAST
~- ~. ~- .~ SAMPLE

C1 C2 C3 C4 C5 C6 C7
DIAGNOSTICGROUPS
SEVENRITUALOR REPETITIVEACTIVITIES
Fig. 1. Comparison of the frequency of endorsed items on the WADIC
for groups of preschool children diagnosed as autistic by four diagnostic
systems ( D S M - I I I , n = 98; D S M - I I I - R , n = 176; D S M - I I ( n = 115; I C D -
10, n = 125), and a COntrast sample of 362 children (252 with develop-
mental language disorder; 100 with nonautistic mental retardation).
Diagnosis and Classification in Autism 67

100

80
70
60 -... y..-" "-..i
DSM IV
40 AUTISTIC
DISORDER
30
20. DSM IV
OTHER
10 PDD
0
A1 A2 A3 A4 A5 A6 A7 A8 A9
DSM IV AUTISTIC DISORDER AND NON.AUTISTIC PDD
N I N E SOCIAL IMPAIRMENT BEHAVIORS

100
90-
8 8o
"/0

Z 50 ". """ DSM IV

40 "'"". ...... .".'" AUTISTIC
DISORDER

DS ,V
OTHER
l o ~ ..p.?.O.
.....
0
B1 B2 B3 B4 B5
DSM IV AUTISTIC DISORDER AND NON-AUTISTIC PDD
FIVE COMMUNICATION IMPAIRMENT BEHAVIORS

z DSM IV
Z
~ AUTISTIC
;. ..........
20 .. ......................... ... DSM IV
". . . . . . . . . OTHER
10 PDD
0
C1 C2 C3 CA C5 C6 C7
DSM IV AUTISTIC DISORDER AND NON-AUTISTIC PDD
SEVEN RITUAL OR REPETITVE ACTIVITIES

Fig, 2. Comparison of the frequency of endorsed items on the

WADIC for 115 preschool children classifiedwith Autistic Disor-
der by a DSM-IV diagnostic algorithm, and 78 children classified
as other-PDD by DSM-IV.
68 Waterhouse et al.

100
9O
O 80
iJJ
~ 70
~
z
'" 50 DSM III
I--
zgl 4O INFANTILE
AUTISM
~ 30
a. 20 DSM III
OTHER
10 PDD
0
A1 A,?. A3 A4 A5 A6 A7 A8 A9
DSM Ill INFANTILE AUTISM AND NON-AUTISTIC PDD
NINE SOCIAL IMPAIRMENT BEHAVIORS

100
90
80
ILl
r
ri- 70
g 60
Z
UJ 50
I-- DSM III
Z 40
ill INFANTILE
30 AUTISM
w
20 DSM In
10 OTHER
PDD
0
B1 132 B3 B4 B5
DSM Ill INFANTILE AUTISM AND NON-AUTISTIC PDD
FIVE COMMUNICATION IMPAIRMENT BEHAVIORS

aoo /

1
~ 80
~ 70
~-.

....... I DSM Ill

~ 40 ..9-.,... :." "...\ ... . . . . ., / INFANTILE
~ 30
w
~ 20
" I U I M I - PI
10
J POD
C1 C2 C3 C4 C5 C6 C7
DSM 111INFANTILE AUTISM AND NON-AUTISTIC PDD
S E V E N R I T U A L OR R E P E T I T V E A C T I V I T I E S

Fig. 3. Comparison of the frequency of endorsed items on the

WADIC for 98 preschool children diagnosed with Infantile Autism
by child psychiatrists on the basis of DSM-H1 criteria, and 96 pre-
school children identified as other-PDD.
Diagnosis and Classification in Autism 69

showed a different pattern (Figure 3). The DSM-III other-PDD children

were significantly more often endorsed for bizarre speech patterns (B3),
impaired prosody (B4), impaired symbolizing (B5), and preservative inter-
ests (C6). All chi-square comparisons were p = .04 or lower.

