2

Autism Spectrum Disorder

Versus Intellectual Disability
JAN BLACHER, BRUCE L. BAKER, AND
C H R I S T I N E T. M O O D Y ■

For decades, clinicians and educators have faced challenges in assessing, ad-
dressing, and educating children who bore the diagnoses of both autism spec-
trum disorder (ASD) and intellectual disability (ID). Parents, too, struggled with
priorities: Which should I be most concerned about, the social communication
differences associated with ASD or the delays in development that come with the
ID? However, a preceding clinical challenge is that of accurately differentiating
and diagnosing these disorders, an essential first step in informing educational
and treatment planning.
This chapter will address the issues that arise for clinicians when considering
whether a child meets criteria for ASD, ID, or both, by presenting clinical guide-
lines for assessment of these diagnoses. To set the context for this, a brief intro-
duction to ID will be provided (see Matson, 2019, for a more in depth overview
of ID). The literature documenting the implications of an ID, with or without co-​
occurring ASD, on functioning in various domains will be provided as well. Next,
the impact of particular co-​occurring diagnoses will be discussed, given that it is
well established that behavior/​psychiatric disorders are more likely in children
and youth with ID and/​or on the autism spectrum than in those with typical
cognitive development (Baker & Blacher, 2015; Einfeld et al., 2011; Emerson &
Hatton, 2007; Gjevik et al., 2011; Lake et al., 2014; Simonoff et al., 2008; Strang
et al., 2012). To achieve these goals, a case study drawing from the clinical experi-
ences of the authors will be utilized throughout the chapter in order to illustrate
some of the diagnostic, clinical, and practical issues faced across several stages of
the lifespan.
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Autism Spectrum Disorder Versus Intellectual Disability23

INTELLECTUAL DISABILITY

Definition, Assessment, and Prevalence

ID has been long defined through two domains: (1) Intelligence, as usually as-
sessed with an IQ test below a score of 70, which is two standard deviations
below the population mean of 100, and (2) Adaptive behaviors, such that the in-
dividual presents with deficits in the skills needed to function adaptively in so-
ciety. The American Association of Intellectual and Developmental Disabilities
(AAIDD, 2010) defines ID similarly, in terms of mental capacity involving rea-
soning, planning, solving problems, thinking abstractly, comprehending complex
ideas, learning efficiently, and learning from experience. Beyond measurement
of ability, the most recent classification in the Diagnostic and Statistical Manual
of Mental Disorders (DSM-​5; APA, 2013) requires the additional consideration
of the extent and type of supports needed (Boat & Wu, 2015; Patel et al., 2018).
This shift in focus on supports needed reflects a larger trend over the past century,
whereby persons with ID have become increasingly accepted and better served,
as evidenced by more tolerant terminology and enhanced integration into society
(Keith & Keith, 2020).
The most commonly used intelligence test for children is the Wechsler
Intelligence Scale for Children, currently in its fifth edition (WISC-​V; Wechsler,
2014). There are preschool (WPPSI; Wechsler, 2012) and adult versions (WAIS;
Wechsler, 2008) of the Wechsler intelligence tests as well. These standardized
assessments capture intelligence through measurement of different constructs,
including verbal comprehension, visual spatial skills, fluid reasoning, working
memory, and processing speed. With respect to adaptive behavior, the Vineland
Adaptive Behavior Scales, third edition, is widely used and includes norms for
ages birth through 90 (VABS-​3; Sparrow et al., 2016). Though various categorical
labels are applied based on the measure, adaptive behaviors definitionally include
Conceptual skills (e.g., language, literacy, self-​direction); Social skills (e.g., inter-
personal skills, problem solving, ability to follow rules); and Practical skills (e.g.,
personal care, occupational skills, use of money and the telephone).
Therefore, in order to diagnostically rule ID in or out, it is necessary to con-
duct an assessment of both cognitive abilities and adaptive behavior. As such, at
all ages, when ASD and/​or ID are being considered as part of the referral ques-
tion, diagnostic assessments should include the following components, shown in
Table 2.1. This assessment battery should be relied upon in most cases, although
if the designation of ID is definitive by standardized assessment tools, there may
be less emphasis on the clinical interview in assessing ID. However, if ASD is
suspected, a clinical interview of parent(s) is advisable for context and possible
trajectory of autism symptoms. Too, given the high rate of comorbidities of be-
havioral and mental health disorders in ASD and ID (Gillberg & Fernell, 2014), it
is often useful to incorporate assessments of these.
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24 D i f f erential D iagnosis o f A utism S pectrum D isorder

