Available via license: CC BY 4.0
Content may be subject to copyright.
Citation: Kapp, S.K. Profound
Concerns about “Profound Autism”:
Dangers of Severity Scales and
Functioning Labels for Support
Needs. Educ. Sci. 2023,13, 106.
https://doi.org/10.3390/
educsci13020106
Academic Editors: Amanda
A. Webster, Jacobus G. Maree
and Debra Costley
Received: 4 October 2022
Revised: 12 January 2023
Accepted: 16 January 2023
Published: 19 January 2023
Copyright: © 2023 by the author.
Licensee MDPI, Basel, Switzerland.
This article is an open access article
distributed under the terms and
conditions of the Creative Commons
Attribution (CC BY) license (https://
creativecommons.org/licenses/by/
4.0/).
education
sciences
Review
Profound Concerns about “Profound Autism”: Dangers of
Severity Scales and Functioning Labels for Support Needs
Steven K. Kapp
Department of Psychology, University of Portsmouth, King Henry Building, King Henry I Street,
Portsmouth PO1 2DY, UK; steven.kapp@port.ac.uk
Abstract:
Recently the Lancet published a Commission on the future of care and clinical research
of autism, which included a side panel arguing for the adoption of “profound autism”, a term in-
tended to describe autistic people who require constant supervision or care, thought to usually have
significant intellectual disability, limited or no language, and an inability to advocate for themselves.
This state-of-the-art review deconstructs problems with autism sublabels such as “profound autism”
and low- and high-functioning labels. It then examines the communicative and cognitive capacities
of minimally speaking autistic people, finding that such individuals can communicate (especially
with responsive partners) and need nonverbal testing that allows them to demonstrate their potential
strengths. It concludes with the ability of minimally speaking autistic people to self-advocate, and
the influences of other people to both support and frustrate their communication.
Keywords: support needs; neurodiversity; profound autism; inclusion; education
1. Introduction
Recently the Lancet published a Commission on the future of care and clinical re-
search in autism, which included a side panel that proposed profound autism as an ad-
ministrative term to describe autistic people likely to have high support needs [
1
]. The
Lancet Commission lacks a clear definition or inclusion criteria for “profound autism” but
operationalizes it through IQ at or below 50 (in the verbal or nonverbal domain, or overall)
and/or minimal or inconsistent use of phrase speech [1].
However, because autistic people have complex diversity in our manifestation of
degrees and types of autistic traits and in our support needs, researchers have failed to
clearly validate (e.g., independently replicate) subtypes of autism [
2
]. Even researchers
who have championed the idea of multiple “autisms” [
3
] and described the need to “take
autism apart” [
4
] have abandoned this fruitless quest to instead call for identifying features
that are shared between multiple diagnostic categories, e.g., [
5
]. Indeed, transcending
the neurodiversity of individuals, environmental influences such as acceptance versus
victimization shape development [
6
,
7
]. For example, studies have found that peers are
more likely reject autistic people with subtler or “milder” behavioral presentations of
autism [
8
–
14
], such as the “active but odd” “social interaction style” proposed by Lorna
Wing [
9
,
10
,
15
]. Autistic children with active initiation of prosocial approaches more often
encounter rejection than autistic children with passive approaches [
8
–
10
]. This may explain
why “social initiation and affiliation” shows only a weak relationship to other putative
“subdomains” of autistic people’s social communication [
16
], as people who are able and
motivated to actively initiate may feel less inclined to do so after rejection. Given the
stressful nature of bullying that may target autistic people who appear “odd” rather than
“disabled” [
11
–
14
,
17
–
19
], autistic adolescents’ tendencies to increase in social anxiety even
while (a) their typically developing peers decline in it [20] and (b) their autistic traits tend
to become less behaviorally pronounced [
21
], supports evidence that many peers put them
into victimization spirals even as they try to “camouflage” or fit in [22,23].
Educ. Sci. 2023,13, 106. https://doi.org/10.3390/educsci13020106 https://www.mdpi.com/journal/education
Educ. Sci. 2023,13, 106 2 of 20
Those who argue for reductionist labels often misapply if not misunderstand pioneers
of autism research. While Lorna Wing introduced the notion of an autism “spectrum” [
24
],
she did not intend this in a linear sense, but rather believed in autism’s multi- dimen-
sionality [
25
,
26
]. Some have referred to autism with intellectual disability as “Kanner’s
autism” or “classic autism”, but Leo Kanner in his first paper on autism described the
“unquestionabl[e]
. . .
good cognitive potentialities” of all autistic children he assessed “Even
though most of these children were at one time or another looked upon as fee- bleminded”
and railed against the ability of standardized IQ tests to measure the intelligence of autistic
children [
27
] (p. 247). He decried the “dumped” institutionalization of an autistic girl
dismissed as “feebleminded” who he thus felt had an underestimated ability [
27
]. Con-
cerns remain today that “profound autism” could be used to promote segregation, while
lacking validity.
This evidence-based review argues against reductionist functioning terms and “pro-
found autism” for reasons that overlap with the Lancet Commission’s repeated acknowl-
edgements (e.g., of autistic people’s “heterogeneity” and “potential for change”) [
1
]. It
questions “profound autism”’s limited scientific validity and feasibility in everyday prac-
tice. Next, it argues that the term describes autistics whose limited speech or verbal IQ has
caused many to underestimate their communication and intelligence. The synthesis sug-
gests instead evidence-based personalized provision for each individual’s profile of strengths
and weaknesses, and unity around systemic issues for autistics with the highest support
needs to live the lives they want.
2. Methodology
This article employs a state-of-the-art review in that it addresses the current matter
of the novel “profound autism” category proposed by “The Lancet Commission on the
future of care and clinical research in autism” [
1
]. As opposed to more traditional literature
reviews, a state-of-the-art review offers a new critical perspective on current issues via a
comprehensive review of the literature [
28
]. It conducts its analysis on the current state of
knowledge using narrative synthesis and concludes with priorities for future research [
28
],
focusing its critique on The Lancet Commission’s report and the historical context of failed
attempts at functioning labels and subtypes for autism.
2.1. Research Questions
This state-of-the-art review aimed to address the following four research questions:
(1)
Are functioning labels for autism valid?
(2) Is the intelligence of autistic people with lower verbal IQs, especially autistic people with
intellectual disability according to tests with verbal components, often underestimated?
(3)
Similarly, on which IQ tests do such autistic people tend to fare best?
(4) Overall, is the communication of autistic people with minimal speech underestimated?
2.2. Design
The review initially followed the following inclusion strategy [29,30]:
(1)
All papers published in the journals American Journal of Intellectual and Developmental
Disabilities,Autism,Autism Research,Intellectual and Developmental Disabilities,Journal
of the American Association of Child and Adolescent Psychiatry,Journal of Autism and
Developmental Disorders,Journal of Child Psychology and Psychiatry, and Research in
Autism Spectrum Disorders between 2005 and 2015.
a. Papers cited in relevant articles within these journals and time span.
b. Papers citing relevant articles within these journals and time span.
(2) Searches for (a) “high-functioning” or “low-functioning” autism, (b) nonverbal IQ tests
and IQ tests with verbal and nonverbal components to which the nonverbal IQ tests
have been compared for autistic people (beginning with the “Raven’s” and “Leiter”),
Educ. Sci. 2023,13, 106 3 of 20
and (c) “minimally verbal” in multiple databases (including Pubmed, PSYCHInfo,
and Google Scholar).
Following publication of “The Lancet Commission on the future of care and clinical
re-search in autism” [1], the inclusion criteria came to encompass:
(3)
The Lancet Commission and academic and community sources relevant to a critique
of its:
a. scientific and social validity
b. feasibility
(4)
An updated search related to:
a. “minimally verbal” autism
b. any literature building from the previously identified sources.
(5)
A multi-database search of literature on autism and augmentative and alternative
communication (AAC), in response to reviewer comments requesting content in
this area.
2.3. Data Analysis
Any identified paper related to the research questions, or otherwise known to the
author, was considered for fit, quality, and breadth [
28
,
30
,
31
]. No papers were excluded for
contradicting other findings [29], but instead such results required critical analysis [28].
2.4. Research Type
This article is a state-of-the art review [
28
], adapted [
31
] from a critical narrative re-
view [
28
,
29
]. It is adapted in that the original review (see (1) and (2) in the Design subsection
for its inclusion criteria) was updated to critique the Lancet Commission’s report on the
care and clinical research of autistic people [
1
], and the inclusion criteria grew to cover (3)
to (5) as well. The author felt a state-of-the-art review was more appropriate as the scope of
the various issues raised by the Commission’s report was too broad for a systematic review.
It is critical because the original review, like the review explicated in this article, found that
functioning labels for autism lack validity, IQ tests with verbal components may underes-
timate the intelligence of minimally speaking autistic people, and the communication of
minimally speaking autistic people may be underestimated. Therefore, the author decided
to critique the empirically unsupported or questionable claims of the Lancet Commission,
throughout the article’s analysis of (1) functioning labels, (2) the “profound autism label”,
(3) the communicative and cognitive capacities of minimally speaking autistic people, and
(4) autistic people’s ability and need to self-advocate. My article extensively and flexibly
researches and critically evaluates the literature through narrative synthesis [28].
3. Functioning Labels
3.1. Developmental Gains
Autism varies broadly in manifestations and autistic people have wide differences in
support needs, although these have too much complexity to reduce to simple terms such as
“profound autism” or “low-“ or “high-functioning”. Autistic people tend to make gains
over time, as acknowledged by the Commission’s repeated assertions of autistic people’s
“potential for change”, that often occurs with age and intervention or environmental modi-
fications [
1
]. This includes people the Commission retroactively labelled with profound
autism, who “moved out” of the category through language and IQ improvements [
1
]
(p. 279). It occurred to the point that the term showed poor stability (only 83%) according
to the Commission’s own dataset, compared with autism as a whole (about 91%) [
32
].
This occurred for a cohort assessed at age 12 and reassessed at age 23 [
1
,
33
], yet the Com-
mission claims “profound autism” works best for adolescents and adults [
1
]. Indeed, the
Commission acknowledges that young autistic people with speech delays often improve
dramatically [
1
], yet it says “profound autism” may be applied to “early school age” [
1
]
(p. 278). Most autistics in early childhood with minimal speech may go on to have fluent
Educ. Sci. 2023,13, 106 4 of 20
speech [
34
]. This dovetails with evidence that autistic people with speech onset delay tend
to have strengths over autistic peers without a history of language delay that helps them to
developmentally catch up [35].
3.2. Within-Person Variability
Autistic people experience so much within-person variability in their abilities and
sensory processing that a participatory study recently identified these as core autistic
traits [
36
]. Performance and functioning commonly change for the same tasks for the same
autistic individuals even within the same day [
37
,
38
]. For example, sensory (e.g., visual,
auditory, tactile) processing has shown atypical variability for autistic people [
37
]. Autistics
have described how factors such as their mental state and the control they have over
the environment affect how they perceive sensory stimuli [
39
]. Similarly, autistic people
have shown more variability in their movement for the same tasks over time than people
identified as hyperactive or with tics, i.e., people with ADHD and Tourette’s [38].
3.3. Uneven Skills
Autistic people tend to have highly uneven skills [
36
,
40
], which invalidates the assign-
ment to binary categories such as “high-” or “low-functioning”. Autistic people often have
large discrepancies between verbal and nonverbal IQ scores, with those who have more
limited speech usually performing significantly better on nonverbal IQ tests [
41
]. IQ scores
poorly predict academic achievement for autistic youth [
42
], who usually have verbal
and mathematical strengths (e.g., hyperlexia) or weaknesses (e.g., dyslexia) significantly
different from their overall IQ score [
43
]. Autistic people as a group tend to struggle in
adaptive functioning, with a gap between (low) adaptive behavior and an IQ that rises
with age and test scores. There is especially a mismatch between (low) adaptive behavior
and IQ with higher age and test scores [44–52].