Distribution of Diagnoses, Taxa A and B, and Social Subtypes

Table II outlines the joint distribution of the four diagnostic systems,

with Taxa A and B. For each of the four diagnostic classifications, a majority
of cases diagnosed as autistic appeared in Taxon B, and a majority of cases
classified as other-PDD appeared in Taxon A. DSM-111 was most consonant
with the taxa: 80 of 102 Taxon B cases were DSM-III Infantile Autism; 74
of 92 Taxon A cases were DSM-III other-PDD.
Table III outlines the joint distribution of autism and other-PDD with
the Wing Social Subtypes: Aloof, Passive, and Active-but-Odd. Borden and
Ollendick (1994) validated the Aloof and Active-but-Odd subtypes, but
not the Passive subtype. Excluding the Passive subgroups, the ratio of
Aloof to Active-but-Odd cases across the four autistic groups was 5.4 to
1, and across the four other-PDD groups was 0.9 to 1. For both autistic
and other-PDD groups, the Passive subtype represented about one half
of the sample.
The interrelationship of the Wing Social Subtypes and Taxa A and B
is reported on 1hble IV. A majority of the Aloof type were Taxon B; a
majority of the Active-but-Odd type were "Ihxon A. The Passive type in-
cluded one half Taxon A, and one half Taxon B.

Table IL Distribution of "lhxa A and B Across Four Diagnostic Systemsa

DSM-II1 by DSM-III-R by DSM-1V by ICD-IO by
psychiatric psychiatric diagnostic diagnostic
evaluation evaluation algorithm algorithm

Other Other Other Other

IA PDD AD PDD AD PDD CA PDD
Taxon A
% 18 77 44 83 37 75 36 68
n 18 74 77 15 42 59 45 47
Taxon B
% 82 23 56 17 63 25 64 32
n 80 22 99 3 73 29 80 22
aAll chi-square comparisons arc significant at p = .02 or lower.
 Table IH. Distribution of Wing Social Subtypes Across Four Diagnostic Systemsa
DSM-III by psychiatric DSM-III-R by psychiatric DSM-IV by diagnostic ICD-IO by diagnostic
evaluation evaluation algorithm algorithm

Autistic Autistic Childhood

Infantile Autism Other PDD Disorder Other PDD Disorder Other PDD Autism Other PDD
(n = 98) (n = 96) (n = 176) (n = 18) (n = 115) (n = 79) (n = 125) (n = 69)
Aloof
% 38 23 36 0 38 19 30 16
n 37 22 59 0 44 15 38 11
Passive
% 51 47 48 67 49 52 45 58
n 50 46 84 12 55 41 56 40
Active-but-Odd
% 4 19 10 22 8 17 9 16
n 4 18 18 4 9 13 11 11
aAll four chi-square comparisons (Wing Social Types and DSM-III, DSM-III-R, DSM-IV, and ICD-10) are significant at p = .003 or lower.
Diagnosis and Classification in Autism 71

Table I~. Distribution of Wing Social Subtypes Across

qTaxa A and Ba
Active-but-
Aloof Passive Odd
Taxon A
% 29 51 77
n 17 49 17
Taxon B
% 71 49 23
n 42 47 5

aChi-square comparison of "lhxa by Wing Social Subtypes

= 16.56, p = .0001.

Taxa A and B, Social SubO~pes, Diagnostic Groups: Characteristics

Figure 4 displays the frequency of endorsed WADIC items for Taxa

A and B. The Taxon B group had significantly more endorsements for
greeting abnormalities (A3), abnormalities in giving comfort (A5), impaired
social imitation (A6), lack of awareness of social rules (A9), impaired prag-
matics (B1), impaired comprehension (B2), motor stereotypies (C1), and
motor and sensory abnormalities (C2). The Taxon A group had significantly
greater frequency of bizarre speech patterns (B3), prosodic impairments
(B4), impaired symbolizing (B5), and perseverative interests (C6). All chi-
square comparisons were at p = .04 or lower. Taxon B group's WADIC
pattern matched that of DSM-1II Infantile Autism (Figures 3 and 4), and
Taxon A group's WADIC pattern matched the pattern of DSM-III other-
PDD (Figures 3 and 4).
Figure 5 displays profiles of the frequency of endorsed items on
the WADIC for the Wing Social Subtypes. Chi-square comparisons re-
vealed significantly greater frequency of impairment (p = .03 or less)
for the Aloof group than Passive and Active-but-Odd in social play (A8),
pragmatics (B1), and comprehension (B2). The Active-but-Odd group
had significantly greater endorsement for perseverative interests (C6),
and the absence of spontaneous activities (C7). All three groups were
significantly differentiated in motor and sensory abnormalities (C2), and
preoccupations with objects (C3). The pattern of the Aloof group closely
matched that found for Taxon B, and DSM-III Infantile Autism (Figures
3, 4, and 5). The pattern of the Active-but-Odd group closely matched
that found for Taxon A, and for DSM-III other-PDD (Figures 3, 4, and
5).
There were no significant differences in the distribution of boys and
girls for autistic and other-PDD cases for any of the four systems, the two
taxa, or the Wing social subtypes. Chronological age, verbal IQ, and non-
72 Waterhouse et al,