Table 2.1. Recommended components of a diagnostic assessment battery

for autism spectrum disorder (ASD) and intellectual disability (ID).
DAS-​2: Differential Ability Scales, Second Edition (Elliott et al., 2018);
Leiter International Performance Scale, Third Edition (Roid et al., 2013);
ADOS-​2: Autism Diagnostic Observation Schedule, Second Edition (Lord
et al., 2012); ADI-​R: Autism Diagnostic Interview, Revised (Rutter et al.,
2003); SRS-​2: Social Responsiveness Scale, Second Edition (Constantino &
Gruber, 2012); ABAS: Adaptive Behavior Assessment System, Third Edition
(Harrison & Oakland, 2015); CBCL: Child Behavior Checklist, YSR: Youth
Self Report, TRF: Teacher Report Form (Achenbach & Rescorla, 2001);
BASC-​3: Behavior Assessment System for Children, Third Edition
(Reynolds & Kamphaus, 2015); DISC-​IV: Diagnostic Interview Schedule
for Children, Fourth Edition (Shaffer et al., 2000).
Evidence Based Assessment of ASD/​ID:
1. Clinical Interviewing
2. History Gathering
3. Behavioral Observations
4. Standardized Assessment of the following four domains:
a. Cognitive b. Autism c. Adaptive Skills d. Social-​Emotional
Abilities Symptoms
(e.g., Weschler (e.g., ADOS-​2, (e.g., VABS-​3, (e.g., CBCL/​YSR/​TRF,
scales of intelligence ADI-​R, SRS-​2) ABAS-​III) BASC-​3, DISC-​IV,
[WPPSI, WISC, Clinical Interview)
WAIS], DAS-​2,
Leiter-​3)

In classifying the depth of impairments in the two domains discussed above

(i.e., intelligence and adaptive behaviors), the terms Mild, Moderate, Severe, and
Profound have been used to describe the severity of ID and associated implica-
tions for the life course. While the DSM-​5 (APA, 2013) moved away from IQ-​
based categories, these are still prominent, both in prior years’ studies and today.
This classification is comprised of the following: (1) Mild ID, IQ range 50–​69, and
representing 85% of persons with ID. As adults, these persons can often live in-
dependently, with some supports. (2) Moderate ID, IQ range of about 36–​49, and
representing 10% of persons with ID. As adults, individuals with Moderate ID can
live semi-​independently, at home or in a group home, with some support needed
in some daily situations. (3 and 4) Severe or Profound ID, representing 5%, re-
quire extensive lifelong support for daily activities and routines. While the intel-
lectual and adaptive functioning deficts must be apparent in the first 18 years of
life, in actuality, Moderate to Severe ID is usually identifiable in early childhood,
while Mild ID may not become apparent until the early school years. Yet another,
but less studied, group now receiving attention is those with borderline intellec-
tual functioning (BIF), which is defined by an IQ that falls between one and two
standard deviations below the mean (i.e., 71–​84; Blasi et al., 2020).
25

Autism Spectrum Disorder Versus Intellectual Disability25

Importantly, in clinical practice, it is common to delay formal diagnosis of ID

until approximately age 5, when the validity, reliability, and stability of standard-
ized assessments of intellectual functioning improve significantly (APA, 2013;
Bishop et al., 2003; Gottfried et al., 2009). Further, given neuroplasticity in early
childhood, comprehensive intervention in this time period has demonstrated the
powerful potential to mitigate functional impairments and developmental delays,
such that by the end of the preschool period, a diagnosis of ID may no longer
be appropriate (Guralnick, 2005, 2017; Majnemer, 1998; Peters-​Scheffers et al.,
2011). Given that ID is considered to be a lifelong disorder, these findings further
support the delayed assignment of the diagnosis. Prior to age 5, when a child fails
to meet developmental milestones in multiple domains for whom the long-​term
clinical severity and functional capacities are unclear, a diagnosis of global devel-
opmental delay may be utilized (APA, 2013).
ID is present in about 1% of the population in the United States, although esti-
mates range from 1% to 3% (Srivastava & Schwartz, 2014). International studies
find a range from 0.22% to 1.55% (McKenzie et al., 2016), as measures of prev-
alence are affected by multiple factors, including age, sex, socioeconomic status,
culture, and definition. For some children, ID results from an identifiable genetic
or biologically based condition, such as Down syndrome, Fragile X, or fetal al-
cohol spectrum disorder. While genetic abnormalities are reportedly higher in
individuals with ID than in ASD, it is not uncommon for the same genes to be
associated with ID and ASD (Thurm et al., 2019). Even if different specific genes
are implicated, research evidence suggests that the genes associated with these
two disorders are broadly involved in similar biological processes (Srivastava &
Schwartz, 2014).