3.4. Social Context
As the Commission states, “a substantial proportion of the risk of poor outcomes is
likely to be socially produced” (p. 277) and “the course of an autistic individual’s develop-
ment is determined by other factors as much as the condition itself” (p. 291), including the
enrichment and modification of the social environment [
1
]. Social context also affects autis-
tic people’s functioning, such as the benefits from parental acceptance of autism [
53
–
57
]
and inclusive educational settings [
58
–
67
]. Moreover, peer
attitudes [11–13]
and a services
drop-off after high/secondary school [
68
–
71
] may disproportionately adversely affect the
functioning of people with subtler autistic traits without intellectual disability. The rest of
this review will explore how the “low-functioning” and “profound autism” labels may
exclude opportunities for and underestimate autistic people. Relatedly, the Neurodevelop-
mental Disorders Workgroup that revised the autism diagnosis in the DSM-5 opposed a
severity scale because autistic people may function well because they have support, sharing
the concern raised by Ari Ne’eman and the Autistic Self Advocacy Network [72,73].
3.5. Need for Support
The DSM-5 Workgroup decided to consolidate all autism diagnoses into one and
opposed a severity scale, not because autistic people all have similar needs, but because
of the above nuances [
40
,
72
,
73
]. What diagnosis on the autism spectrum an individual
received in the DSM-IV era had more to do with the site of assessment they went to
than their individual characteristics [
74
]. Therefore, because the American Psychiatric
Association (APA) imposed some form of severity scale, the classifier became reframed
as being about “need for support” to try to focus on access needs even when individuals
function well [
40
,
73
]. The Workgroup similarly also adopted ASAN’s recommendation
that the levels of need for support “should not be used for eligibility for and provision
of services; these can only be developed at an individual level and through discussion of
personal priorities and targets” [40] (p. 51, 72). Indeed, separate “severity levels” exist for
Educ. Sci. 2023,13, 106 5 of 20
the domains of social communication and restrictive, repetitive behaviors [
40
], so service
providers cannot reduce all autistic people to a single severity level.
How these levels get measured has huge implications if used for services, yet the
DSM-5 does not offer specifics. As the Commission acknowledges, differences in the
methods used to assess intellectual ability, language ability, and autistic traits make a big
difference [
1
]. Against the DSM-5’s advice, systems such as Australia’s National Disability
Insurance Scheme make decisions about eligibility for and the provision of services based
on which “severity level” an autistic person supposedly has. It problematically prioritizes
these severity levels above actual functional assessments [
75
]. As the Commission noted,
autistic people’s support needs have the potential to fluctuate, justifying monitoring and
follow-up assessments [
1
]. However, clinicians and service providers often rely on the
initial diagnostic assessment [
1
], treating the diagnosis as prescriptive when it is more
accurate to think of it as descriptive. Despite recognizing such limitations of clinical practice,
the Commission nevertheless introduces the term “profound autism” that presents further
scientific and practical problems.
4. “Profound Autism” Label
The “profound autism” term recommended by the Lancet Commission [
1
] comes with
several self-contradictions that reflect its limitations. As the Global Autistic Task Force
on Autism Research noted, the term implies that it describes profoundly autistic individ-
uals [
76
]. Instead, it describes co-occurring intellectual disability or structural language
impairment [
1
,
76
], or (implicitly) apraxia of speech (motor problems with speech produc-
tion) [
77
,
78
]. Therefore, it may mislead practitioners and individuals or families to think of
those separately diagnosable disabilities as core autistic traits [
76
]. Moreover, someone with
intellectual disability or language impairment may not have “profound” autistic traits [
76
].
Indeed, autistic traits have only a modest, or even statistically insignificant, relationship
to adaptive functioning [
79
–
83
]. Among minimally speaking autistic people, the number
of words expressed do not clearly relate to autistic traits [
41
]. However, the Commission
defines “profound autism” through cognitive and language skills, even as it admits that
research has explained little about how these or co-occurring conditions “contribute to
responses to different treatments” [1] (p. 291).
The Commission acknowledges that the DSM-5 [
40
] and ICD-11 [
84
] current classifica-
tion systems encourage diagnosing co-occurring intellectual and language impairments
in autistic people [
1
]. Nevertheless, the report notes that these “are not consistently used
in practice or in research” (p. 278) in citing the need for a “profound autism” label [
1
].
This unofficial label would repeat the same DSM-IV problems of inconsistent research
and the practical applications of autism. Indeed, the Commission acknowledges autism’s
“unreliable categorical subtypes” (p. 293), yet it proposes a new one [1].
4.1. IQ below 50
One of the two main pathways to eligibility for “profound autism” is having an IQ
below 50, which the Commission operationalized as being in either the verbal or nonverbal
domain [
1
]. The discrepancy between these domains for such individuals favors nonverbal
scores [
41
], such that someone may have a high nonverbal IQ alongside an extremely low
(if testable) verbal IQ [
85
,
86
]. Some minimally speaking individuals with a high nonverbal
IQ have a good understanding of language [
87
], and their support needs may look quite
different from people who have profound intellectual disability (as the term “profound
autism” may also imply).
Diagnosing “profound autism” in practice risks commonly diagnosing non-autistic
people with severe to profound intellectual disability as autistic. The DSM-5 stipulates
that the diagnosis of autism in the presence of intellectual disability should only occur
when social communication traits exceed those expected for the (nonverbal) developmental
level [
19
], which the Commission generally acknowledges [
1
]. However, among people
with severe to profound intellectual disability, people with and without autism diagnoses
Educ. Sci. 2023,13, 106 6 of 20
may share similar levels of social communication difficulties [
88
]. That data again comes
from adolescents and adults [
84
], the Commission’s recommended period for assigning
“profound autism” [
1
]. It also comes from the first author of the Lancet Commission using
the ADI-R [
89
] and ADOS-2 [
90
] tools the Commission recommended as being better at
differentiating between autism and severe intellectual disability or developmental delay,
whereas most other instruments perform worse [1].
Rather than express concern about the possibility of over-diagnosing non-autistic
people with severe to profound ID as autistic, the Commission advocates for applying
autism interventions to people who do not meet the criteria [
1
] However, this conflicts with
the Commission’s repeated advocacy for personalized, evidence-based assessments and
interventions that consider individuals’ strengths and weaknesses [
1
], considering that
autism-related weaknesses and strengths can inform treatment. Autistic people tend to
have strengths in visual perception [
91
,
92
], which especially apply to autistic people with a
history of speech onset delay and lower scores in verbal comprehension [
93
–
98
], including
those who remain minimally speaking well into childhood [
85
]. These strengths related
to greater core autistic traits [
99
–
101
], perhaps because autistic people can usually take
in greater amounts of visual information [
102
,
103
], but this risks becoming overloading.
Colored filters overlaid onto words enabled autistic children with and without intellectual
disability to read faster than peers matched for receptive vocabulary, whereas peers had
a marginal benefit [
104
]. Other studies reported similar patterns for colored overlays on
photographs for reading facial expressions helping only autistic children [105,106].
4.2. Minimal Speech
In addition to a (verbal or nonverbal) IQ below 50, the Commission describes al-
lowing the eligibility for meeting “profound autism” through a lack of short phrases or
sentences in speech [
1
]. However, autistic individuals may have expressive language or
other communication without speech, especially if they have sensory-motor impairments
such as apraxia of speech [
77
,
78
] and severe dyspraxia of movement [
107
–
109
]. These
render some autistic individuals unable to produce their own speech without affecting an
understanding of language [
78
], but through accessing a communication system they may
express their ideas. While such individuals generally understand more language than they
can convey, the Lancet Commission unfortunately does not necessarily advise assessing
receptive language (only if “this is in question”, p. 296), and never mentions apraxia of
speech [
1
]. Individualized approaches to testing can help minimally speaking autistics
demonstrate receptive language, which may require multiple types of assessments, such as
eye-tracking and responses by touchscreen [86].
Assessment plays a gigantic role in understanding minimally speaking autistics. Stud-
ies vary widely in the measures and definitions they use [
110
]. Five commonly used
instruments to measure “minimally verbal” autistics resulted in an overlap ranging wildly
from 3 to 100% in a sample of 257 children [
91
]. However, the Commission did not offer
specifics in its definition or how to implement it, and indeed applied different definitions
and measurements that contributed to different results [1].
5. Establishing Communicative and Cognitive Competencies in Minimally Speaking
Autistic People
Designation of “profound” or “low-functioning” autism risks creating the false im-
pression that autistic people cannot communicate or advocate for themselves, an assertion
that the Lancet Commission makes about most people they consider to meet criteria for
“profound autism” [
1
] yet minimally speaking autistic children can agree or disagree, re-
quest, label, and respond [
111
]; make clear bids for attention [
112
,
113
]; and gesture [
114
].
Autistic children with minimal to no speech can generally learn from observation [
115
]
and understand and engage with goals [
116
], the syntax of phrases [
117
]), and stories [
118
].
They demonstrate interest and affection (e.g., approach, active gaze, touch) and reciprocal
imitation in response to others’ interactive imitation of their behavior [112,119].
Educ. Sci. 2023,13, 106 7 of 20
5.1. Responsive Communication from Social Partners
Labels such as “profound autism” may cause unintended underappreciation for the
role of social partners in autistic people’s communication. It appears that minimally speak-
ing autistic children often lack sufficient opportunity to engage, since others may act
intrusively instead of following their lead and imitating their unusual behaviors to elicit
their attention [
120
]. They often exhibit difficulties with disengaging their attention (or
a sustained focus that resists distraction), turning their head, and executing intentional
actions alongside possibly enhanced perception that may enable skill in peripheral vision.
These features may give their bids for joint attention atypical and underrecognized manifes-
tations [
121
]. Thus, especially perhaps because of these children’s difficulty with processing
and producing quick and well-coordinated body language, slower facial expressions and
other nonverbal cues from their communication partners help autistic children and adoles-
cents with limited speech to imitate [
122
]. Similarly, parents’ observation of clinical sessions
that model how to interact with their minimally speaking autistic child of elementary school
age, and the first month of training on how to communicate with their child produced the
greatest gains for parents’ implementation of an intervention for joint engagement with
their child [
123
]. The parents’ fidelity drove the shared engagement [
73
] that helped the
children produce language gains [
124
] through a greater initiation of interactions [
125
].
Parents’ use of strategies that synchronize their behavior in response to their child’s, such
as matching their child’s pace, mainly account for the gains of this intervention across
developmental levels [126].
5.2. Educational Inclusion
Such responsive rather than directive communication especially helps speech-delayed
autistic people to build language and cognitive skills [
127
–
130
]. Responsive approaches
require an understanding of the individual to follow their lead and focus of interest,
yet autistic and non-autistic people often struggle to understand one another [
131
–
133
].
Early maternal understanding of and bond with their autistic child accounted for the
child’s placement in an inclusive educational setting, beyond the effects of the child’s IQ
or interpersonal competence [
63
]. Perhaps reflecting difficulties relating to their autistic
children, parents have more often preferred inclusion for children with Down syndrome
rather than autistic children [
134
]. Low IQ has also influenced placement decisions for
autistic children [
135
,
136
]. Higher levels of education inclusion relate to the better func-
tioning of autistic youth, including with intellectual disabilities, beyond the effects of
demographic and individual characteristics [
59
]. The Lancet Commission likewise recog-
nized and documented the evidence base of intellectual, educational, academic, and other
improvements from educational inclusion for autistic children and adolescents of various
abilities [1,114–117]
. This evidence underlines the travesty that historically befell children
with intellectual disabilities who were assigned diagnoses of idiot,imbecile, and moron and
graded for their supposed educability [137,138].
5.3. Augmentative and Alternative Communication
Segregated settings for autistic children may cause them to suffer from the lack of
typically developing peers as classmates as well as lower expectations and educational
quality, such as less instruction and a focus on applied skill development [
60
–
62
,
139
,
140
].