lOO
90
..,- - ...... ~ . . . . ~
80
...........
70
60
50
40
30
20 TAXON A
,,,,,,,,,,,,
lO TAXON B

1
A ..... A2. A3 A4 A5 A6 A7 A8 A9
TAXA A AND B
NINE SOCIAL IMPAIRMENT BEHAVIORS

100
90
80
70
60
50
40
30
20 TAXON A
..... ,,,.,,,
10
TAXON B
0
B1 B2 B3 B4 B5
TAXA A AND B
FIVECOMMUNICATIONIMPAIRMENTBEHAVIORS

1 0 0 "'

I
so
7O

~ 50
~ 4o ,O.o
~ 30 ,Y" "'..
=. 2o "" .:~x:.'."~w"."
10 TAXON B
0 "
C1 C2 C3 C,4 C5 C6 C7
TAXA A AND B
SEVEN RITUAL OR REPETITVE ACTIVITIES

Fig. 4. Comparison of the frequency of endorsed items on the

W A D I C for two groups o f P D D preschool children identified
through statistical analysis as autism "lhxon A (n = 92) and autism
Taxon B (n = 102).
Diagnosis a n d C l a s s i f i c a t i o n in Autism 73

100 ,,,

8or '.~.~\ /..."J ........... ".~.~

70 "".~M.~" "".~
8 60 "-x/
Z
"' 50
Z
u.I 40 ALOOF
~
tu
so
PASSIVE
O. 20 -----
ACTIVE-
10 BUT-ODD

/ A2 A3 A4 A5 A6 A7 A8 A9
WING SUBGROUPS
NINE SOCIAL IMPAIRMENT BEHAVIORS

100-
90-
a 80
uJ
70 ~176176176
...... ~176176176176 ".~176 ~
o ~176176 .'~
60
Z
LU 50
I-.
Z
ILl 40 ALOOF
=o 30
LU
n PASSIVE
20
10 ACTIVE-
BUT-ODD
, ....... ,,.,

1 B2 B3 B4 [35

WING SUBGROUPS
FIVE COMMUNCATION IMPAIRMENT BEHAVIORS

~ 70
60 : ............
O 50 ...::" '

~ 40
ALOOF

20
I -PASSIVE
- ~ ACTIVE-
BUT-ODD
0 ~ ...........
C1 C2 C3 C4 C5 C6 C7

WING SUBGROUPS
SEVEN RITUAL OR REPETITIVE ACTIVITIES
Fig. 5. Comparison of the frequency of endorsed items on t h e
W A D I C for thre~ groups of P D D preschool children identified as
Aloof (n = 59), Passive (n = 96), and Active-but-Odd (n = 22).
 Table V. Chronological Age and IQ for Four Diagnostic Groups, Two Taxa, and Three Wing Social Subtypesa
Chronological age
in months Verbal IQ Nonverbal IQ

n M SD M SD M SD

DSM-III
Infantile Autism 98 60.54 16.77 28.50 17.33 48.96 26.64
Other PDD 96 57.76 15.18 50.00 28.40 77.69 32.33

DSM-III-R
Autistic Disorder 176 59.12 16.20 37.44 24.93 62.30 33.20
Other PDD 18 59.61 14.65 55.72 28.69 72.50 28.46

DSM-1V
Autistic Disorder 115 59.38 15.93 34.14 22.51 57.66 31.38
Other PDD 79 58.85 16.27 46.42 28.50 71.32 33.45