Behavioral and Mental Health Problems

in Intellectual Disability

Across the life span, persons with ID are at much greater risk than their typi-
cally developing peers for experiencing clinically significant behavior and mental
health disorders (Baker et al., 2002; Caplan et al., 2015; Emerson, 2003; Tonge
& Einfeld, 2003). Given this, the American Academy of Child and Adolescent
Psychiatry (AACAP, 2018) has asserted that when ID is being considered, com-
prehensive evaluations must include assessment of socioemotional functioning
and evaluation for co-​occurring behavioral/​mental health disorders. In under-
standing this elevated risk, the AACAP commented that most children with IDs
recognize that they are behind others of their own age, which can bring frustra-
tion, anxiety, withdrawal, and/​or depression. Further, individuals with ID may
not have the language skills needed to express emotions or needs, leading to mal-
adaptive manifestations of their negative emotions through problems in their be-
havior, eating, and sleeping.
Prevalence of co-​occurring mental health and behavioral disorders among per-
sons with ID is difficult to summarize, as some studies focus on specific disorders
26

26 D i f f erential D iagnosis o f A utism S pectrum D isorder

(e.g., attention-​deficit/​hyperactivity disorder, oppositional defiant disorder, de-

pression) while others consider problem areas more broadly (e.g., aggression,
sleep disturbance). The prevalence rate of specific psychological disorders in chil-
dren with ID has been reported as 20% to 35%, which is three to five times higher
than such disturbances in the general child population (Ageranioti-​Belanger et al.,
2012). However, the prevalence rate of behavior problems not strictly diagnosti-
cally categorized is much higher; in an early study of children with ID, almost 50%
had a total behavior problem score in the clinical range, as compared with 18% of
children without ID (Dekker et al., 2002). While a wide range of behavior prob-
lems have been reported as co-​occurring with ID, the most common comorbid
disorder is attention-​deficit/​hyperactivity disorder, characterized by inattention,
hyperactivity, and impulsive behaviors (Alka et al., 2013). Other common beha-
vior disorders with ID are social problems, sleep disturbances, aggression, self-​
injury, and conduct problems (Ageranioti-​Belanger et al., 2012; Emerson et al.,
2014). Assessments of individuals with ID should incorporate interviewing, ques-
tionnaires, observations, and standardized measures that specifically tap into
these disorders.
Of concern, in a longitudinal study of 578 children and adolescents with ID,
existence of psychopathology co-​occurring with ID was both “substantial and
persistent” over a 14-​year period, and mental health treatment was rare (Einfeld
et al., 2006). The limited availability of treatment for co-​occurring behavioral
and mental health disorders in ID can exacerbate the childrearing challenges
for parents and cause disruption for the family. Indeed, research indicates that
these behavioral and mental health problems are likely to cause as much—​or
more—​distress for parents and other family members as the youth’s ID itself
(Baker et al., 2002, 2003; Blacher & Baker, 2007). This surprising finding has
been replicated and extended in other studies, showing that the behavior prob-
lems of youth with neurodevelopmental disorders exert greater influence on
parents’ stress, marital adjustment, physical health, and mental health (Baker
et al., 2003; Eisenhower et al., 2009; Neece et al., 2012; Yorke et al., 2018). Munir
(2016) summarized the evidence regarding the deleterious effects of these behav-
ioral/​mental health disorders on the individual and family with two points: (1)
Co-​occurring mental health disorders in children and adolescents with ID are
more predictive of major restrictions in educational and vocational participa-
tion and social inclusion than the severity of the ID; and (2) mental well-​being
of parents of young people with ID is more strongly influenced by the severity
of their children’s co-​occurring behavioral/​mental health disorder than by the
severity of the children’s ID.

Intellectual Disability in the Family System

Though many families cope very well, there are wide-​ranging effects on family
life when a child has ID, from the emotional impacts (e.g., parent mental health,
27

Autism Spectrum Disorder Versus Intellectual Disability27

sibling adjustment) to practical concerns (e.g., financial challenges, navigating

service systems; Blacher & Baker, 2002). In particular, parenting a child with
ID can present unique challenges that have been associated with elevations in
parents’ stress, depression, anxiety, and sense of helplessness (Gallagher et al.,
2008; Jess et al., 2018; Kanner & Kessler, 1953; Olsson & Huang, 2001). These
findings may help to explain a growing body of research showing that among
families of children with ID, parent–​child relationships are, on average, less
adaptive and more conflictual when compared to parent–​child relationships in
families with neurotypical (NT) children (Gerstein & Crnic, 2016; Marquis et al.,
2017). Specifically, the literature has reported parents of children with ID to be
more controlling, intrusive, and directive, while also showing less eye contact,
being less attentive, and displaying a more limited range of emotions compared
to parents of NT children (Blacher et al., 2013; Fenning et al., 2014; Gerstein &
Crnic, 2016). In this domain, children with BIF are similarly more likely to be ex-
posed to less positive, engaging, and sensitive parenting behaviors than children
with typical development (Fenning et al., 2007). Moreover, while children with
BIF were not observed to be more problematic, their mothers perceived more ex-
ternalizing symptoms than did mothers of typically developing children. Given
these findings, observations of parent–​child interactions during the assessment
and treatment planning phase for children with ID and their families could be
informative in identifying targets for intervention to improve child and family
functioning.
Despite this risk for maladjustment in the parent–​child relationship, researchers
have also identified parents’ positivity and dispositional optimism as particular
protective factors. Jess and coauthors (2018) reported that positivity in mothers
of children with severe ID, age 3–​18 years, moderated the impact of child beha-
vior problems, such that they experienced less stress in parenting. Another study
found that optimism in mothers of children also bolstered their ability to engage
in positive parenting behaviors (Ellingsen et al., 2013). Further, there is strong and
consistent evidence across studies that mothers higher in optimism cope much
better with adversity (Blacher et al., 2013; Blacher & Baker, 2007). In one illus-
trative study, mothers of teenagers with ID and/​or on the autism spectrum with
clinical level behavior disorders who were higher in optimism reported the lowest
stress and psychological symptoms (Blacher & Baker, 2019).
Sibling relationships are another perspective from which to view the impact of
a child with ID on the family. While at one time these relationships were deemed
to be deleterious for the typically developing sibling (Farber & Kirk, 1959; Farber
& Rowitz, 1986), many recent studies indicate the opposite may true. Although
there are contradictory findings in the literature, a recent study that utilized
multimethod and multiple informants showed that the children with siblings
who had ID scored significantly higher on empathy, teaching, and closeness in
their sibling relationship, and scored lower on conflict and rivalry in their sib-
ling relationships than those with typically developing siblings (Zaidman-​Zait
et al., 2020).
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28 D i f f erential D iagnosis o f A utism S pectrum D isorder