In a classroom of minimally speaking autistic children, the classroom quality lacked an
association with their IQ scores and the adults at school missed many of their frequent
communication attempts, limiting them to little engagement mostly with aides [
139
]. Only
one child in a study of 36 minimally speaking autistic students in segregated classrooms
used an AAC device and he had among the greatest communication [
139
]. In the U.S., most
special education teachers who supported students with complex disabilities using AAC
identify challenges such as a lack of training and of comprehensive assessment, inadequate
preparation time, and inconsistent implementation of AAC across staff [
141
]. Similarly, in
Saudi Arabia, special education teachers recognized the school as the biggest barrier to
Educ. Sci. 2023,13, 106 8 of 20
student access to AAC and professionals’ need for training, but family members’ support
also played a role [
142
]. Indeed, the perceived value of both parents and professionals
toward AAC affect whether and how it becomes used [
143
]. Unfortunately, many parents,
teachers, clinicians, and other practitioners falsely believe AAC may interfere with their
minimally speaking autistic child’s language development [144].
Instead, AAC can be used to teach a variety of communicative functions, and all
systematically reviewed studies showed improvements in communication skills, with the
strongest effects for speech-generating devices (SGDs) and communication boards [
145
];
also see [
146
–
148
]. The study with the strongest quality of evidence [
145
] showed that an
SGD-assisted tablets enabled more speech and communication for minimally speaking
autistics [
124
], an effect maintained over time [
149
]. Individual preference also influences
which AAC devices help students gain reliable access to communication [150].
Eye-tracking may help to design even better AAC systems for minimally speaking
autistic children [
151
], given their reduced demands [
152
]. For example, studies from
autistic children suggest that using less realistic and less socially complex images and
showing the displays for long enough for them to interpret may help [
151
]. Minimally
speaking autistic children have had less success with eye-tracking trials (60%: [
82
]) than
the rates of the above 80% for non-autistic children with intellectual disability and 90% for
autistic children without intellectual disability [
152
]. Perhaps significant eye-movement
problems complicate eye-tracking use; poor oculomotor control relates to lower IQs for
both autistic and non-autistic children [153].
5.4. Nonverbal IQ Testing
Searching for strengths, especially among those with less language, may help them
to communicate and demonstrate their intelligence. The following section will argue that,
among IQ tests, minimally speaking autistic people tend to perform best on the Raven’s
(Colored) Progressive Matrices, followed, respectively, by the Leiter,
Stanford–Binet
, and
Weschler. A study recruited 30 autistic children ages six to 12 with minimal or no spoken
language attending schools for profoundly impaired autistic children, who could not
complete a standard IQ test with a verbal component (the Wechsler). Almost all could
complete a nonverbal IQ test that taps into many autistic people’s visual–spatial skills
(the Raven’s Colored Progressive Matrices), and related visual–spatial tasks (a visual
search task, and the Children’s Embedded Figures Test). Raven’s scores varied extremely
but the children scored an average IQ of 83, well outside of intellectual disability and
nearly within a standard deviation of typical. The autistic children performed faster than
Raven’s-matched typically developing children, with positive relationships among their
performance on the tests. These results indicate that many children potentially considered
“low-functioning” or “untestable” show autism-typical perceptual strengths; recognizing
them may help tap into their abilities or potential [
85
]. Indeed, tasks and interventions that
use adaptations such as visual supports help to unveil stronger understanding than the
expression of language among many minimally verbal autistic children [117,118].
Another study likewise found that autistic children who could not complete tests
with verbal IQ scores such as the Wechsler had a mean at the boundary of the normal
range of intellectual performance on both the original and revised nonverbal Leiter IQ
test, with strengths in visual processing [
154
]. Their findings parallel the mean IQ at
the border of the average range for autistic children on the Leiter at a time (1985) when
autism had much more restricted criteria, which surpassed that of the Wechsler [
155
].
Similar to Courchesne and colleagues’ results through the Raven’s test [
85
], Krueger [
139
]
found an extreme range of scores on the Leiter test among the 28 able to complete it in
a sample of 36 minimally speaking autistic children, with a child in both samples at the
90th percentile (equivalent of IQ of 120). Studies using the Leiter with autistic children
classified as intellectually disabled, “minimally verbal”, or untestable on IQ tests with
verbal components have consistently reported a mean score at least near the threshold of
the average range of intellectual ability: 65 to 72 [
124
,
154
–
156
]. Another study finding a
Educ. Sci. 2023,13, 106 9 of 20
mean in the intellectual disability range (66.5) on the classic Stanford–Binet Intelligence
Scales for autistic children reported a score fully within the average range (88) on the
Leiter [
157
]. Courchesne et al. [
85
] argue the superiority of the Raven’s over the Leiter for
most autistic people, with the mean they reported comparable to the much more verbal
children in Grondhuis and Mulick’s [157] sample.
Ravens’ greater appropriateness over even the Leiter, especially for autistic children
with the lowest language [
85
], may support the notion that most minimally speaking
autistic people qualify as “high-functioning” if defined by an IQ above 70. The Leiter
has resulted in higher scores for most autistic people over not only the Wechsler and
Stanford–Binet
tests but also the Kaufmann (KBIT-2) scale, even when compared with
peers with language impairments [
158
]. The Leiter and nonverbal IQ of the KBIT-2 almost
exactly matched means for autistic children (above 86), while the average verbal IQ on
the KBIT-2 again scored in the intellectual disability range (below 67: [
158
]. In turn, the
nonverbal IQ of the Kaufmann test resulted in higher scores for autistic children than the
Wechsler. Three quarters classified within the mild intellectual disability or below average
ranges on the Weschler compared with the same proportion scoring in the average or above
average ranges on the Kaufmann, with none in that highest range on the Weschler [
159
].
Timing constraints of the Weschler apparently contributed to the discrepancy in this study,
as autistic children in this study performed slowly on subtests other than Block Design [
159
].
That task taps into visuospatial abilities, which several studies have replicated as an area of
strength, particularly for autistic people with lower verbal IQ scores [
160
]. Carothers and
Taylor [
161
] analyzed additional problems of how the challenges of autism and the design
of the Wechsler may deflate IQ scores.
This analysis of IQ tests and their applications has shown that the IQ of autistic people
with language impairments is often underestimated. The publication date of the studies
using the Leiter nonverbal test covered above ranged from 1985 to 2022 [
124
,
139
,
154
–
156
].
In 1987, prevailing views in the autism field included that three quarters of autistic children
possessed intellectual disability and that intelligence tests did not underestimate autistic
children’s intelligence [
162
]. Teachers and especially parents often resisted [
163
], and
by the mid-2010s scientific research overturned [
164
,
165
] these beliefs as misconceptions.
This brought research full circle to the original accounts of autism, which declared the
cognitive potential of all autistic people and, at times, the inadequacy of standard measures
of intelligence or otherwise to assess their abilities [
27
,
166
,
167
]. Furthermore, the analysis
of claims that most autistic people have intellectual disability suffer from serious empirical
problems, such as the fact that most studies repeating this long-standing claim measured
development or adaptive behavior rather than intelligence [168,169].
Critics might point out that, in some minimally speaking people, measured expres-
sive [
78
] and even receptive language [
78
,
170
] does not relate to a nonverbal IQ yet this
means that an autistic person may have little language but a high IQ; families, schools,
and clinicians are likely underestimate their intelligence. Critics might also point out
that some minimally speaking autistic people test on the floor even on the Ravens [
86
].
However, tests may generally underestimate autistic people, who may choose to engage
little in them [
86
,
171
]. Adaptations such as for visual support [
118
], timing [
117
], and at-
tention [
172
] may help to produce higher scores. Autistic people generally do not perform
on command for audiences, which has accounted for why some have scored low on tasks
measuring supposed core deficits, such as in ‘theory of mind’ [173].
6. Recognizing the Self-Advocacy of Autistic People
As the Lancet Commission says, meeting autistic people’s needs requires our inclusion
and participation, and must consider our preferences [
1
]. However, the Lancet Commission
has little focus on self-advocacy, and few autistic people contributed to it [
74
]. Indeed,
autistic advocates and autistic researchers have lined up against “profound autism”, just as
we did against functioning labels [74,174,175].
Educ. Sci. 2023,13, 106 10 of 20
6.1. A Call for Calm
While the Commission reports that “profound autism” concept often means minimal
ability to self-advocate, this appears to discount the communication and self-advocacy of
autistic people limited by language. As the late nonspeaking autistic advocate Mel Baggs
said, “When people generally said to be incapable of communication find ways of making
clear what they do and don’t want through means other than words, this is self-advocacy”
(p. 223). Baggs clarified that self-advocacy includes what some refer to as behavioral
problems in response to abuse or violence against them [
176
]. For example, bidirectional
effects exist between autistic people’s externalizing behaviors and parental distress or criti-
cism, but they appear more driven by parents’ impacts on their children [
177
,
178
]. People
may tend to underestimate a trend for self-other emotional blurring in autistic people
associated with affective sharing in a variety of contexts that may lead to dysregulation
from overarousal. For example, autistic people experience heightened distress in response
to parents’ distress [
178
–
180
], or embarrassment [
181
] and anger [
182
] in reaction to other’s
such emotions outside the family. Emotional dysregulation may constitute a core feature of
autism [
183
], and anxiety overlaps with core traits in various domains [
184
]. Anxiety often
manifests atypically in autistic people, such as the possibly automatic “flight” or “freeze”
responses of shutdowns, avoidance, or withdrawal [
185
,
186
] and the “fight” responses of
meltdowns (externalizing frustration as aggression or irritability [
187
,
188
]). Non-autistic
people often misunderstand autistic people’s facial expressions [
189
,
190
], further compli-
cating an understanding of the emotions of a minimally verbal autistic person. Autistic
people’s relationships with teachers often fares better than with parents [
191
,
192
] (although
both may function well [
193
]), which may help to explain why autistics may demonstrate
more externalizing behavior around their parents than teachers [
194
–
196
]. Certainly, a
positive teacher-student relationship promotes academic engagement [197].
6.2. Relevance of Neurodiversity
Moreover, the claim of a limited ability to self-advocate for individuals labelled with
“profound autism” [
1
] might have unintended consequences for discrediting the relevance
of any advocacy autistic people make on their behalf. Autistic activists’ attempts to speak
on behalf of fellow autistics often encounter resistance. These include designations as either
“too autistic” to have insight or “not really autistic” and thus not representative because
of their articulate capacities. Similarly, critics have defined “functioning” in terms of an
ability to effectively communicate and autism advocacy as focused on “low-functioning”
individuals [198–201].
Likewise, many classify the neurodiversity movement as only inclusive of or rel-
evant for “high-functioning” people, or—as the Lancet Commission hinted—as against
all treatment or mitigation of autistic people’s core struggles [
1
], despite evidence to the
contrary [
202
,
203
]. In 1992, autistic rehabilitation counselor Jim Sinclair co-founded the
neurodiversity movement that originated with autism, and galvanized autistic culture
and community through coordinating the first autistic-run autism organization: Autism
Network International (ANI; [
204
,
205
]). The founders all had speech delays as children,
such as Sinclair’s which was onset at age 12 [
204
], who noted “we had all fit descriptions of
‘low functioning’ autistic people when we were younger” [
205
] (p. 22). Sinclair [
206
] em-
phasizes developmental principles such as the importance that parents learn to speak their
child’s language for the growth and well-being of the family. This need finds widespread
agreement among self-identified autistic people and non-autistic people regardless of
neurodiversity views [202].
Perhaps some confusion about neurodiversity stems from the views of the main coiner
of the term neurodiversity, Judy Singer. As she stated regarding her thesis, the first time
neurodiversity appeared in print within the autistic community, “My thesis made clear
from the start that I was only advocating for people with high-functioning autism, (or
the Syndrome-formerly-known-as-Asperger) when I argued that Aspies should view our-
selves as a neurological minority, and that our focus should be on minority rights, not
Educ. Sci. 2023,13, 106 11 of 20
medicalization” [
207
] (p. 15). However, autistics active in the neurodiversity movement
have denounced “aspie supremacy” [
208
,
209
], acknowledge both difference and disabil-
ity [
210
,
211
], and advocate for supports that ameliorate aspects of autism that threaten
quality of life [
202
]. For example, the movement has prioritized AAC and meaningful com-
munication for all autistic people [
212
]. Organizations such as the Autistic Self Advocacy
Network promote services that particularly benefit people with the highest support needs,
such as home- and community-based services for people to live in their own home with
the support they need [213].