ICD-IO
Childhood Autism 125 60.09 16.53 36.10 23.95 57.70 31.68
Other PDD 69 57.49 15.04 44.65 28.13 73.22 32.78
Taxon A 92 62.90 16.23 55.23 24.53 85.62 28.32
Taxon B 102 55.02 14.05 24.63 16.69 42.87 21.51
Aloof 59 58.54 17.96 30.95 23.12 59.03 34.96
Passive 96 59.34 15.02 38.31 24.90 61.88 32.30
Active-but-Odd 22 59.91 14.76 55.00 26.14 73.68 25.33
aAll verbal and nonverbal IQ ANOVA group comparisons significant at p = .03 or lower. g
 Table VI. Vineland Adaptive Behavior Scores for Four Diagnostic Groups, Two Taxa, and Three Wing Social Subtypesa
Communication Daily Living Maladaptive
domain Domain Motor Domain Social Domain Composite Scales I + II
r

n M SD M SD M SD M SD M SD M SD
DSM-III ~o

IA 98 50.57 12.32 49.76 14.89 59.43 16.19 54.50 9.38 48.78 10.77 20.13 9.56
Other PDD 95 72.96 19.71 66.32 16.13 72.64 16.30 66.60 11.59 63.98 13.93 14.64 7.39
DSM-III-R
AD 175 60.41 19.83 56.71 17.68 64.90 17.17 59.61 11.86 54.84 14.67 18.17 9.04 B
Other PDD 18 73.06 16.02 69.56 11.08 80.39 14.47 68.67 11.90 66.78 10.12 11.93 6.26
DSM-IV
AD 114 58.34 18.75 54.63 17.30 63.90 17.87 58.42 12.48 53.47 14.95 18.44 9.79
Other PDD 79 66.28 20.49 62.63 16.95 69.65 16.43 63.39 11.02 59.54 13.65 16.14 7.63
ICD-IO
CA 124 58.11 20.24 53.86 17.48 63.71 17.00 57.79 11.86 52.91 14.75 19.25 9.19
PDD 69 67.84 17.49 65.17 15.31 70.73 17.57 65.25 11.15 61.62 12.90 14.30 7.69

Taxon A 91 71.10 15.99 70.76 12.12 75.19 15.55 69.73 9.89 67.93 10.47 13.96 7.68
Taxon B 102 47.13 8.41 48.44 13.18 55.71 13.33 52.19 6.78 45.28 8.32 20.45 8.96

Aloof 59 56.51 19.67 52.80 16.63 64.11 16.99 56.27 12.67 51.80 13.89 19.24 9.58
Passive 95 61.23 18.10 59.03 18.15 65.65 17.18 60.27 10.04 55.78 13.93 18.18 8.84
Active-but- 22 77.18 20.21 66.18 10.89 75.25 20.02 67.81 11.53 66.41 13.32 12.88 5.29
Odd
aAll Diagnostic Group and Taxon ANOVA are significant at p = .01 or lower. All but the Vineland Motor Domain ANOVA are significant for the
Wing Social Subtypes at p = .01 or lower.
76 Waterhouse et aL

verbal IQ for autistic and other-PDD cases for the four diagnostic systems,
for the two taxa (A and B), and for the three Wing Social Subgroups are
reported on Table V. Only Taxa A and B were significantly different in age.
We found higher verbal and nonverbal IQ for the four other-PDD groups
than the four autistic groups, and significantly higher verbal and nonverbal
IQ for "Ihxon A than Taxon B. The Wing Social Subtypes were significantly
different in verbal IQ, but not in nonverbal IQ.
Table VI presents the VABS scores for four domains (Communica-
tion, Daily Living, Motor Skills, Social), a VABS composite score, and a
combined score for the VABS Maladaptive Behavior Scales I and II for
autistic and other-PDD for the four diagnostic systems, for Taxa A and
B, and for the three Wing Social Subtypes. Scores for all four autistic
groups were significantly lower than the four other-PDD groups on all
four Vineland domains, and on the Vineland composite score. With the
exception of DSM-1V, the Vineland Maladaptive Behavior Scales I and II
scores were significantly higher for autistic groups than for the other-PDD
groups.
Taxon A and Taxon B groups showed the sharpest differentiation of
Vineland domain and composite scores, with Taxon B lower than A in every
comparison. The Aloof group showed greatest developmental impairment
and the Active-but-Odd group showed the least developmental impairment,
with the Passive subgroup falling in-between.