Education and Services for Intellectual Disability

Clinicians interacting with children with ID must also be aware of the complex
educational and service systems through which families access needed supports.
A thorough and accurate assessment can inform a child’s eligibility for special
education services under the Individuals with Disabilities Education Act (IDEA).
This 1975 law provides for a free and appropriate public education for children
with a wide range of disabilities, and it gives their parents, or legal guardians,
a voice in the child's education. Individuals with ID are eligible for services
through IDEA from birth through high school (or age 21, whichever comes first).
Recommendations following assessment where a diagnosis of ID was assigned
should include the provision of an individualized education plan (IEP), through
which academic and adaptive skills (e.g., communication, health and safety, social
skills, vocational skills) can be targeted with supplemental supports and services
in school. Given deficits in intellectual functioning, individuals with ID will ben-
efit from being taught skills that have been broken into small steps, using concrete
instructions, with immediate feedback and repetition.
Unfortunately, there are sometimes barriers to accessing such services, even
for those who would be eligible and would benefit. For example, as compared
to urban areas, children with a developmental disability living in rural areas are
significantly less likely to have regular access to mental health, medical, special
education, and early intervention services (Zablotsky & Black, 2020). Further,
children with BIF are likely to be underidentified for special education services,
despite evidence documenting their difficulty learning at a similar pace as their
peers and subsequent risk for school failure (Baglio et al., 2016; Blasi et al., 2020;
Karande et al., 2008). However, high-​quality intervention has been shown to have
demonstrable positive effects on the IQ, social skills, and adaptive behavior in
this population (Blasi et al., 2020). In diagnostic assessment for ID, it is essential
that providers, parents, and teachers attend to BIF in order to take advantage of a
powerful opportunity to intervene and enhance outcomes for this group as well.

CONSIDERING AUTISM SPECTRUM DISORDER AND

INTELLECTUAL DISABILITY TOGETHER

Given the above introduction to ID and relevant considerations, we will now tran-
sition into discussing what is known about the presentation of ASD and ID to-
gether, as well as identifying clinical guidelines for differential diagnosis of ASD/​
ID. However, this discussion must be tempered by the selectivity of autism cases
in the research literature, which has significant implications for our discussion.
Specifically, Russell and colleagues (2019) suggested the presence of a selection
bias, such that populations with ID were umderrepresented across all areas of
autism research. They analyzed 301 studies worldwide and concluded that 94%
of the participants with autism did not have ID. This figure of ID with ASD (6%)
29

Autism Spectrum Disorder Versus Intellectual Disability29

contrasts markedly with the studies focused on co-​occurring ASD/​ID in the lit-
erature, where rates range around 25%. Russell and her colleagues point out that
generally in ASD studies, persons with co-​occurring ID were “excluded or rou-
tinely under-​recruited,” and thus many studies presumably from the entire autism
spectrum were “actually based on the findings drawn from predominantly non-​
ID samples.”
This selection bias is a disservice to the clinical populations of autistic individ-
uals with ID. In fact, the disorder with the greatest rate of clinical co-​occurrence
with ASD is ID, with estimates ranging from 25% to 33% of autistic youth also
meeting criteria for ID (Maenner et al., 2020; Matson & Shoemaker, 2009;
Saunders et al., 2015). Similarly, previous studies have consistently found that
of youth with ID, the percentage with co-​occurring ASD is approximately 25%
(Arias et al., 2018; Bryson et al., 2008; CDC, 2012; Schalock et al., 2016). Thus, we
would expect about ~25% of children with either diagnosis to have both ASD and
ID. It is also important to note that the presence of other co-​occurring conditions
can confound the diagnosis of ASD (Polyak et al., 2015), but these are outside the
focus of this chapter. This high rate of co-​occurring diagnoses further reinforces
the need for careful differential diagnostic assessments that consider and assess
for both ASD and ID when one or the other is part of a referral question. To il-
lustrate some guidelines for diagnostic assessment of ASD and ID, we turn to our
clinical case example.