The tendency for greater support for the neurodiversity movement or opposition
to autism’s medical model among autistic people includes autistic people who are close
to other autistic people with intellectual disability or non-speaking autistic people [
214
].
Furthermore, both autistic and non-autistic people who are close to non-speaking autis-
tic people tend to have enhanced support for the notion that “Autistic people who can
communicate their needs should play a leading role in the development of intervention
goals” [
214
]. Similarly, parents’ acceptance of their child’s autism [
53
–
55
,
215
] and positive
emotions toward their autistic child [
216
] do not relate to their autistic child’s core traits
or support needs, or, if anything, acceptance grows as their child’s autism becomes more
apparent [
217
]. These studies suggest the potential for consensus in helping autistic people
to express their needs and listening to them when they do.
6.3. A Call for Unity
A unified autism diagnosis can allow practitioners to provide support at a personalized
level with the recognition of individual strengths and needs; developmental, psychiatric,
and medical co-occurring conditions; and demographic and social factors. Advocates have
more strength in numbers to find a common cause with people with other disabilities
for cross-disability systems change, so more people can live happy, safe, self-determined
lives in the community. As the Lancet Commission acknowledges, around the world
autistic adults often lack access to services, and biomarkers have not usefully helped
autistic people [
1
]. Instead, governments and research organizations can fund more applied
services research (including for adults), which may benefit many non-autistic disabled
people as well. Research has identified interventions to increase self-determination in
high school for students with intellectual disabilities [
218
,
219
], which can be adapted as
needed for autistic people with intellectual disabilities. Interviews can creatively include
minimally speaking autistic youth where possible to discuss what they would like in their
future, such as one with an IQ of 33 [
220
]. With the right support (perhaps consultation
with organizations such as ASAN), many parents may elect for supported decision-making
rather than guardianship, to help autistic people with the highest support needs make
choices about their lives. Indeed, the Commission advocates for “shared decision-making
that takes into account patient and family preferences and resources” (p. 283) [
1
], yet
its rhetoric about “profound autism” might inadvertently encourage parents to conserve
their children.
With systems change more people can live like Joaquin, a minimally speaking autistic
man regarded as having significant intellectual disability, with a history of aggression,
self-injury, and seizures. He lives in his own house in the community with around-the-
clock paid support staff, friendly neighbors who accept him, and chores and walks in the
community he enjoys. His nearby sister, Diana Pastora Carson, understands his limited
speech that may seem meaningless to a stranger, and together they advocated to get him
out of an institution [221].
7. Conclusions
Let us always consider the transactional dynamics of communication and have humil-
ity when we do not understand others’ communicative acts. We also need to have humility
about the vague terms that define “profound autism” and our ability to measure capacities
and needs, remembering that the choice of assessment (such as an inappropriate IQ test
Educ. Sci. 2023,13, 106 12 of 20
with verbal components) may have serious consequences for the individual. Indeed, the
implementation of “profound autism” could backfire into service providers only offering
services to autistic people who meet that designation, applied conservatively (restrictively)
in definition and measurement (e.g., IQ below 50 on the Raven’s). Overall, we must strive
for inclusion in society and not use terms to promote segregation.
Funding: This research received no external funding.
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Not applicable.
Data Availability Statement: Not applicable.
Acknowledgments:
The author would like to thank Shannon Des Roches Rosa, Kristen Bottema-
Beutel, Ruth Kapp, Amy Pearson, and Kim Bard for their comments on earlier versions of the article.
He would like to thank Guest Editor Amanda A. Webster and reviewers for their helpful comments.
Conflicts of Interest: The author declares no conflict of interest.
References
1.
Lord, C.; Charman, T.; Havdahl, A.; Carbone, P.; Anagnostou, E.; Boyd, B.; Carr, T.; de Vries, P.J.; Dissanayake, C.; Divan, G.; et al.
The Lancet Commission on the future of care and clinical research in autism. Lancet 2022,399, 271–334. [CrossRef] [PubMed]
2.
van Rentergem, J.A.A.; Deserno, M.K.; Geurts, H.M. Validation strategies for subtypes in psychiatry: A systematic review of
research on autism spectrum disorder. Clin. Psychol. Rev. 2021,87, 102033. [CrossRef] [PubMed]
3. Coleman, M.; Gillberg, C. The Autisms; Oxford University Press: Oxford, UK, 2012.
4. Waterhouse, L.; Gillberg, C. Why autism must be taken apart. J. Autism Dev. Disord. 2014,44, 1788–1792. [CrossRef] [PubMed]
5.
Waterhouse, L. Heterogeneity thwarts autism explanatory power: A proposal for endophenotypes. Front. Psychiatry
2022
,
13, 947653. [CrossRef] [PubMed]
6.
Sameroff, A. A unified theory of development: A dialectic integration of nature and nurture. Child Dev.
2010
,81, 6–22. [CrossRef]
7.
Swearer, S.M.; Hymel, S. Understanding the psychology of bullying: Moving toward a social-ecological diathesis–stress model.
Am. Psychol. 2015,70, 344. [CrossRef]
8.
Jones, A.P.; Frederickson, N. Multi-informant predictors of social inclusion for students with autism spectrum disorders attending
mainstream school. J. Autism Dev. Disord. 2010,40, 1094–1103. [CrossRef]
9.
Scheeren, A.M.; Koot, H.M.; Begeer, S. Social interaction style of children and adolescents with high-functioning autism spectrum
disorder. J. Autism Dev. Disord. 2012,42, 2046–2055. [CrossRef]
10.
Sreckovic, M.A.; Brunsting, N.C.; Able, H. Victimization of students with autism spectrum disorder: A review of prevalence and
risk factors. Res. Autism Spectr. Disord. 2014,8, 1155–1172. [CrossRef]
11.
Libster, N.; Knox, A.; Engin, S.; Geschwind, D.; Parish-Morris, J.; Kasari, C. Personal victimization experiences of autistic and
non-autistic children. Mol. Autism 2022,13, 51. [CrossRef]
12.
Rowley, E.; Chandler, S.; Baird, G.; Simonoff, E.; Pickles, A.; Loucas, T.; Charman, T. The experience of friendship, victimization
and bullying in children with an autism spectrum disorder: Associations with child characteristics and school placement. Res.
Autism Spectr. Disord. 2012,6, 1126–1134. [CrossRef]
13.
Shtayermman, O. Peer victimization in adolescents and young adults diagnosed with Asperger’s syndrome: A link to depressive
symptomatology, anxiety symptomatology and suicidal ideation. Issues Compr. Pediatr. Bursing
2007
,30, 87–107. [CrossRef]
[PubMed]
14.
Shtayermman, O. An exploratory study of the stigma associated with a diagnosis of Asperger’s syndrome: The mental health
impact on the adolescents and young adults diagnosed with a disability with a social nature. J. Hum. Behav. Soc. Environ.
2009
,
19, 298–313. [CrossRef]
15.
Wing, L.; Gould, J. Severe impairments of social interaction and associated abnormalities in children: Epidemiology and
classification. J. Autism Dev. Disord. 1979,9, 11–29. [CrossRef] [PubMed]
16.
Zheng, S.; Kaat, A.; Farmer, C.; Kanne, S.; Georgiades, S.; Lord, C.; Esler, A.; Bishop, S.L. Extracting latent subdimensions of social
communication: A cross-measure factor analysis. J. Am. Acad. Child Adolesc. Psychiatry 2021,60, 768–782. [CrossRef] [PubMed]
17.
Feldman, D.B.; Crandall, C.S. Dimensions of mental illness stigma: What about mental illness causes social rejection? J. Soc. Clin.
Psychol. 2007,26, 137–154. [CrossRef]
18. Hinshaw, S.P.; Stier, A. Stigma as related to mental disorders. Annu. Rev. Clin. Psychol. 2008,4, 367–393. [CrossRef]
19.
Weiner, B. On sin versus sickness: A theory of perceived responsibility and social motivation. Am. Psychol.
1993
,48, 957–965.
[CrossRef]
20.
Kuusikko, S.; Pollock-Wurman, R.; Jussila, K.; Carter, A.S.; Mattila, M.L.; Ebeling, H.; Pauls, D.L.; Moilanen, I. Social anxiety
in high-functioning children and adolescents with autism and Asperger syndrome. J. Autism Dev. Disord.
2008
,38, 1697–1709.
[CrossRef]
Educ. Sci. 2023,13, 106 13 of 20
21.
Shattuck, P.T.; Seltzer, M.M.; Greenberg, J.S.; Orsmond, G.I.; Bolt, D.; Kring, S.; Lounds, J.; Lord, C. Change in autism symptoms
and maladaptive behaviors in adolescents and adults with an autism spectrum disorder. J. Autism Dev. Disord.
2007
,37, 1735–1747.
[CrossRef]
22.
Chapman, L.; Rose, K.; Hull, L.; Mandy, W. “I want to fit in
. . .
but I don’t want to change myself fundamentally”: A qualitative
exploration of the relationship between masking and mental health for autistic teenagers. Res. Autism Spectr. Disord.
2022
,
99, 102069. [CrossRef]
23.
Pearson, A.; Rose, K.; Rees, J. ‘I felt like I deserved it because I was autistic’: Understanding the impact of interpersonal
victimisation in the lives of autistic people. Autism 2022. [CrossRef] [PubMed]
24.
Wing, L. Differentiation of retardation and autism from specific communication disorders. Child Care Health Dev.
1979
,5, 57–68.
[PubMed]
25. Wing, L. Reflections on opening Pandora’s box. J. Autism Dev. Disord. 2005,35, 197–203. [CrossRef] [PubMed]
26.
Silberman, S. Neurotribes: The Legacy of Autism and How to Think Smarter about People Who Think Differently; Atlantic Books: London,
UK, 2017.
27. Kanner, L. Autistic disturbances of affective contact. Nerv. Child 1943,2, 217–250.
28.
Grant, M.J.; Booth, A. A typology of reviews: An analysis of 14 review types and associated methodologies. Health Inf. Libr. J.
2009,26, 91–108. [CrossRef]
29.
Greenhalgh, T.; Wieringa, S. Is it time to drop the ‘knowledge translation’metaphor? A critical litera-ture review. J. R. Soc. Med.
2011,104, 501–509. [CrossRef]
30.
Pillay, I. The impact of inequality and COVID-19 on education and career planning for South African children of rural and
low-socioeconomic backgrounds. Afr. J. Career Dev. 2021,3, 7. [CrossRef]
31.
Maree, J.G. Rekindling hope and purpose in resource-constrained areas during COVID-19: The merits of counselling for career
construction. S. Afr. J. Sci. 2022,118, 1–7. [CrossRef]
32.
Eigsti, I.M.; Fein, D.; Larson, C. Editorial Perspective: Another look at ‘optimal outcome’in autism spectrum disorder. J. Child
Psychol. Psychiatry 2022,64, 332–334. [CrossRef]
33.
Simonoff, E.; Kent, R.; Stringer, D.; Lord, C.; Briskman, J.; Lukito, S.; Pickles, A.; Charman, T.; Baird, G. Trajectories in symptoms
of autism and cognitive ability in autism from childhood to adult life: Findings from a longitudinal epidemiological cohort. J. Am.
Acad. Child Adolesc. Psychiatry 2019,59, 1342–1352. [CrossRef] [PubMed]
34.
Maltman, N.; DaWalt, L.S.; Hong, J.; Mailick, M. Brief report: Socioeconomic factors associated with minimally verbal status in
individuals with ASD. J. Autism Dev. Disord. 2021,51, 2139–2145. [CrossRef]
35.
Kapp, S.K. The Strengths of Speech Delay: Getting a Grip on the Sensory-Motor Complexity of Autism. 2022; unpub-
lished manuscript.
36.