DISCUSSION

In the introduction we outlined three proposals for the relationship of

autism to PDD: (1) PDD comprising an autistic core with other-PDD re-
mainder groups; (2) PDD comprising an autistic spectrum without a
bounded core; and, (3) PDD comprising two major autistic groups based
on functioning level. We interpret present data as supporting a fourth pro-
posal binding proposals (2) and (3): (4) two major overlapping autistic con-
tinua differentiated by functioning level together forming a large
continuum. We have organized the discussion of our interpretation by ex-
amining the findings as they relate to each proposal.

Proposal 1: Do These Data Support a Bounded Autistic Core?

The present dataset provides problems for the core autism proposal.
Cohen and colleagues (1987) proposed core autism as "autistic individuals
with a nonverbal IQ of 70 or above and/or a global IQ of 55" because they
Diagnosis and Classification in Autism 77

"appear to mirror most closely Kanner's (1943) original description of the

autistic syndrome" (Cohen et al., 1987, p. 30). However, in this sample,
fewer than 20% of what would be core autism cases by four diagnostic
systems (IA, AD, CA) fell within this IQ range. Kanner and Eisenberg
(1956) operationalized Kanner's criteria to include profound lack of affec-
tive contact; (b) preservation of sameness in the child's own elaborate re-
petitive routines; (c) fascination with objects which are handled with skill
in fine motor movements; (d) mutism or language not intended to com-
municate with others; (e) good cognitive potential shown in feats of mem-
ory; and, (f) onset before 30 months. Current diagnostic criteria (DSM-III
IA, DSM-II1-R AD, DSM-IV AD, and lCD-lO CA), however, do not include
"good cognitive potential shown in feats of memory" or "fascination with
objects which are handled with skill in fine motor movements," thus current
criteria are less likely to identify core autism as the high-functioning indi-
viduals Kanner and Eisenberg outlined. In fact, for all four diagnostic for-
mulations it is the group excluded from a diagnosis of core autism that
had the highest IQs.
However, all four diagnostic systems (DSM-III, DSM-III-R, DSM-11(
1CD-IO) do provide diagnostic criteria to identify autistic core groups.
These four autistic groups are all significantly lower in IQ and adaptive
functioning, and express significantly more autistic symptomatology than
the four other-PDD groups that each of these systems excludes from a
diagnosis of autism. Because of these significant differences any one of
these four autistic groups could be justified as a core. Current justifications
for particular sets of criteria, however, do not address the central assump-
tion that a core group exists. Consensus of clinical experts on criteria (DSM-
Ili, III-R, Ill, and 1CD-IO) has generated core paradigms shared by those
clinicians. Appeal to historical precedent for criteria, for example, most
like Karmer's original description (Cohen et al., 1987), frames a core with
a single clinical vision. Evaluating existing core criteria pragmatically for
example, selection of the system with the greatest coverage (Waterhouse;
1994), can only modify the size or character of the core group. Identifying
those criteria that best fit with current clinical practice (e.g., choosing the
highest specificity and sensitivity by generating a statistical "gold standard,"
Szatmari, Volkmar, & Walter, 1995) will only ensure better criterial reali-
zation of an assumed core paradigm.
The present data make the assumption of a single core group ex-
tremely difficult. Most important, all four other-PDD groups in our sample
of 194 subjects expressed an overall pattern of autistic characteristics that
is nearly identical to the pattern found for "core autism" (see Figures 2
and 3). This pattern identity between core autism and other-PDD obtained
even for DSM-III-R, the diagnostic system with the greatest coverage (91%)
78 Waterhouse et al.

for Autistic Disorder. The parallel pattern of abnormal behaviors on the

WADIC (Figures 2 and 3) identifies other-PDD groups as very autistic-like.
The significant differences between core autism and other-PDD on the
Vineland and IQ measures (Tables V and VI) and the greater frequency
of the more severe Aloof subtype in the core autism groups (Table III),
therefore, suggest that differential diagnosis of core autism from other-
PDD depends on degree of developmental compromise rather than pres-
ence or absence of a pattern of autistic syrnptomatology.

Proposal 2: Do These Data Support an Autistic Continuum?

