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Preschool Children with Inadequate Communication: Developmental Language Disorder, Autism, Mental Deficiency.
  1. MARIAN PERKINS, Consultant child and adolescent neuropsychiatrist

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    Preschool Children with Inadequate Communication: Developmental Language Disorder, Autism, Mental Deficiency. Edited by Isabelle Rapin. (Pp 299; £45 hardback.) Mac Keith Press, 1996. ISBN 1-898-68307-7 .

    As a clinician, one of the most difficult tasks that I repeatedly face is the assessment of a preschool child who has been referred because of concerns regarding the child’s language acquisition, but nearly always there is the concomitant worry from the parents about ‘other odd behaviours’. I know immediately that I am entering the diagnostic dilemma of social and communication developmental disorders. I am also very aware of the relative limitations in our knowledge regarding certain aspects of these children’s functioning and particularly regarding prognosis that parents are bound to raise. Any rigorous research that furthers our thinking about the aetiology and clinical picture of these disorders so we can diagnostically differentiate such categories as developmental language disorder is to be welcomed. This monograph edited by Isabelle Rapin has addressed many of these issues. While at present the vast amount of data presented reflects the previous functioning of these children, the great strength will be future data generated from the proposed longitudinal component of this study.

    The monograph describes the extremely detailed evaluation of four groups of children with developmental neurobehavioural disabilities. The four groups are higher functioning autistic children, autistic children with lower IQs, children with developmental language delay, and children with low non-verbal IQ who are not autistic.

    Batteries of well validated assessment instruments were used to assess the children. Interestingly, the volume also includes the first publication of two new assessment instruments, the ‘Wing Schedule of Handicaps, Behaviour and Skills’ and the ‘Wing Autistic Disorder Interview Checklist’ (WADIC).

    Descriptions of particular clinical differentiations prove most interesting. For example, the value of performing a rigorous neurological examination on these children was discussed. While the overall conclusion was that this provided little additional information to the assessment and diagnostic issues, it highlighted some differences that may have aetiological importance. The finding of macrocephaly in some autistic children was confirmed. This finding occurred most often in higher functioning autistic children. This has been previously postulated as representing or suggesting atypical brain development, such as the lack of normal pruning of redundant cells or connections that would mark optimal maturation of the nervous system. Due to methodological constraints, there can only be supportive evidence for particular aetiological theories. This was forthcoming in support for the notion that developmental language disorder and autism are aetiologically distinct. Children with developmental language delay have more family members with reading and spelling difficulties, while there is a higher incidence of autistic disorder among siblings. There was no support for the claims of recent associations between autistic disorder and either Gilles de la Tourette’s syndrome or manic depressive disorder. Other interesting associations were epilepsy syndromes with the lower functioning autistic children and the non-autistic lower functioning children. Both groups of autistic children had higher incidence of sleep problems, and parents more often reported loss of skills within the autistic group rather than those with developmental language disorders.

    These clinical details are not only of theoretical interest but provide some important directions for therapeutic interventions. An example comes from the data provided on the neuropsychological profiles. In the higher functioning autistic group this included normal non-verbal ability but poor self organisation of connected speech, poor pragmatic and impaired socialisation, inadequate language comprehension but a relatively stronger confrontation naming and written language skills. The children had better short term auditory verbal memory for non-meaningful material than for meaningful material and relatively spared visual memory with a particular strength in rote learning and long term memory. The authors point out that it is crucial to remember when assessing these children not to judge their language comprehension from their output, as they do not exhibit the more typical pattern of better comprehension than expression of language seen in most language impaired children. This sort of detail can be very influential in the educational approaches to these groups of children.

    While the monograph raised some very interesting aetiological questions and discussions regarding proposed classificatory systems, it was for the wealth of informative clinical detail and potential this may have for making one’s assessments and therapeutic interventions that I found this text most valuable.

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