Ratto, A.B.; Bascom, J.; daVanport, S.; Strang, J.F.; Anthony, L.G.; Verbalis, A.; Pugliese, C.; Nadwodny, N.; Brown, L.X.; Cruz,
M.; et al. Centering the Inner Experience of Autism: Development of the Self-Assessment of Autistic Traits. Autism Adulthood
2022. [CrossRef]
37. Haigh, S.M. Variable sensory perception in autism. Eur. J. Neurosci. 2018,47, 602–609. [CrossRef] [PubMed]
38.
Geurts, H.M.; Grasman, R.P.; Verté, S.; Oosterlaan, J.; Roeyers, H.; van Kammen, S.M.; Sergeant, J.A. Intra-individual variability
in ADHD, autism spectrum disorders and Tourette’s syndrome. Neuropsychologia 2008,46, 3030–3041. [CrossRef]
39.
Robertson, A.E.; Simmons, D.R. The sensory experiences of adults with autism spectrum disorder: A qualitative analysis.
Perception 2015,44, 569–586. [CrossRef]
40.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th ed.; American Psychiatric Publishing:
Arlington, VA, USA, 2013.
41.
Bal, V.H.; Katz, T.; Bishop, S.L.; Krasileva, K. Understanding definitions of minimally verbal across instruments: Evidence for
subgroups within minimally verbal children and adolescents with autism spectrum disorder. J. Child Psychol. Psychiatry
2016
,
57, 1424–1433. [CrossRef]
42.
Estes, A.; Rivera, V.; Bryan, M.; Cali, P.; Dawson, G. Discrepancies between academic achievement and intellectual ability in
higher-functioning school-aged children with autism spectrum disorder. J. Autism Dev. Disord. 2011,41, 1044–1052. [CrossRef]
43.
Jones, C.R.; Happé, F.; Golden, H.; Marsden, A.J.; Tregay, J.; Simonoff, E.; Pickles, A.; Baird, G.; Charman, T. Reading and
arithmetic in adolescents with autism spectrum disorders: Peaks and dips in attainment. Neuropsychology
2009
,23, 718–728.
[CrossRef]
44.
Alvares, G.A.; Bebbington, K.; Cleary, D.; Evans, K.; Glasson, E.J.; Maybery, M.T.; Pillar, S.; Uljarevi´c, M.; Varcin, K.; Wray, J.; et al.
The misnomer of ‘high functioning autism’: Intelligence is an imprecise predictor of functional abilities at diagnosis. Autism
2020
,
24, 221–232. [CrossRef]
45.
Balfe, M.; Tantam, D. A descriptive social and health profile of a community sample of adults and adolescents with Asperger
syndrome. BMC Res. Notes 2010,3, 300–306. [CrossRef] [PubMed]
46.
Kanne, S.M.; Gerber, A.J.; Quirmbach, L.M.; Sparrow, S.S.; Cicchetti, D.V.; Saulnier, C.A. The role of adaptive behavior in autism
spectrum disorders: Implications for functional outcome. J. Autism Dev. Disord. 2011,41, 1007–1018. [CrossRef] [PubMed]
47.
Klin, A.; Saulnier, C.A.; Sparrow, S.S.; Cicchetti, D.V.; Volkmar, F.R.; Lord, C. Social and communication abilities and disabilities
in higher functioning individuals with autism spectrum disorders: The Vineland and the ADOS. J. Autism Dev. Disord.
2007
,
37, 748–759. [CrossRef] [PubMed]
Educ. Sci. 2023,13, 106 14 of 20
48.
Lee, H.J.; Park, H.R. An integrated literature review on the adaptive behavior of individuals with Asperger syndrome. Remedial
Spec. Educ. 2007,28, 132–139.
49.
Levy, A.; Perry, A. Outcomes in adolescents and adults with autism: A review of the literature. Res. Autism Spectr. Disord.
2011
,
5, 1271–1282. [CrossRef]
50.
Myles, B.S.; Lee, H.J.; Smith, S.M.; Tien, K.-C.; Chou, Y.-C.; Swanson, T.C.; Hudson, J. A large-scale study of the characteristics of
Asperger syndrome. Educ. Train. Dev. Disabil. 2007,42, 448–459.
51.
Saulnier, C.A.; Klin, A. Brief report: Social and communication abilities and disabilities in higher functioning individuals with
autism and Asperger syndrome. J. Autism Dev. Disord. 2007,37, 788–793. [CrossRef]
52.
Volker, M.A.; Lopata, C.; Smerbeck, A.M.; Knoll, V.A.; Thomeer, M.L.; Toomey, J.A.; Rodgers, J.D. BASC-2 PRS profiles for
students with high-functioning autism spectrum disorders. J. Autism Dev. Disord. 2010,40, 188–199. [CrossRef]
53.
Hutman, T.; Siller, M.; Sigman, M. Mothers’ narratives regarding their child with autism predict maternal synchronous behavior
during play. J. Child Psychol. Psychiatry 2009,50, 1255–1263. [CrossRef]
54.
Oppenheim, D.; Koren-Karie, N.; Dolev, S.; Yirmiya, N. Maternal insightfulness and resolution of the diagnosis are associated
with secure attachment in preschoolers with autism spectrum disorders. Child Dev. 2009,80, 519–527. [CrossRef]
55.
Wachtel, K.; Carter, A.S. Reaction to diagnosis and parenting styles among mothers of young children with ASDs. Autism
2008
,
12, 575–594. [CrossRef] [PubMed]
56.
Dolev, S.; Sher-Censor, E.; Baransi, N.; Amara, K.; Said, M. Resolution of the child’s ASD diagnosis among Arab–Israeli mothers:
Associations with maternal sensitivity and wellbeing. Res. Autism Spectr. Disord. 2016,21, 73–83. [CrossRef]
57.
Oppenheim, D.; Koren-Karie, N.; Dolev, S.; Yirmiya, N. Maternal sensitivity mediates the link between maternal insightful-
ness/resolution and child–mother attachment: The case of children with Autism Spectrum Disorder. Attach. Hum. Dev.
2012
,
14, 567–584. [CrossRef]
58.
Nahmias, A.S.; Kase, C.; Mandell, D.S. Comparing cognitive outcomes among children with autism spectrum disorders receiving
community-based early intervention in one of three placements. Autism 2014,18, 311–320. [CrossRef] [PubMed]
59.
Woodman, A.C.; Smith, L.E.; Greenberg, J.S.; Mailick, M.R. Contextual factors predict patterns of change in functioning over
10 years among adolescents and adults with autism spectrum disorders. J. Autism Dev. Disord.
2016
,46, 176–189. [CrossRef]
[PubMed]
60.
Kurth, J.A.; Mastergeorge, A.M. Academic and cognitive profiles of students with autism: Implications for classroom practice
and placement. Int. J. Spec. Educ. 2010,25, 8–14.
61.
Kurth, J.; Mastergeorge, A.M. Impact of setting and instructional context for adolescents with autism. J. Spec. Educ.
2012
,46, 36–48.
[CrossRef]
62.
Kurth, J.; Mastergeorge, A.M. Individual education plan goals and services for adolescents with autism: Impact of age and
educational setting. J. Spec. Educ. 2010,44, 146–160. [CrossRef]
63.
Dolev, S.; Oppenheim, D.; Koren-Karie, N.; Yirmiya, N. Early attachment and maternal insightfulness predict educational
placement of children with autism. Res. Autism Spectr. Disord. 2014,8, 958–967. [CrossRef]
64.
Magnus, P.; Birke, C.; Vejrup, K.; Haugan, A.; Alsaker, E.; Daltveit, A.K.; Handal, M.; Haugen, M.; Høiseth, G.; Knudsen, G.P.; et al.
Cohort profile update: The Norwegian mother and child cohort study (MoBa). Int. J. Epidemiol. 2016,45, 382–388. [CrossRef]
65.
Gal, E.; Selanikyo, E.; Bar-Haim Erez, A.; Katz, N. Integration in the vocational world: How does it affect quality of life and
subjective well-being of young adults with ASD. Int. J. Environ. Res. Public Health 2015,12, 10820–10832. [CrossRef] [PubMed]
66.
Kim, S.H.; Bal, V.H.; Lord, C. Longitudinal follow-up of academic achievement in children with autism from age 2 to 18. J. Child
Psychol. Psychiatry 2018,59, 258–267. [CrossRef] [PubMed]
67.
Jones, R.M.; Pickles, A.; Lord, C. Evaluating the quality of peer interactions in children and adolescents with autism with the
Penn Interactive Peer Play Scale (PIPPS). Mol. Autism 2017,8, 28. [CrossRef]
68.
Shattuck, P.T.; Wagner, M.; Narendorf, S.; Sterzing, P.; Hensley, M. Post–high school service use among young adults with an
autism spectrum disorder. Arch. Pediatr. Adolesc. Med. 2011,165, 141–146. [CrossRef] [PubMed]
69.
Taylor, J.L.; Seltzer, M.M. Employment and post-secondary educational activities for young adults with autism spectrum disorders
during the transition to adulthood. J. Autism Dev. Disord. 2011,41, 566–574. [CrossRef] [PubMed]
70.
Taylor, J.L.; Seltzer, M.M. Changes in the autism behavioral phenotype during the transition to adulthood. J. Autism Dev. Disord.
2010,40, 1431–1446. [CrossRef]
71.
Taylor, J.L.; Seltzer, M.M. Changes in the mother–child relationship during the transition to adulthood for youth with autism
spectrum disorders. J. Autism Dev. Disord. 2011,41, 1397–1410. [CrossRef]
72. Moore, M.J. On the Spectrum: Autistics, Functioning, and Care. Ph.D. Thesis, UC Santa Cruz, Santa Cruz, CA, USA, 2014.
73.
Kapp, S.K.; Ne’eman, A. Lobbying autism’s diagnostic revision in the DSM-5. In Autistic Community and the Neurodiversity
Movement; Palgrave Macmillan: Singapore, 2020; pp. 167–194.
74.
Lord, C.; Petkova, E.; Hus, V.; Gan, W.; Lu, F.; Martin, D.M.; Ousley, O.; Guy, L.; Bernier, R.; Gerdts, J.; et al. A multisite study of
the clinical diagnosis of different autism spectrum disorders. Arch. Gen. Psychiatry 2012,69, 306–313. [CrossRef]
75.
Anderson, J.; Birch-Hanger, E.; Burn, G.; Dodevska, G.; Fitzgerald, J.; Harrison, M.; McVilly, K.; Moore, R.; Staples, D.; Thomas, S.;
et al. The Scope-University of Melbourne Partnership Submission to the Senate Select Committee on Autism; The University of Melbourne:
Parkville, VIC, Australia, 2020.
Educ. Sci. 2023,13, 106 15 of 20
76.
Pukki, H.; Bettin, J.; Outlaw, A.G.; Hennessy, J.; Brook, K.; Dekker, M.; Doherty, M.; Shaw, S.C.; Bervoets, J.; Rudolph, S.; et al.
Autistic perspectives on the future of clinical autism research. Autism Adulthood 2022,4, 93–101. [CrossRef]
77.
Shriberg, L.; Strand, E.; Fourakis, M.; Jakielski, K.J.; Hall, S.D.; Karlsson, H.B.; Mabie, H.L.; McSweeny, J.L.; Tilkens, C.M.; Wilson,
D.L. A diagnostic marker to discriminate childhood apraxia of speech from speech delay: I. Development and description of the
pause marker. J. Speech Lang. Hear. Res. 2017,60, S1096–S1117. [CrossRef]
78.
Chenausky, K.; Brignell, A.; Morgan, A.; Tager-Flusberg, H. Motor speech impairment predicts expressive language in minimally
verbal, but not low verbal, individuals with autism spectrum disorder. Autism Dev. Lang. Impair.
2019
,4, 2396941519856333.
[CrossRef] [PubMed]
79.
Hill, T.L.; Gray, S.A.O.; Kamps, J.L.; Varela, R.E. Age and adaptive functioning in children and adolescents with ASD: The effects
of intellectual functioning and ASD symptom severity. J. Autism Dev. Disord. 2015,45, 4074–4083. [CrossRef] [PubMed]
80.