There is support for a continuum of developmental severity in these

data. No matter how few or how many autistic cases a diagnostic system
captured in this sample of 194 (ranging from DSM-I11 IA 98 to DSM-II1-R
AD 176), the positively diagnosed group was always significantly more se-
verely affected than the other-PDD group excluded from a diagnosis of
core autism, nonetheless the other-PDD group still had parallel autistic
pattern symptomatology. Moreover, in a total project combined sample of
505 preschool children (194 PDD children, 201 children with developmen-
tal language disorder, and 110 children with nonautistic mental retarda-
tion), we found the base rate of autistic symptomatology endorsed was very
high for the lowest IQ children and decreased monotonically to zero for
the highest IQ range of the 505 children (Golden, in preparation; Golden,
Dunn, Rapin, & Morris, 1996; Rapin, in press). These data support a de-
velopmental severity continuum of autistic symptomatology.

Proposal 3: Do These Data Support Two Autistic Groups

Within PDD?

Monte Carlo methods applied to the complete dataset of indicators

(V'meland ABS, WADIC, Verbal IQ, Nonverbal IQ, MRC Handicap Sched-
ule, and scores from a neurological examination) suggested a taxonic divi-
sion of the sample of 194 children (Golden, Duma, Rapin, & Morris, 1996;
Rapin, in press). If there were a single developmental severity continuum,
the taxometric analysis would have identified one large continuum of 194
cases. Instead, taxometric analyses have indicated regression nonlinearity
in the combined group of variable indicators. The taxometric analyses,
along with supporting cluster analyses, have identified two overlapping dis-
tributions, and have pointed to the possibility of an underlying hypothesized
neurobiological taxonic factor that would define the two distributions.
Diagnosis and Classification in Autism 79

The significant association of the two taxa with the diagnostic division
of autisrn/other-PDD, and with the W'mg social subtypes, Aloof and Ac-
tive-but-Odd, indicates convergent validity. Taxometric analysis, diagnostic
divisions, and the two Wing subtypes which have been shown to have va-
lidity (Borden & Ollendick, 1994) unite to identify two groups. Group A
includes taxon A/other-PDD/Active-but-Odd and shows significantly higher
cognitive and adaptive functioning and relatively fewer autistic behaviors.
Group B includes Taxon B/autistic/Aloof and shows significantly lower cog-
nitive and adaptive functioning and relatively more autistic behaviors.
Furthermore, the motor-based impairments, including absent social imi-
tation, absent language production, motor stereotypies, and motor and sensory
abnormalities appeared with significantly greater frequency for the Taxon
B/autistic/Aloof groups than for the Taxon A/other-PDD/Active-but-Odd
groups. These motor abnormalities have been interpreted as a general marker
for severity. However, it may be that these motor-based impairments mark a
meaningful symptom cluster identifying Group B autism within the severe end
of the overall continuum of motor impairment. Although the aberrant speech
content and abnormal emotional intonation of Group A autism may appear
as a pseudosymptom cluster because nearly all the children (59/63; 95%) with
little or no speech were included in Group B, and thus did not express either
measurable speech content or intonation, nonetheless presence versus absence
of speech marks a general difference between Group A and Group B. Ritual
and repetitive behaviors that appeared significantly more often in Group A
autism (Taxon A/other-PDD/Active-but-Odd groups) may also mark a mean-
ingful symptom cluster identifying Group A autism within the less severe end
of the overall continuum of autistic social and cognitive impairment.
Finally, data from this sample of preschool children studied at school age
(Dunn, in preparation) indicated that the same two taxa appear in taxometric
analyses of indicator variables in this sample at school age. Taxon A and Taxon
B individuals developed differently: Taxon A individuals at school age showed
improvement in social skills, but an increase and intensifying of ritual and
repetitive activities; Taxon B individuals at school age showed a lessening in
motor stereotypies, and no improvement in social functioning. Communication
skills in both groups improved slightly. These findings suggest support for a
continued taxonic differentiation across development.

Proposal 4: Do These Data Support Two Overlapping Autistic

Continua Within PDD ?

