**3. Autism Spectrum Disorders (ASD)**

nonverbal intelligence has been tested and found to be within the normal range and if there are no apparent sensory or neurological dysfunctions. As [38] points out, SLI is not used if there is an autism-related disorder, but [38] also comment on the fact that "a notable minority of individuals with SLI move across subtypes throughout development" (p. 944). These authors made a review of possible links between different language impairments and autism spectrum disorders and ended up with the recommendation to "concentrate on those aspects of language impairment that predominate in each disorder rather than on those comparatively small areas of potential overlap" (p. 944). There are also several, but rare genetic disorders that cause both problems with language acquisition and autistic traits. Therefore, children with language problems should always be evaluated broadly as [13] pointed out in his formulation of Early Symptomatic Syndromes Eliciting Neurodevelopmental Clinical Examinations, ESSENCE. The speech and language therapist have a central role in the teamwork that scaffolds families with preschool children. However, in line with the ESSENCE thinking, the team must include disciplines representing child development as well as clinical psychologists, physio‐ therapists and social workers. The team must have access to several other consultant serviceschild neurologists, child psychiatrists and sometimes even adult psychiatrists. The latter should preferably have experience of developmental disorders in adults, as parents sometimes

realize that they have or have had similar problems as their children have.

functions and, in case of delays in any ability, to consult other specialists.

of causes as well as symptomatology.

82 Autism Spectrum Disorder - Recent Advances

In line with the ESSENCE thinking, the child is often presented to the pediatrician as a child with a delayed gross motor function, especially delayed walking ability, often before two years of age. It is of great importance for the pediatrician not only to analyze and possibly exclude any neurological pathology behind this, but also to, in collaboration with the physiotherapist, instruct the parents how to stimulate the child´s development of gross motor function during everyday activities. It is also important to assess the level of the child´s development in all aspects including language production as well as comprehension, vision and hearing ability and social interaction. As the parents often at the first visit mainly are aware of the child's gross motor function and language production, the child must be observed and the parents must be asked to describe the level of other abilities. It is highly recommended to see the child regularly during the following years in order to, by watchful expectancy, observe development in all

Language and communication problems occur in different disorders and vary in symptoma‐ tology. Language is a complex skill covering perception as well as production of language and comprises both structural aspects such as phonology, morphology, syntax, and functional aspects, such as use of language in different social contexts, often referred to as pragmatic skill or ability of social communication. Another language skill reflects the meaning of words, the content of language, both in order to understand and interpret, and to retrieve words in narration, a skill which has many labels, i.e. semantic, lexical or vocabulary skill. For these reasons language problems often tend to coexist and be intertwined with other problems, and furthermore they tend to be persistent over time [34] although there is a large heterogeneity

Expressive language problems often elicit early concerns in parents. One reason is that expressive language is fairly easy for parents to notice and possibly take notes of. Another As described above, problems with social communication can, in children with language impairment, be either the main problem or a possible consequence of the weak and vulnerable language. To make the picture even more complex, communication problems are one of the core characteristics in autism spectrum disorders. Although less frequently occurring, problems with structural language, often recognized in specific language impairment, SLI, can also be seen in children with ASD, something that Williams, Botting and Boucher referred to as ASD-LI (2008). Cognitive, communication and language problems are commonly found to co-occur, although in different combinations and levels of severity, which reflects their nature of being complex and heterogeneous. Family studies that found a relation between genetic vulnerability to autism and language impairment revived the interest to more thoroughly study aspects of language in autism [35]. Diagnoses based on mainly communication and language problems are therefore difficult to discriminate and differentiate between [38]. Many trials have been performed with psychometric as well as language tests (i.e. [10]. When the concept of pragmatic language impairment was introduced [5], it became particularly tricky to delineate this kind of language impairment from autism spectrum disorder, in particular in individuals with average or high intellectual functioning. Furthermore these problems not seldom change picture over time [11]. However, it is important to try to discriminate between different symptoms since they might require different types of intervention.

The parents may have worries and questions concerning long time prognosis for their child. When there is a severe developmental problem, as an autism spectrum disorder with intel‐ lectual disability, it is necessary to plan very well in advance for the child's transition into adulthood and adult services [17]. The complete puzzle is laid when child and youth psychia‐ trists, pediatricians, psychologists and speech and language therapist collaborate with adult psychiatrists. Also in adult patients it has been shown that those with developmental problems often had shown the ESSENCE deviances in childhood [31]. Persistent language problems have been shown in long-term follow-ups [12, 19, 24, 34]. [9] made a follow-up of children with developmental language disorders in later adult life and found severe literacy impairments as well as phonological processing problems. Furthermore, they reported unemployment and social problems, i.e. very few close friends.

The prognosis, or the functioning in adulthood is of course depending not only on the degree of communication difficulties, but also on several other factors. Foremost is the individual's general cognitive functioning, or IQ. An intellectual disability, at least in the range of moderate or severe, is generally accompanied by severe language and communication problems, especially in the many cases where there is also an autism spectrum disorder [29]. In these cases, the prognosis is poor, and the individual will need constant support, supervision and augmentative communication also in adult life [2, 26]. As Noens and Van Berckelaer-Onnes highlight, the comprehension problems, including the strong tendency to attend to details rather than, and instead of, "seeing the whole picture" is supposed to be at the core of the communication difficulties.