CASE STUDY

At 3 years old, Roberto was described as not being very interested in playing with
his parents or peers. His mother told the pediatrician that he has a lot more tan-
trums than the other kids and is having a hard time with toilet training. The pedi-
atrician tried to make silly faces and brought out some toy cars to show Roberto.
He showed interest in the cars, but not in the pediatrician’s funny faces; however,
even while interested, Roberto’s facial expression still seemed sad or neutral when
looking at the cars. On a developmental screener completed by Roberto’s mother
(e.g., Ages and Stages Questionnaire), he fell below the expected cutoff in all areas
(Communication, Problem-​Solving, Fine Motor, Gross Motor, and Personal-​
Social). Roberto’s pediatrician referred him for a complete psycho-​diagnostic de-
velopmental assessment because she wanted to rule out autism spectrum disorder
(ASD) based on some of the mother’s reported behaviors.
Results of the assessment revealed that Roberto’s Full-​Scale IQ, as determined
by the WPPSI-​IV (Wechsler, 2012), was valid, and equated to a standard score of
65, which is more than two standard deviations below the mean. The VABS-​III
(Sparrow et al., 2016) yielded an Adaptive Behavior Composite standard score
of 63, also more than two standard deviations below the mean. Per his mother’s
report, Roberto’s adaptive skills in the areas of communication, social skills, daily
living skills, and motor skills also fell in the below average range for his age.
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30 D i f f erential D iagnosis o f A utism S pectrum D isorder

To assess autism symptomatology, Roberto was administered Module 2 of the

ADOS-​2 (Lord et al., 2012). Roberto did not initiate or exhibit joint attention
with the examiner when playing, and he was noted to have very little variation
in facial expressions. His requests (e.g., during snack, for toys) were overtures
of poor quality, without well-​integrated eye contact, and he struggled to engage
in pretend play. His score fell in the classification range for autism. The ADOS-​
2 was accompanied by a clinical interview, during which Roberto’s mom stated
that he only likes to wear a couple items of clothing—​which mom has bought
multiples of. She also mentioned that he is “obsessed” with videos from a pop-
ular children’s show and will watch the same clips repeatedly, imitating what the
characters say from the show. When Roberto’s mother takes his iPad away, he
becomes dysregulated and takes a long time to recover. The lack of self-​regulation
was consistent with parent report on the Child Behavior Checklist (Achenbach &
Rescorla, 2001), where Roberto’s Externalizing Behavior T-​score was highly ele-
vated and in the clinical range. Furthermore, parent report on the CBCL also re-
vealed that Roberto was in the clinically elevated range for Withdrawn/​Depressed
and Pervasive Developmental Problems.

Clinical Impressions

As discussed above, the diagnosis of ID is founded in two criteria: deficits in in-

tellectual and adaptive functioning. Per standardized assessments, Roberto meets
these two criteria, with standardized scores on well-​established assessments.
Further, evidence that Roberto’s development is delayed across all areas, as seen
on the developmental screener, is also suggestive of ID.
Importantly however, for a child with ID to additionally meet criteria for ASD,
deficits in social communication must be beyond those that would be expected
given the ID diagnosis. Children with ID will have less well-​developed social and
communicative skills than their same-​age peers, which can cause difficulties in
social interactions. However, in a child with ID only, these skills will be commen-
surate with their intellectual capacity, thus following a similar trajectory of nor-
mative social communicative development, but immature for their chronological
age. For Roberto in particular, abnormalities with respect to several early social
communication skills (e.g., eye contact, joint attention, facial expression) would
not be expected for a child who has already developed phrase speech.
As discussed, young children with ID or those on the autism spectrum can also
present with emotion regulation deficits (Cai et al., 2018; Norona & Baker, 2017),
so this is not a strong diagnostic indicator on its own. However, as the clinical
interview revealed, Roberto’s dysregulation was frequently tied to specific ante-
cedents, like getting dressed, during play, and in response to limits pertaining
to screen or computer time. The additional information gained when exploring
these topics indicated that Roberto may have sensory sensitivity to certain tex-
tiles, an insistence on sameness, restricted interests, and echolalia. These char-
acteristics are diagnostically consistent with the restricted repetitive patterns of
31

Autism Spectrum Disorder Versus Intellectual Disability31

Are significant intellectual and adaptive functioning deficits present?

— If so, are they pervasive across domains or specific? (more pervasive = suggestive of ID)
— Are there clear patterns in severity of deficits? (e.g., nonverbal skills > verbal skills is
common in ASD)

Do social communication deficits exceed impairment expected given level of

intellectual disability?
— Are there deficits in basic social communication skills?
— Is there developmental deviance, not just delay of normative milestones?

Is there evidence of restricted or repetitive behaviors and interests (RRBs)?

— Are RRBs better explained by developmental level?
— Does the individual display hypo-or hypersensitivity to sensory stimuli?

Are any symptoms better explained by other social-emotional processes?