We infer that there are two autistic groups, but they do have overlap-
ping continua of IQ, adaptive functioning, and expressed severity of autistic
80 Waterhouse et al.

symptomatology. We infer that the lower functioning and higher functioning

division serves as a rough indicator of the point of overlap of two continua
of autism. Our inference rests on these fmdings: (a) Clinical diagnosis and
taxometric analysis have shown significant association in identifying an over-
lapping division of two groups; (b) there are symptom clusters that mark
significant differences between the two groups; (c) the two groups have
shown significant developmental stability and continued developmental dif-
ferentiation of the identifying symptom clusters; (d) the character of these
groups was predicted (Tsai, 1992) on the basis of a review of prior research;
(e) cognitive and adaptive functioning level--though most often interpreted
as a confound for understanding "pure" autism--is an extremely powerful
discriminator for the two groups; and yet, (f) the two overlapping groups
together form one large continuum of developmental severity.

Conclusion

As current diagnostic systems determine core autism by counting the

number of autistic abnormalities, and as the number of autistic abnormali-
ties is reciprocally linked to developmental status, diagnostic systems iden-
tify a higher symptom count/lower IQ group as core autism (IA, AD, CA).
We have concluded that diagnostic systems should also separately identify
a lower symptom count/higher IQ autistic group because this higher func-
tioning group: (a) has an autistic symptom profile; (b) is significantly linked
to the autistic social subtype Active-but-Odd; (c) is significantly associated
with a meaningful and developmentally consistent autistic symptom cluster;
and (d) was predicted explicitly on review of research (Tsai, 1992). More-
over, because autistic symptoms are reciprocally related to cognitive and
adaptive functioning, we concur with Cohen et al. (1987) and Tsai (1992)
that functioning level is an integral aspect of each of the two proposed
autistic groups.
Because the two proposed groups have significant behavioral overlap,
it may prove difficult to form clinical criteria. The general pattern of autistic
impairment is similar for both groups, but higher verbal and nonverbal IQ,
presence of speech with bizarre features and impaired prosody, and pres-
ence of perseverative behaviors may identify Group A individuals, while
lower verbal and nonverbal IQ, presence of motor stereotypies and sensory
abnormalities, with significantly impaired language comprehension, and im-
paired social imitation may serve to identify Group B. However, because
of the overlap, clinical diagnosis of the taxa necessarily involve associative
probabilities of levels of verbal and nonverbal IQ for the expression of sev-
Diagnosis and Classification in Autism 81

eral diagnostic variables. Nonetheless, this may offer clinical utility when
established as reference tables (Fein et al., 1996; Rapin, in press).
Researchers have selected small samples of higher IQ/high symptom
count (IA, AD, or CA) autistic individuals in order to improve inferential
power by studying autism as a pure group without the presumptive con-
found of impaired functioning level (Gaffney & Tsai, 1987; Ozonoff, Pen-
nington, & Rogers, 1991; Wainwright-Sharp & Bryson, 1993). We argue that
the findings of the present study suggest that this research strategy is more
likely to capture a mixed group than a pure group because it selects subjects
from the mixed overlap zone of the highest functioning end of the high
symptom/lower IQ group continuum and the low functioning end of the
fewer symptom/higher IQ group continuum. Future studies might fruitfully
include high and low functioning groups of autistic and PDD individuals
to further explore the possibility that there may be two autistic subgroups
of PDD.
Because we excluded all PDD children with known lesions, seizures,
neurological or genetic disorders, in Cohen et al.'s typology (1987) our sam-
ple of 194 PDD children included idiopathic autism (no observable bio-
logical condition) and stigmatic autism ("soft" neurological findings not
clearly marking any known syndrome), but excluded syndromic autism (a
known biological syndrome is diagnosed along with autism). Therefore the
two groups identified in our study may not be successful in characterizing
autism linked to known biological conditions. Moreover, because each of
the two groups comprises a continuum of functioning, it is possible that
there are subgroups within these groups. Further behavioral and neurobi-
ological research is required to determine the coverage, internal structure,
and external validity of two proposed autistic groups.
The present data may have relevance for future family studies of
autism. Our sample of autistic children is comparable to that of a current
large-scale family study (Bolton et al., 1994) in three ways. First, in our
sample we found a rate of 6.6% of siblings with autism or other-PDD
(Rapin, in press). This is consonant with the 5.8% rate of autistic proband
siblings with autism, atypical autism, or Asperger syndrome reported by
Bolton et al. (1994). Second, in our sample, through morphometric analyses
of neural imaging, we found significantly enlarged brain volumes for autistic
and other-PDD cases, with larger volumes for high functioning individuals
than low functioning (Filipek et al., 1992). This is consistent with the in-
creased head circumference in autism that has been reported by Bolton et
al. (1994) and Bailey et al. (1995).
Third, Bolton et al. (1994) reported evidence for a much milder ver-
sion (lesser variant) of autism in some family members of autistic probands.
Our study was not a family study, but we cannot interpret our higher func-
82 Waterhouse et al.