The same can be said about individuals with autism spectrum disorders and intellectual abilities within the normal range. Many authors have described the so-called weak central coherence as an autism-specific cognitive style, which causes dysfunction and impairment in most situations [15]. This is especially the case in social situations, where the quick and intuitive grasping of the whole situation and thus the meaning in the ongoing communication is essential. Even in cases with good over-all cognitive skills, adults with autism spectrum disorders find it difficult to find work and to keep up relationships [1, 14, 23] since their pragmatic communication skills are not on par with their intellectual level. It can be speculated that the communication difficulties contribute to the vulnerability to psychiatric disorder, which is often seen in these cases [16, 32]. Even when an adult with autism spectrum disorder seeks help in adult psychiatry, communication problems in association with receptive language problems [22], may be an obstacle to diagnosis and treatment.

### **4. Connections and coexistence between LI, SLI and ASD**

In order to prevent negative – and perhaps additional and secondary-consequences of the language delay, e.g. problems with social communication and learning, it is important to identify persistent problems and differentiate them from transient ones. This requires valid and reliable methods of prediction, which seems to be easier at a later age when the variation is not any longer so large. Botting, Faragher, Simkin, Knox and [11] found that narrative skills and expressive syntax were the strongest predictors of future outcome.

seldom change picture over time [11]. However, it is important to try to discriminate between

The parents may have worries and questions concerning long time prognosis for their child. When there is a severe developmental problem, as an autism spectrum disorder with intel‐ lectual disability, it is necessary to plan very well in advance for the child's transition into adulthood and adult services [17]. The complete puzzle is laid when child and youth psychia‐ trists, pediatricians, psychologists and speech and language therapist collaborate with adult psychiatrists. Also in adult patients it has been shown that those with developmental problems often had shown the ESSENCE deviances in childhood [31]. Persistent language problems have been shown in long-term follow-ups [12, 19, 24, 34]. [9] made a follow-up of children with developmental language disorders in later adult life and found severe literacy impairments as well as phonological processing problems. Furthermore, they reported unemployment and

The prognosis, or the functioning in adulthood is of course depending not only on the degree of communication difficulties, but also on several other factors. Foremost is the individual's general cognitive functioning, or IQ. An intellectual disability, at least in the range of moderate or severe, is generally accompanied by severe language and communication problems, especially in the many cases where there is also an autism spectrum disorder [29]. In these cases, the prognosis is poor, and the individual will need constant support, supervision and augmentative communication also in adult life [2, 26]. As Noens and Van Berckelaer-Onnes highlight, the comprehension problems, including the strong tendency to attend to details rather than, and instead of, "seeing the whole picture" is supposed to be at the core of the

The same can be said about individuals with autism spectrum disorders and intellectual abilities within the normal range. Many authors have described the so-called weak central coherence as an autism-specific cognitive style, which causes dysfunction and impairment in most situations [15]. This is especially the case in social situations, where the quick and intuitive grasping of the whole situation and thus the meaning in the ongoing communication is essential. Even in cases with good over-all cognitive skills, adults with autism spectrum disorders find it difficult to find work and to keep up relationships [1, 14, 23] since their pragmatic communication skills are not on par with their intellectual level. It can be speculated that the communication difficulties contribute to the vulnerability to psychiatric disorder, which is often seen in these cases [16, 32]. Even when an adult with autism spectrum disorder seeks help in adult psychiatry, communication problems in association with receptive

In order to prevent negative – and perhaps additional and secondary-consequences of the language delay, e.g. problems with social communication and learning, it is important to identify persistent problems and differentiate them from transient ones. This requires valid

language problems [22], may be an obstacle to diagnosis and treatment.

**4. Connections and coexistence between LI, SLI and ASD**

different symptoms since they might require different types of intervention.

social problems, i.e. very few close friends.

84 Autism Spectrum Disorder - Recent Advances

communication difficulties.

This scenario of complexity and variability both on presentation and longitudinally highlights the importance of working in multidisciplinary teams that include professionals from different clinical disciplines and with focus on a longer perspective from childhood to adulthood. Such early soft signs or symptoms of vulnerability as are understood by the term ESSENCE might reflect developmental problems as well as persistent impairments. The symptoms vary between individuals, and dynamically shift in different contexts as well as over time, i.e. they are heterogeneous and dynamically changing. As described above, one dilemma is that comprehension problems and social communication problems are difficult to identify for parents who are part of the communication themselves. Another dilemma occurs when young children are referred to see different professionals one at a time; this practice makes it difficult to grasp the whole picture, for both the specialists and the parents.

Individuals with language and communication delays require different intervention principles in different ages and contexts. Therefore language and communication impairments as well as autism spectrum disorders can be regarded as relational and contextual.