— Depression, anxiety, and posttraumatic stress can all produce presentations that
may be misinterpreted as cognitive, adaptive, or social communication deficits,
as well as mistaken for RRBs.

Figure 2.1. Key questions to inform differential diagnostic decisions for autism spectrum
disorder (ASD) and intellectual disability (ID).

behavior seen in ASD. See Figure 2.1 for some key questions to consider when
differentially assessing for ASD and/​or ID.
Taken together, evidence suggests that Roberto meets criteria for both ASD
and comorbid ID, given his deficits in intellectual and adaptive functioning, so-
cial communication deficits beyond what would be expected for his develop-
mental level, and the additional presence of restricted, repetitive behaviors and
interests.

The Added Impact of an Autism Spectrum Disorder

Diagnosis (ASD/​ID Vs. ID Only)

In this section, we examine the impact on children and their families when the
child has co-​occurring autism and ID, in comparison to children with ID only.
The weight of this evidence shows co-​occurring ASD and ID having a more neg-
ative impact than ID alone, across multiple domains of child and family func-
tioning (e.g. Matson & Shoemaker, 2009; Taheri et al., 2016; Viecilli & Weiss,
2015). Tonnsen and coauthors (2016), in a sample of 2,208 children, reported
that autistic children with ID had greater symptom severity than children with ID
alone, marked by poorer psychosocial and family-​related outcomes. These broad
effects are echoed in studies that have demonstrated that autistic youth with ID
have lower quality of life and are not thriving developmentally (Arias et al., 2018;
Weiss & Riosa, 2015).
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32 D i f f erential D iagnosis o f A utism S pectrum D isorder

In looking at specific outcome domains, previous literature has reported that

autistic youth with ID were more vulnerable to anxiety, mood disorders, physical
aggression, sleep problems, stereotypies, and tics than the ID only group (Bradley
et al., 2004; Farmer et al., 2015). These findings have been replicated in other
studies demonstrating that autistic youth with ID were at significantly heightened
risk across multiple measures of youth behavioral and mental health problems, as
compared to both youth with ID as well as those who were NT (Baker & Blacher,
2020). In this study, these youth scored higher on indicators of internalizing
problems, with greater anxiety-​depression, withdrawal, and thought problems.
Teachers scored those on the spectrum with co-​occurring ID as lower in making
friends/​social acceptance by peers. Their mothers also reported lower well-​being
for themselves, indicating greater anxiety and depression. Even in this relatively
small sample, when autism was diagnosed along with ID, there were multiple neg-
ative outcomes. Further, ID alone was not more problematic than the combined
diagnoses of autism and ID in any outcome measured.
Additionally, while social participation and friendships are impaired in chil-
dren with ID, these impairments appear to be even more pronounced in those on
the spectrum with co-​occurring ID. Taheri et al. (2016) examined the social par-
ticipation and friendships of children and adolescents with NT, ID, or ASD/​ID.
In a combined sample of 628 youth aged 3 to 19 years, a parent-​completed survey
asked about the youths’ activity participation and friendships. Results showed
that autistic youth with ID reported fewer friends than both the NT and ID only
groups.
It is not unexpected to find that autistic children with co-​occurring ID would
also have a greater effect on family life than ID alone. We will note two illustrative
studies. Ouyang et al. (2014) focused on parent-​reported financial burden and
need to quit employment. Family financial burden was reported in 52% of fam-
ilies of autistic youth with ID versus 29% with ID only. Similarly, 46% of families
of autistic youth with ID had parents who quit their employment related to care-
giving needs versus 25% with ID only. Petalas and colleagues (2009) conducted a
within-​family study focused on siblings (age 5–​19 years). The siblings of autistic
children with ID had higher emotional problems (but not behavior problems)
than siblings of children with ID only.

The Added Impact of an Intellectual Disability Diagnosis

(ASD/​ID Vs. ASD Only)

Here we continue to examine autistic youth with ID, but in comparison to those
youth with autism only. Overall, there is a paucity of studies comparing youth on
the spectrum with ID to those on the spectrum without ID, perhaps related to
the selection bias highlighted previously. However, available evidence seems to
suggest that there are few significant differences in the outcomes of autistic in-
dividuals based on the presence of a co-​occurring ID diagnosis. This appears to
suggest that that autism elevates risk for a wide range of negative outcomes, and
3