tioning Group A as a lesser variant of autism because (a) they had been
clinically identified as autistic; Co) they showed a complete pattern of autis-
tic symptomatology (Figures 2 and 3); (c) they included the majority of
Active-but-Odd cases; (d) they were identified by taxometric analyses as a
taxa of autism; and, (e) their symptoms were much more severe than that
proposed by Bolton et al. for the lesser variant. However, Bolton et al. did
report that in autistic probands with speech, the number of the proband's
autistic symptoms was significantly associated with number of relatives (de-
gree of familial loading) who expressed the milder version of autism. This
association did not appear in the families of autistic individuals without
speech (Bolton, et al., 1994, p. 892). As the majority of autistic children
in our sample without speech were included in lower functioning Group B
(59/63, 95%), it may be that Bolton and colleagues' findings point to the
possibility of a variant genetic basis for the two groups of idiopathic autism
we have proposed.

APPENDIX A

Wing Autistic Disorders Interview Checklist Items with Interrater Kappas A1

A. Social Impairment kappa

1~ Marked lack of awareness of or attention to the existence of others .92
2. Absence of joint attention or sharing of interests .83
3. Abnormalities of greeting behavior .59
4. Abnormalities in seeking comfort .70
5. Abnormalities in givingcomfort to others .72
6. Impairment of social imitation .75
7. Impaired ability to make friends .89
8. Impairment of pretend play .58
9. Lack of awareness of social rules .62

13. Communication Impairment

1. Abnormalitiesin pragmatics .72
2. Impairedcomprehension .91
3. Bizarrespeech patterns .80
4. Impairedpitch, stress, rate, volume, or rhythm of speech .63
5. Impairedability to express abstract symbolizing .51

C. Ritual or Repetitive Activities

1. Motor stereotypies .85
2. Abnormalsensory or motor behaviors .65
3. Preoccupationwith objects .68

A1Kappas were computed for 81 PDD cases with 6 clinician raters (Waterhouse, 1986).
Diagnosis and Classification in Autism 83

4. Need to maintain sameness in environment .66

5. Fixed routines .70
6. Restricted and/or perseverative interests .77
7. Absence of spontaneous interest and activities .77

APPENDIX B

Diagnostic Algorithm Equivalences

Sample of DSM-1V Algorithms

DSM-IVAutistic Disorder Criteria A (1) (a), p. 70. Marked impairment

in the use of multiple nonverbal behaviors such as eye-to-eye gaze, facial
expression, body postures, and gestures to regulate social interaction.
Algorithm Equivalent = WADIC A(1). Absence or impairment of use
of eye-to-eye gaze, facial expression, body posture and gestures to initiate
and modulate reciprocal interaction.
DSM-IV Autistic Disorder Criteria C, p. 71. The disturbance is not better
accounted for by Rett's Disorder or Childhood Disintegrative Disorder.
Algorithm Equivalent. Coded items from Neurological Examination by a
pediatric neurologist, and coded items from the Developmental History In-
terview with mother or caretaker. Exclusion of any subject meeting criteria
for Rett syndrome by the presence of the following: normal prenatal or per-
inatal development; normal development for the first 6 months; normal head
circumference at delivery; deceleration of head growth up to 4 years of age;
loss of hand skills; emergence of hand wringing stereotypy; social impairment.

Sample of an ICD-IO Algorithm

ICD-IO Childhood Autism Criteria B (1) (d) p. 148.'Lack of spontane-

ous seeking to share enjoyment, interests or achievements with other peo-
ple (e.g., a lack of showing, bringing, or pointing out to other people objects
of interest to the individual).
Algorithm Equivalent = WADIC A (2) (a). Does not spontaneously bring
toys or other possessions to show other people to share pleasure or interest.

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