Yang, S.; Paynter, J.M.; Gilmore, L. Vineland Adaptive Behavior Scales: II profile of young children with autism spectrum disorder.
J. Autism Dev. Disord. 2016,46, 64–73. [CrossRef] [PubMed]
81.
Franchini, M.; Zöller, D.; Gentaz, E.; Glaser, B.; Wood de Wilde, H.; Kojovic, N.; Eliez, S.; Schaer, M. Early adaptive functioning
trajectories in preschoolers with autism spectrum disorders. J. Pediatr. Psychol. 2018,43, 800–813. [CrossRef]
82.
Pathak, M.; Bennett, A.; Shui, A.M. Correlates of adaptive behavior profiles in a large cohort of children with autism: The Autism
Speaks Autism Treatment Network registry data. Autism 2019,23, 87–99. [CrossRef] [PubMed]
83.
Hodge, M.A.; Boulton, K.A.; Sutherland, R.; Barnett, D.; Bennett, B.; Chan, E.; Cramsie, J.; Drevensek, S.; Eapen, V.; Ganesalingam,
K.; et al. Predictors of adaptive functioning in preschool aged children with autism spectrum disorder. Autism Res.
2021
,14,
1444–1455. [CrossRef] [PubMed]
84.
World Health Organisation (WHO). ICD-11 International Classification of Diseases for Mortality and Morbidity Statistics (11th
Revision). 2018. Available online: https://icd.who.int/browse11/l-m/en (accessed on 11 January 2023).
85.
Courchesne, V.; Meilleur, A.A.S.; Poulin-Lord, M.P.; Dawson, M.; Soulières, I. Autistic children at risk of being underestimated:
School-based pilot study of a strength-informed assessment. Mol. Autism 2015,6, 12. [CrossRef]
86.
Plesa Skwerer, D.; Jordan, S.E.; Brukilacchio, B.H.; Tager-Flusberg, H. Comparing methods for assessing receptive language skills
in minimally verbal children and adolescents with autism spectrum disorders. Autism 2016,20, 591–604. [CrossRef]
87.
Tager-Flusberg, H.; Kasari, C. Minimally verbal school-aged children with autism spectrum disorder: The neglected end of the
spectrum. Autism Res. 2013,6, 468–478. [CrossRef]
88.
Elias, R.; Lord, C. Diagnostic stability in individuals with autism spectrum disorder: Insights from a longitudinal follow-up study.
J. Child Psychol. Psychiatry 2022,63, 973–983. [CrossRef]
89.
Le Couteur, A.; Lord, C.; Rutter, M. The Autism Diagnostic Interview-Revised (ADI-R); Western Psychological Services: Los Angeles,
CA, USA, 2003.
90.
Lord, C.; Rutter, M.; DiLavore, P.; Risi, S.; Gotham, K.; Bishop, S. Autism Diagnostic Observation Schedule, 2nd ed.; Western
Psychological Services: Los Angeles, CA, USA, 2012.
91.
Dawson, M.; Soulières, I.; Ann Gernsbacher, M.; Mottron, L. The level and nature of autistic intelligence. Psychol. Sci.
2007
,18,
657–662. [CrossRef] [PubMed]
92.
Mottron, L.; Dawson, M.; Soulières, I.; Hubert, B.; Burack, J. Enhanced perceptual functioning in autism: An update, and eight
principles of autistic perception. J. Autism Dev. Disord. 2006,36, 27–43. [CrossRef] [PubMed]
93.
Barbeau, E.B.; Soulières, I.; Dawson, M.; Zeffiro, T.A.; Mottron, L. The level and nature of autistic intelligence III: Inspection time.
J. Abnorm. Psychol. 2013,122, 295. [CrossRef]
94.
Bölte, S.; Dziobek, I.; Poustka, F. Brief report: The level and nature of autistic intelligence revisited. J. Autism Dev. Disord.
2009
,
39, 678–682. [CrossRef] [PubMed]
95.
Bucaille, A.; Grandgeorge, M.; Degrez, C.; Mallégol, C.; Cam, P.; Botbol, M.; Planche, P. Cognitive profile in adults with Asperger
syndrome using WAIS-IV: Comparison to typical adults. Res. Autism Spectr. Disord. 2016,21, 1–9. [CrossRef]
96.
Nader, A.M.; Jelenic, P.; Soulières, I. Discrepancy between WISC-III and WISC-IV cognitive profile in autism spectrum: What
does it reveal about autistic cognition? PLoS ONE 2015,10, e0144645. [CrossRef]
97.
Sahyoun, C.P.; Soulieres, I.; Belliveau, J.W.; Mottron, L.; Mody, M. Cognitive differences in pictorial reasoning between high-
functioning autism and Asperger’s syndrome. J. Autism Dev. Disord. 2009,39, 1014–1023. [CrossRef]
98.
Soulières, I.; Dawson, M.; Gernsbacher, M.A.; Mottron, L. The level and nature of autistic intelligence II: What about Asperger
syndrome? PLoS ONE 2011,6, e25372. [CrossRef]
99.
Gliga, T.; Bedford, R.; Charman, T.; Johnson, M.H.; Baron-Cohen, S.; Bolton, P.; Cheung, C.; Davies, K.; Liew, M.; Fernandes, J.;
et al. Enhanced visual search in infancy predicts emerging autism symptoms. Curr. Biol. 2015,25, 1727–1730. [CrossRef]
100.
Joseph, R.M.; Keehn, B.; Connolly, C.; Wolfe, J.M.; Horowitz, T.S. Why is visual search superior in autism spectrum disorder? Dev.
Sci. 2009,12, 1083–1096. [CrossRef]
101.
Keehn, B.; Joseph, R.M. Exploring what’s missing: What do target absent trials reveal about autism search superiority? J. Autism
Dev. Disord. 2016,46, 1686–1698. [CrossRef] [PubMed]
102.
Remington, A.M.; Swettenham, J.G.; Lavie, N. Lightening the load: Perceptual load impairs visual detection in typical adults but
not in autism. J. Abnorm. Psychol. 2012,121, 544. [CrossRef] [PubMed]
103.
Remington, A.; Swettenham, J.; Campbell, R.; Coleman, M. Selective attention and perceptual load in autism spectrum disorder.
Psychol. Sci. 2009,20, 1388–1393. [CrossRef] [PubMed]
Educ. Sci. 2023,13, 106 16 of 20
104.
Ludlow, A.K.; Wilkins, A.J.; Heaton, P. Colored overlays enhance visual perceptual performance in children with autism spectrum
disorders. Res. Autism Spectr. Disord. 2008,2, 498–515. [CrossRef]
105.
Ludlow, A.K.; Taylor-Whiffen, E.; Wilkins, A.J. Coloured filters enhance the visual perception of social cues in children with
autism spectrum disorders. Int. Sch. Res. Not. 2012,2012, 298098. [CrossRef]
106.
Whitaker, L.; Jones, C.R.; Wilkins, A.J.; Roberson, D. Judging the intensity of emotional expression in faces: The effects of colored
tints on individuals with autism spectrum disorder. Autism Res. 2016,9, 450–459. [CrossRef]
107.
Dziuk, M.A.; Larson, J.G.; Apostu, A.; Mahone, E.M.; Denckla, M.B.; Mostofsky, S.H. Dyspraxia in autism: Association with
motor, social, and communicative deficits. Dev. Med. Child Neurol. 2007,49, 734–739. [CrossRef]
108. Leary, M.R.; Hill, D.A. Moving on: Autism and movement disturbance. Ment. Retard. 1996,34, 39–53.
109.
Shoener, R.F.; Kinnealey, M.; Koenig, K.P. You can know me now if you listen: Sensory, motor, and communication issues in a
nonverbal person with autism. Am. J. Occup. Ther. 2008,62, 547–553. [CrossRef]
110.
Koegel, L.K.; Bryan, K.M.; Su, P.L.; Vaidya, M.; Camarata, S. Definitions of nonverbal and minimally verbal in research for autism:
A systematic review of the literature. J. Autism Dev. Disord. 2020,50, 2957–2972. [CrossRef]
111.
La Valle, C.; Plesa-Skwerer, D.; Tager-Flusberg, H. Comparing the pragmatic speech profiles of minimally verbal and verbally
fluent individuals with autism spectrum disorder. J. Autism Dev. Disord. 2020,50, 3699–3713. [CrossRef] [PubMed]
112.
Nadel, J. Perception–action coupling and imitation in autism spectrum disorder. Dev. Med. Child Neurol.
2015
,57, 55–58.
[CrossRef] [PubMed]
113.
Stiegler, L.N. Discovering communicative competencies in a nonspeaking child with autism. Lang. Speech Hear. Serv. Sch.
2007
,
38, 400–413. [CrossRef] [PubMed]
114.
Valle, C.L.; Chenausky, K.; Tager-Flusberg, H. How do minimally verbal children and adolescents with autism spectrum disorder
use communicative gestures to complement their spoken language abilities? Autism Dev. Lang. Impair.
2021
,6, 23969415211035065.
[CrossRef]
115.
Nadel, J.; Aouka, N.; Coulon, N.; Gras-Vincendon, A.; Canet, P.; Fagard, J.; Bursztejn, C. Yes they can! An approach to
observational learning in low-functioning children with autism. Autism 2011,15, 421–435. [CrossRef]
116.
Somogyi, E.; Király, I.; Gergely, G.; Nadel, J. Understanding goals and intentions in low-functioning autism. Res. Dev. Disabil.
2013,34, 3822–3832. [CrossRef]
117.
McGonigle-Chalmers, M.; Alderson-Day, B.; Fleming, J.; Monsen, K. Profound expressive language impairment in low functioning
children with autism: An investigation of syntactic awareness using a computerised learning task. J. Autism Dev. Disord.
2013
,
43, 2062–2081. [CrossRef]
118.
Mucchetti, C.A. Adapted shared reading at school for minimally verbal students with autism. Autism
2013
,17, 358–372. [CrossRef]
119.
Heimann, M.; Laberg, K.E.; Nordøen, B. Imitative interaction increases social interest and elicited imitation in non-verbal children
with autism. Infant Child Dev. 2006,15, 297–309. [CrossRef]
120. Gernsbacher, M.A. Toward a behavior of reciprocity. J. Dev. Process. 2006,1, 139–152.
121.
Gernsbacher, M.A.; Stevenson, J.L.; Khandakar, S.; Goldsmith, H.H. Why does joint attention look atypical in autism? Child Dev.
Perspect. 2008,2, 38–45. [CrossRef] [PubMed]
122.
Lainé, F.; Rauzy, S.; Tardif, C.; Gepner, B. Slowing down the presentation of facial and body movements enhances imitation
performance in children with severe autism. J. Autism Dev. Disord. 2011,41, 983–996. [CrossRef] [PubMed]
123.
Shire, S.Y.; Goods, K.; Shih, W.; Distefano, C.; Kaiser, A.; Wright, C.; Mathy, P.; Landa, R.; Kasari, C. Parents’ adoption of social
communication intervention strategies: Families including children with autism spectrum disorder who are minimally verbal. J.
Autism Dev. Disord. 2015,45, 1712–1724. [CrossRef] [PubMed]
124.
Kasari, C.; Kaiser, A.; Goods, K.; Nietfeld, J.; Mathy, P.; Landa, R.; Murphy, S.; Almirall, D. Communication interventions for
minimally verbal children with autism: A sequential multiple assignment randomized trial. J. Am. Acad. Child Adolesc. Psychiatry
2014,53, 635–646. [CrossRef] [PubMed]
125.
DiStefano, C.; Shih, W.; Kaiser, A.; Landa, R.; Kasari, C. Communication growth in minimally verbal children with ASD: The
importance of interaction. Autism Res. 2016,9, 1093–1102. [CrossRef]
126.