Autism Spectrum Disorder Versus Intellectual Disability33

that the addition of co-​occurring ID has not usually been found to add in appre-
ciable ways to the major impacts of autism. That being said, there are some con-
tradictory findings, where there are significant differences noted between these
two groups.
Behavior problems and/​or psychiatric disorders are generally not reported to
be higher in autistic youth with ID than in autistic youth without ID. Goldin et. al
(2014) conducted a study of symptoms in 219 autistic youth aged 3–​16 years, with
or without ID. These researchers examined a wide range of behavior problems,
including tantrums, repetitive behaviors, worry/​depression, avoidant behavior,
undereating, conduct problems, and overeating. There were no significant group
differences on any of the domains assessed. Baker and Blacher (2019) conducted
a study addressing the question of whether 13-​year-​old autistic youth with ID
differed from autistic youth without cognitive impairments, across a wide range
of 39 mother-​or teacher-​assessed positive and negative domains. Data were gath-
ered through standardized parent and teacher questionnaires, parent interviews,
and observation. The finding was clear: Autistic youth with ID did not differ sig-
nificantly from autistic youth without ID on any variable. Domains assessed in-
cluded behavior problems, psychiatric diagnoses, social skills, social acceptance,
and student teacher relationships. Both diagnostic groups, however, differed from
NT children in multiple domains.
While behavior problems and/​or psychiatric disorders are generally not higher
in autistic youth with ID than autistic youth without ID, there are exceptions
that beg further study. Totsika and colleagues (2011) reported that the preva-
lence of aggressive behavior was higher among autistic individuals with ID when
compared with autistic individuals without ID. Conversely, two studies have re-
ported a higher incidence of depression in autistic youth and young adults and
no cognitive impairments, as compared to those on the spectrum with ID (Fung
et al., 2015; Rai et al., 2018). One of these studies was quite large, including 4,073
persons (1,146 with co-​occurring ASD/​ID and 2,927 with ASD only). In autistic
people without ID, 19.8% reported elevated depressive symptoms, compared
with only 6% of those with ID. It is plausible that this finding may be unique
to depression. The authors noted that “those with greater cognitive ability and
thus insights into being different may be more prone to depression.” They also
considered that depression in persons with ID may be missed, due to diagnostic
overshadowing (clinicians missing depressive symptoms or misattributing it to
the ID) or to persons with ID having less advanced verbal skills to express their
difficulties.
From the perspective of family adaptability to disability, a study by Baker and
colleagues (2011) is relevant to the ASD/​ID versus ASD comparison. These au-
thors examined whether family-​level adaptability promoted beneficial outcomes
for families of autistic adolescents over a 3-​year period. Family-​level adaptability
predicted positive change in both maternal depression and child behavior prob-
lems over this study period, above and beyond the contribution of the dyadic
mother–​youth relationship. Co-​occurring ID was present in 56% of these youth.
Yet the relationship between higher family adaptability and decreased youth
34

34 D i f f erential D iagnosis o f A utism S pectrum D isorder

behavior problems was independent of ID status. That is, the beneficial effects of
family adaptability did not differ between ASD/​ID and ASD only families.
The impact on family finances and employment was also found to be greater
for families of autistic children with co-​occurring ID, as compared to autistic chil-
dren without ID (Saunders et al., 2015). This echoes the previous finding that
these financial burdens were greater in ASD/​ID as compared to ID only as well.
Interestingly, no differences were found between caregivers of children with sin-
gular diagnoses of autism or ID only. In this domain, it may be that the presence
of a dual diagnosis is always more impactful, given the need to pursue more inten-
sive or different types of services as a result.
Of note, from a developmental neuroscience perspective, Vivanti et al. (2013)
have hypothesized that the presence or absence of ID is a critical factor affecting
symptom severity in autistic individuals. They argue that rather than a co-​occurring
condition (unrelated to etiology and causality from the ASD), ID in individuals
on the autism spectrum may be conceptualized as an emergent “consequence of
severe social-​communication deficits on the experience-​dependent mechanisms
underlying neurocognitive development.” From each of two independent samples
of autistic young children, they found that the risk of co-​occurring ID increased
as the number and severity of ASD social-​communicative impairments increased.
This finding is consistent with other reports that when ASD and ID coexist, au-
tism symptoms are more severe than in children on the autism spectrum without
cognitive impairments.

Looking Ahead: Autism Spectrum Disorder and/​

or Intellectual Disability During the Transition
to Young Adulthood

Before concluding, we will reinforce the concepts discussed in this chapter

through revisiting the case study in young adulthood. Roberto had participated in
a transition program through the public-​school district from the ages of 18 to 21
that was focused on enhancing his job skills and independence. With the support
of that high school program, Roberto learned how to take the bus largely inde-
pendently, though his mother would often ride with him the first few times on a
new route to make sure he knew the bus number, route, and where to go. Roberto
still displayed instances of impaired social judgment, as demonstrated by mother’s
report of his difficulties understanding the social conventions of how to ask to
sit next to someone, smile politely, or respond to small talk on the bus. Roberto’s
mother reported worrying most about Roberto being taken advantage of; for ex-
ample, she thinks he’d be easily influenced to give someone money or open a store
credit card if asked. Roberto continued to struggle with behavioral outbursts, but
these outbursts are less frequent as he has learned self-​regulation strategies such
as counting and calming breathing.
After Roberto exited from the public high school system at age 21, his family
also found a program through a local community college where Roberto is able
35