Gulsrud, A.C.; Hellemann, G.; Shire, S.; Kasari, C. Isolating active ingredients in a parent-mediated social communication
intervention for toddlers with autism spectrum disorder. J. Child Psychol. Psychiatry 2016,57, 606–613. [CrossRef] [PubMed]
127. Haebig, E.; McDuffie, A.; Ellis Weismer, S. Brief report: Parent verbal responsiveness and language development in toddlers on
the autism spectrum. J. Autism Dev. Disord. 2013,43, 2218–2227. [CrossRef]
128. Haebig, E.; McDuffie, A.; Weismer, S.E. The contribution of two categories of parent verbal responsiveness to later language for
toddlers and preschoolers on the autism spectrum. Am. J. Speech Lang. Pathol. 2013,22, 57–70. [CrossRef]
129.
Kasari, C.; Paparella, T.; Freeman, S.; Jahromi, L.B. Language outcome in autism: Randomized comparison of joint attention and
play interventions. J. Consult. Clin. Psychol. 2008,76, 125. [CrossRef]
130.
Siller, M.; Hutman, T.; Sigman, M. A parent-mediated intervention to increase responsive parental behaviors and child communi-
cation in children with ASD: A randomized clinical trial. J. Autism Dev. Disord. 2013,43, 540–555. [CrossRef]
131.
Crompton, C.J.; DeBrabander, K.; Heasman, B.; Milton, D.; Sasson, N.J. Double empathy: Why autistic people are often
misunderstood. Front. Young Minds 2021,9, 554875. [CrossRef]
132. Milton, D.E. On the ontological status of autism: The ‘double empathy problem’. Disabil. Soc. 2012,27, 883–887. [CrossRef]
133.
Milton, D.; Gurbuz, E.; Lopez, B. The ‘double empathy problem’: Ten years on. Autism
2022
,26, 1901–1903. [CrossRef] [PubMed]
Educ. Sci. 2023,13, 106 17 of 20
134.
Kasari, C.; Freeman, S.F.; Bauminger, N.; Alkin, M.C. Parental perspectives on inclusion: Effects of autism and Down syndrome. J.
Autism Dev. Disord. 1999,29, 297–305. [CrossRef] [PubMed]
135.
Harris, S.L.; Handleman, J.S. Age and IQ at intake as predictors of placement for young children with autism: A four-to six-year
follow-up. J. Autism Dev. Disord. 2000,30, 137–142. [CrossRef]
136.
Segall, M.J.; Campbell, J.M. Factors influencing the educational placement of students with autism spectrum disorders. Res.
Autism Spectr. Disord. 2014,8, 31–43. [CrossRef]
137. Doll, E.A. The nature of mental deficiency. Psychol. Rev. 1940,47, 395–415. [CrossRef]
138. Goldsmith, D.M. Grading People. Vimeo. 2010. Available online: https://vimeo.com/12901883 (accessed on 11 January 2023).
139.
Krueger, K.K. Minimally Verbal School-Aged Children with Autism: Communication, Academic Engagement and Classroom Quality;
Unpublished Doctoral Dissertation; University of California: Los Angeles, CA, USA, 2013.
140.
Ravet, J. Inclusive/exclusive? Contradictory perspectives on autism and inclusion: The case for an integrative position. Int. J. Incl.
Educ. 2011,15, 667–682. [CrossRef]
141.
Andzik, N.R.; Chung, Y.C.; Doneski-Nicol, J.; Dollarhide, C.T. AAC services in schools: A special educator’s perspective. Int. J.
Dev. Disabil. 2019,65, 89–97. [CrossRef]
142.
Aldabas, R. Barriers and facilitators of using augmentative and alternative communication with students with multiple disabilities
in inclusive education: Special education teachers’ perspectives. Int. J. Incl. Educ. 2021,25, 1010–1026. [CrossRef]
143.
Biggs, E.E.; Hacker, R. Engaging stakeholders to improve social validity: Intervention priorities for students with complex
communication needs. Augment. Altern. Commun. 2021,37, 25–38. [CrossRef] [PubMed]
144.
DiStefano, C.; Kasari, C. The window to language is still open: Distinguishing between preverbal and minimally verbal children
with ASD. Perspect. ASHA Spec. Interest Groups 2016,1, 4–11. [CrossRef]
145.
Logan, K.; Iacono, T.; Trembath, D. A systematic review of research into aided AAC to increase social-communication functions in
children with autism spectrum disorder. Augment. Altern. Commun. 2017,33, 51–64. [CrossRef] [PubMed]
146.
Aydin, O.; Diken, I.H. Studies comparing augmentative and alternative communication systems (AAC) applications for in-
dividuals with autism spectrum disorder: A systematic review and meta-analysis. Educ. Train. Autism Dev. Disabil.
2020
,
55, 119–141.
147.
Hong, E.R.; Gong, L.Y.; Ninci, J.; Morin, K.; Davis, J.L.; Kawaminami, S.; Shi, Y.; Noro, F. A meta-analysis of single-case research
on the use of tablet-mediated interventions for persons with ASD. Res. Dev. Disabil. 2017,70, 198–214. [CrossRef]
148.
Syriopoulou-Delli, C.K.; Eleni, G. Effectiveness of different types of Augmentative and Alternative Communication (AAC) in
improving communication skills and in enhancing the vocabulary of children with ASD: A review. Rev. J. Autism Dev. Disord.
2021,9, 493–506. [CrossRef]
149.
Almirall, D.; DiStefano, C.; Chang, Y.C.; Shire, S.; Kaiser, A.; Lu, X.; Nahum-Shani, I.; Landa, R.; Mathy, P.; Kasari, C. Longitudinal
effects of adaptive interventions with a speech-generating device in minimally verbal children with ASD. J. Clin. Child Adolesc.
Psychol. 2016,45, 442–456. [CrossRef]
150.
van der Meer, L.; Sutherland, D.; O’Reilly, M.F.; Lancioni, G.E.; Sigafoos, J. A further comparison of manual signing, picture
exchange, and speech-generating devices as communication modes for children with autism spectrum disorders. Res. Autism
Spectr. Disord. 2012,6, 1247–1257. [CrossRef]
151. Gillespie-Smith, K.; Fletcher-Watson, S. Designing AAC systems for children with autism: Evidence from eye tracking research.
Augment. Altern. Commun. 2014,30, 160–171. [CrossRef]
152.
Light, J.; McNaughton, D. From basic to applied research to improve outcomes for individuals who require augmentative and
alternative communication: Potential contributions of eye tracking research methods. Augment. Altern. Commun.
2014
,30, 99–105.
[CrossRef]
153.
Kelly, D.J.; Walker, R.; Norbury, C.F. Deficits in volitional oculomotor control align with language status in autism spectrum
disorders. Dev. Sci. 2013,16, 56–66. [CrossRef] [PubMed]
154.
Tsatsanis, K.D.; Dartnall, N.; Cicchetti, D.; Sparrow, S.S.; Klin, A.; Volkmar, F.R. Concurrent validity and classification accuracy of
the Leiter and Leiter-R in low-functioning children with autism. J. Autism Dev. Disord. 2003,33, 23–30. [CrossRef]
155.
Shah, A.; Holmes, N. Brief report: The use of the Leiter International Performance Scale with autistic children. J. Autism Dev.
Disord. 1985,15, 195–203. [CrossRef] [PubMed]
156.
Chenausky, K.V.; Norton, A.C.; Tager-Flusberg, H.; Schlaug, G. Auditory-motor mapping training: Testing an intonation-based
spoken language treatment for minimally verbal children with autism spectrum disorder. Ann. N. Y. Acad. Sci.
2022
,1515, 266–275.
[CrossRef] [PubMed]
157.
Grondhuis, S.N.; Mulick, J.A. Comparison of the Leiter International Performance Scale-Revised and the Stanford-Binet In-
telligence Scales, in children with autism spectrum disorders. Am. J. Intellect. Dev. Disabil.
2013
,118, 44–54. [CrossRef]
[PubMed]
158.
Scattone, D.; Raggio, D.J.; May, W. Brief report: Concurrent validity of the Leiter-R and KBIT-2 scales of nonverbal intelligence for
children with autism and language impairments. J. Autism Dev. Disord. 2012,42, 2486–2490. [CrossRef] [PubMed]
159.
McGonigle-Chalmers, M.; McSweeney, M. The role of timing in testing nonverbal IQ in children with ASD. J. Autism Dev. Disord.
2013,43, 80–90. [CrossRef]
160.
Charman, T.; Jones, C.R.; Pickles, A.; Simonoff, E.; Baird, G.; Happé, F. Defining the cognitive phenotype of autism. Brain Res.
2011,1380, 10–21. [CrossRef]
Educ. Sci. 2023,13, 106 18 of 20
161.
Carothers, D.E.; Taylor, R.L. Differential effect of features of autism on IQs reported using Wechsler scales. Focus Autism Other
Dev. Disabil. 2013,28, 54–59. [CrossRef]
162. Stone, W.L. Cross-disciplinary perspectives on autism. J. Pediatr. Psychol. 1987,12, 615–630. [CrossRef]
163.
Stone, W.L.; Rosenbaum, J.L. A comparison of teacher and parent views of autism. J. Autism Dev. Disord.
1988
,18, 403–414.
[CrossRef] [PubMed]
164.
Gillespie-Lynch, K.; Brooks, P.J.; Someki, F.; Obeid, R.; Shane-Simpson, C.; Kapp, S.K.; Daou, N.; Smith, D.S. Changing college
students’ conceptions of autism: An online training to increase knowledge and decrease stigma. J. Autism Dev. Disord.
2015
,
45, 2553–2566. [CrossRef] [PubMed]
165.
Tipton, L.A.; Blacher, J. Brief report: Autism awareness: Views from a campus community. J. Autism Dev. Disord.
2014
,44, 477–483.
[CrossRef] [PubMed]
166.
Asperger, H. ‘Autistic psychopathy’ in childhood. In Autism and Asperger Syndrome; Frith, U., Ed.; Cambridge University Press:
Cambridge, UK, 1991; pp. 37–92.
167. Asperger, H. Die autistischen Psychopathen im Kindesalter. Arch. Psychiatre Nervenkrankh. 1944,117, 76–136. [CrossRef]
168.
Edelson, M.G. Are the majority of children with autism mentally retarded? A systematic evaluation of the data. Focus Autism
Other Dev. Disabil. 2006,21, 66–83. [CrossRef]
169.
Freeman, B.J.; Van Dyke, M. Are the majority of children with autism mentally retarded? Focus Autism Other Dev. Disabil.
2006
,
21, 86–88. [CrossRef]
170.
Slušná, D.; Rodríguez, A.; Salvadó, B.; Vicente, A.; Hinzen, W. Relations between language, nonverbal cognition, and conceptual-
ization in non-or minimally verbal individuals with ASD across the lifespan. Autism Dev. Lang. Impair.
2021
,6, 23969415211053264.
[CrossRef]
171.
Akshoomoff, N. Use of the Mullen Scales of Early Learning for the assessment of young children with autism spectrum disorders.
Child Neuropsychol. 2006,12, 269–277. [CrossRef]
172.
Courchesne, V.; Girard, D.; Jacques, C.; Soulières, I. Assessing intelligence at autism diagnosis: Mission impossible? Testability
and cognitive profile of autistic preschoolers. J. Autism Dev. Disord. 2019,49, 845–856. [CrossRef]
173.
Chevallier, C.; Parish-Morris, J.; Tonge, N.; Le, L.; Miller, J.; Schultz, R.T. Susceptibility to the audience effect explains performance
gap between children with and without autism in a theory of mind task. J. Exp. Psychol. Gen. 2014,143, 972. [CrossRef]
174.
Autistic Self Advocacy Network. Functioning Labels Harm Autistic People. 9 December 2021. Available online: https:
//autisticadvocacy.org/2021/12/functioning-labels-harm-autistic-people/ (accessed on 11 January 2023).
175.
Keating, C.T.; Hickman, L.; Leung, J.; Monk, R.; Montgomery, A.; Heath, H.; Sowden, S. Autismrelated language preferences of
English-speaking individuals across the globe: A mixed methods investigation. Autism Res. 2022. [CrossRef] [PubMed]
176.
Baggs, A. The meaning of self-advocacy. In Loud Hands: Autistic People, Speaking; Bascom, J., Ed.; The Autistic Press: Washington,
DC, USA, 2012; pp. 223–225.
177.
Baker, J.K.; Smith, L.E.; Greenberg, J.S.; Seltzer, M.M.; Taylor, J.L. Change in maternal criticism and behavior problems in
adolescents and adults with autism across a 7-year period. J. Abnorm. Psychol. 2011,120, 465–475. [CrossRef] [PubMed]
178.
Zaidman-Zait, A.; Mirenda, P.; Duku, E.; Szatmari, P.; Georgiades, S.; Volden, J.; Zwaigenbaum, L.; Vaillancourt, T.; Bryson, S.;
Smith, I.; et al. Examination of bidirectional relationships between parent stress and two types of problem behavior in children
with autism spectrum disorder. J. Autism Dev. Disord. 2014,44, 1908–1917. [CrossRef] [PubMed]
179.
Park, S.; Park, M.H.; Kim, H.J.; Yoo, H.J. Anxiety and depression symptoms in children with Asperger syndrome compared with
attention-deficit/hyperactivity disorder and depressive disorder. J. Child Fam. Stud. 2013,22, 559–568. [CrossRef]
180.
Totsika, V.; Hastings, R.P.; Emerson, E.; Lancaster, G.A.; Berridge, D.M.; Vagenas, D. Is there a bidirectional relationship between
maternal well-being and child behavior problems in autism spectrum disorders? Longitudinal analysis of a population defined
sample of young children. Autism Res. 2013,6, 201–211. [CrossRef] [PubMed]
181.
Adler, N.; Dvash, J.; Shamay-Tsoory, S.G. Empathic embarrassment accuracy in autism spectrum disorder. Autism Res.
2015
,
8, 241–249. [CrossRef]
182.
Pouw, L.B.; Rieffe, C.; Oosterveld, P.; Huskens, B.; Stockmann, L. Reactive/proactive aggression and affective/cognitive empathy
in children with ASD. Res. Dev. Disabil. 2013,34, 1256–1266. [CrossRef]
183.
Samson, A.C.; Phillips, J.M.; Parker, K.J.; Shah, S.; Gross, J.J.; Hardan, A.Y. Emotion dysregulation and the core features of autism
spectrum disorder. J. Autism Dev. Disord. 2014,44, 1766–1772. [CrossRef]
184.
Wood, J.J.; Gadow, K.D. Exploring the nature and function of anxiety in youth with autism spectrum disorders. Clin. Psychol. Sci.
Pract. 2010,17, 281–292. [CrossRef]
185.
Jahromi, L.B.; Meek, S.E.; Ober-Reynolds, S. Emotion regulation in the context of frustration in children with high functioning
autism and their typical peers. J. Child Psychol. Psychiatry 2012,53, 1250–1258. [CrossRef]
186.
Mazefsky, C.A.; Borue, X.; Day, T.N.; Minshew, N.J. Emotion regulation patterns in adolescents with high-functioning autism
spectrum disorder: Comparison to typically developing adolescents and association with psychiatric symptoms. Autism Res.
2014,7, 344–354. [CrossRef] [PubMed]
187.
Evans, D.W.; Canavera, K.; Kleinpeter, F.L.; Maccubbin, E.; Taga, K. The fears, phobias and anxieties of children with autism
spectrum disorders and Down syndrome: Comparisons with developmentally and chronologically age matched children. Child
Psychiatry Hum. Dev. 2005,36, 3–26. [CrossRef]
Educ. Sci. 2023,13, 106 19 of 20
188.
Gotham, K.; Bishop, S.L.; Hus, V.; Huerta, M.; Lund, S.; Buja, A.; Krieger, A.; Lord, C. Exploring the relationship between anxiety
and insistence on sameness in autism spectrum disorders. Autism Res. 2013,6, 33–41. [CrossRef] [PubMed]
189.
Brewer, R.; Biotti, F.; Catmur, C.; Press, C.; Happé, F.; Cook, R.; Bird, G. Can neurotypical individuals read autistic facial
expressions? Atypical production of emotional facial expressions in autism spectrum disorders. Autism Res.
2016
,9, 262–271.
[CrossRef] [PubMed]
190.
Sheppard, E.; Pillai, D.; Wong, G.T.L.; Ropar, D.; Mitchell, P. How easy is it to read the minds of people with autism spectrum
disorder? J. Autism Dev. Disord. 2016,46, 1247–1254. [CrossRef]
191.
Humphrey, N.; Symes, W. Perceptions of social support and experience of bullying among pupils with autistic spectrum disorders
in mainstream secondary schools. Eur. J. Spec. Needs Educ. 2010,25, 77–91. [CrossRef]
192.
Lasgaard, M.; Nielsen, A.; Eriksen, M.E.; Goossens, L. Loneliness and social support in adolescent boys with autism spectrum
disorders. J. Autism Dev. Disord. 2010,40, 218–226. [CrossRef]
193.
Cottenceau, H.; Roux, S.; Blanc, R.; Lenoir, P.; Bonnet-Brilhault, F.; Barthélémy, C. Quality of life of adolescents with autism
spectrum disorders: Comparison to adolescents with diabetes. Eur. Child Adolesc. Psychiatry 2012,21, 289–296. [CrossRef]
194.
Barnhill, G.P.; Hagiwara, T.; Myles, B.S.; Simpson, R.L.; Brick, M.L.; Griswold, D.E. Parent, teacher, and self-report of problem and
adaptive behaviors in children and adolescents with Asperger syndrome. Assess. Eff. Interv. 2000,25, 147–167. [CrossRef]
195.
Kanne, S.M.; Mazurek, M.O. Aggression in children and adolescents with ASD: Prevalence and risk factors. J. Autism Dev. Disord.
2011,41, 926–937. [CrossRef]
196.
Kanne, S.M.; Abbacchi, A.M.; Constantino, J.N. Multi-informant ratings of psychiatric symptom severity in children with autism
spectrum disorders: The importance of environmental context. J. Autism Dev. Disord. 2009,39, 856–864. [CrossRef] [PubMed]
197.
Losh, A.; Eisenhower, A.; Blacher, J. Impact of student-teacher relationship quality on classroom behavioral engagement for
young students on the autism spectrum. Res. Autism Spectr. Disord. 2022,98, 102027. [CrossRef]
198.
Milton, D.E.M. Autistic expertise: A critical reflection on the production of knowledge in autism studies. Autism
2014
,18, 794–802.
[CrossRef] [PubMed]
199.
Silverman, C. Understanding Autism: Parents, Doctors, and the History of a Disorder; Princeton University Press: Princeton, NJ,
USA, 2012.
200.
Smukler, D. Unauthorized minds: How “theory of mind” theory misrepresents autism. Ment. Retard.
2005
,42, 11–24. [CrossRef]
201. Yergeau, M. Circle wars: Reshaping the typical autism essay. Disabil. Stud. Q. 2010,30. [CrossRef]
202.
Kapp, S.K.; Gillespie-Lynch, K.; Sherman, L.E.; Hutman, T. Deficit, difference, or both? Autism and neurodiversity. Dev. Psychol.
2013,49, 59–71. [CrossRef]
203. Nicolaidis, C. What can physicians learn from the neurodiversity movement? Virtual Mentor 2012,14, 503–510.
204. Silberman, S. NeuroTribes: The Legacy of Autism and the Future of Neurodiversity; Avery: New York, NY, USA, 2015.
205.
Sinclair, J. Autism Network International: The development of a community and its culture. In Loud Hands: Autistic People,
Speaking; Bascom, J., Ed.; The Autistic Press: Washington, DC, USA, 2012; pp. 17–48. Available online: http://www.autreat.com/
History_of_ANI.html (accessed on 17 January 2023).
206.
Sinclair, J. Don’t mourn for us. In Loud Hands: Autistic People, Speaking. Bascom, J., Ed.; The Autistic Press: Washington, DC, USA,
2012; pp. 13–16.
207. Singer, J. Neurodiversity: The Birth of an Idea; The University of Edinburgh: Edinburgh, UK, 2017.
208.
Botha, M.; Cage, E. “Autism Research is in Crisis”: A mixed method study of researcher’s constructions of autistic people and
autism research. Front. Psychol. 2022,13, 1050897. [CrossRef]
209.
Hillary, A. Neurodiversity and cross-cultural communication. In Neurodiversity Studies; Routledge: New York, NY, USA, 2020;
pp. 91–107.
210. Den Houting, J. Neurodiversity: An insider ’s perspective. Autism 2019,23, 271–273. [CrossRef]
211.
Gillespie-Lynch, K.; Kapp, S.K.; Brooks, P.J.; Pickens, J.; Schwartzman, B. Whose expertise is it? Evidence for autistic adults as
critical autism experts. Front. Psychol. 2017,8, 438. [CrossRef]
212.
Ne’eman, A. The future (and the past) of Autism advocacy, or why the ASA’s magazine, The Advocate, wouldn’t publish this
piece. Disabil. Stud. Q. 2010,30. [CrossRef]
213.
Ne’eman, A.; Bascom, J. Autistic self advocacy in the developmental disability movement. Am. J. Bioeth.
2020
,20, 25–27.
[CrossRef]
214.
Hersh, L.H. Autism Stakeholder Views on Autism Intervention: Effects of Closeness to Autistic People with High Support Needs.
Bachelor’s Thesis, University of California, Davis, CA, USA. Unpublished.
215.
Milshtein, S.; Yirmiya, N.; Oppenheim, D.; Koren-Karie, N.; Levi, S. Resolution of the diagnosis among parents of children with
autism spectrum disorder: Associations with child and parent characteristics. J. Autism Dev. Disord.
2010
,40, 89–99. [CrossRef]
[PubMed]
216.
Totsika, V.; Hastings, R.P.; Emerson, E.; Lancaster, G.A.; Berridge, D.M. A population-based investigation of behavioural and
emotional problems and maternal mental health: Associations with autism spectrum disorder and intellectual disability. J. Child
Psychol. Psychiatry 2011,52, 91–99. [CrossRef] [PubMed]
217.
Yirmiya, N.; Seidman, I.; Koren-Karie, N.; Oppenheim, D.; Dolev, S. Stability and change in resolution of diagnosis among
parents of children with autism spectrum disorder: Child and parental contributions. Dev. Psychopathol.
2015
,27 Pt 1, 1045–1057.
[CrossRef] [PubMed]
Educ. Sci. 2023,13, 106 20 of 20
218.
Shogren, K.A.; Burke, K.M.; Anderson, M.H.; Antosh, A.A.; Wehmeyer, M.L.; LaPlante, T.; Shaw, L.A. Evaluating the differential
impact of interventions to promote self-determination and goal attainment for transition-age youth with intellectual disability.
Res. Pract. Pers. Sev. Disabil. 2018,43, 165–180. [CrossRef]
219.
Shogren, K.A.; Hicks, T.A.; Burke, K.M.; Antosh, A.; LaPlante, T.; Anderson, M.H. Examining the impact of the SDLMI and whose
future is it? Over a two-year period with students with intellectual disability. Am. J. Intellect. Dev. Disabil.
2020
,125, 217–229.
[CrossRef]
220.
Tesfaye, R.; Courchesne, V.; Mirenda, P.; Mitchell, W.; Nicholas, D.; Singh, I.; Zwaigenbaum, L.; Elsabbagh, M. Autism voices:
Perspectives of the needs, challenges, and hopes for the future of autistic youth. Autism 2022, 13623613221132108. [CrossRef]
221.
Carson, D. Walking with Joaquin. YouTube. 13 December 2017. Available online: https://www.youtube.com/watch?v=ruXB3
lbiD3U&t=1s (accessed on 11 January 2023).
Disclaimer/Publisher’s Note:
The statements, opinions and data contained in all publications are solely those of the individual
author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to
people or property resulting from any ideas, methods, instructions or products referred to in the content.