Autism Spectrum Disorder Versus Intellectual Disability35

to take a reduced course load in a supported program, which provided indi-

vidualized tutoring and executive functioning supports (e.g., how to set alarms,
making to-​do lists, prioritizing steps). Outside of school, Roberto spends several
hours every day drawing anime, watching anime shows, and chatting online to
others about anime. For the last few years, Roberto has volunteered at local anime
conventions doing structured tasks (e.g., helping with registration, set-​up, and
distributing lunch). He has loved it, but it is event-​based and limited in hours.
Roberto’s mother helped to coordinate his volunteering and expressed hopes that
it could lead to a paid job at some point.
Roberto has continued to live at home, where he is described by his family
as having flat affect and intonation in social conversations. The amount of time
he spends on activities related to anime suggests a highly fixated interest; fur-
ther, much of his independently driven social engagement is focused on anime,
in chats online. When asked, Roberto expressed wishing he had more friends. His
mom shared that she used to organize get-​togethers for Roberto in high school
with a few classmates in his special education class, but she’s trying to step back
so Roberto can initiate these activities. Roberto is also interested in having a girl-
friend, but his attempts are either too forward or misinterpreted.
A common feature of young adults with ID and/​or on the autism spectrum is
diminished social support networks, especially with respect to friendships (van
Asselt-​Goverts et al., 2015). However, although young adults with either diagnosis
may have difficulties navigating social nuances in public spaces, there are some
potential distinctive factors to consider in this case study. Roberto’s mother’s con-
cerns about money suggests that he may be characterized as “naïve” or “gullible,”
a feature that is most closely associated with the diagnosis of ID (Greenspan et al.,
2011). However, the concerns about Roberto’s social behavior point to differences
in social approach, initiation, nonverbal communication (e.g., smiling), reci-
procity, and ability to switch social behavior based on context (e.g., just meeting
someone vs. knowing them for a long time). These concerns are more representa-
tive of the social communication differences seen in autism, which are very likely
to persist into adulthood.

DIAGNOSTIC CONUNDRA: CONCLUDING COMMENTS

Further research is needed to form a conclusive understanding of how the

strengths, challenges, and support needs of autistic individuals differ across the
full range of cognitive abilities. This understudied area could benefit too from an
expanded examination, beyond clinical outcomes, into potential neurocognitive
profiles. Such information would not only have implications for treatment, but it
also could be informative in differential diagnosis.
One of the dilemmas facing professionals diagnosing ASD and/​or ID is deter-
mining primary diagnosis and immediate treatment. There is often a rush to indi-
cate ASD, because of the increasing awareness and prevalence of the disorder, and
the importance of beginning early behavioral treatment. However, knowledge
36

36 D i f f erential D iagnosis o f A utism S pectrum D isorder

about the co-​occurrence of ID is more than an academic exercise. It is crucial

information for early interventionists and school-​based educators and can help
determine the match between content and curricular materials. For example, in-
tensive early intervention programs have been shown to result in increases of IQ
into the typical range in almost half of children with ASD (e.g., Lovaas, 1987). In
cases of autism with co-​occurring ID, intervention can vastly improve adaptive
skills and increase cognitive development, but not likely into the typically devel-
oping range.
As autistic youth are likely to be in different school placements dependent on
intellectual functioning, it seems valuable to clinicians and educators to have a
better understanding of whether, and if so, how the two groups differ, beyond
intelligence and related academic abilities. This chapter suggests that, given the
similarity in behavior problems and social skills, the same general interventions
may be effective for autistic youth with or without ID. However, there are remark-
ably few readily accessible, evidence-​based treatments for emotional, behavioral,
and social problems in either ASD or ID populations. This is an area in desperate
need of further study, given the distress these problems cause for families. As de-
velopment and testing of effectiveness occurs, it will be essential to test how treat-
ment response is or is not linked with IQ, and whether traditional mental health
intervention methods that require abstract thinking (e.g., cognitive behavioral
therapy) can be adapted to successfully treat those with ID. Additional questions
remain about treatment planning based on these diagnostic presentations; for ex-
ample, what is to be gained by differential placement into programs for autistic
preschoolers who are also diagnosed with ID? How or should long-​range goals
for autistic youth with co-​occurring ID differ from the population of youth with
ID, or autism, alone?
Although there are areas that are still unclear in this field, there is also clarity.
For example, in addition to interventions to improve core features of ASD and/​or
ID (e.g., social communication, intellectual functioning, adaptive skills), research
would suggest that when concluding a diagnostic assessment in which ASD and/​
or ID was diagnosed, it would be important to consider the following in recom-
mendations: (1) prioritization of treatment of any behavioral or mental health
problems that are part of the clinical presentation, given the significant impact on
individual and family functioning, (2) incorporation of recommendations related
to parenting interventions, to both reduce parenting stress and negative parent–​
child interactions, (3) initiation of process to request an IEP or to discuss how
accommodations in workplaces may be beneficial, and (4) referrals to supportive
resources to mitigate the negative impact on parents’ productivity.

ACKNOWLEDGMENTS

The authors acknowledge funding from the NICHD (R01HD034879, B. L. Baker,

J. Blacher, and K. Crnic, PIs) that supported much of the work cited herein.
37

Autism Spectrum Disorder Versus Intellectual Disability37

REFERENCES

Achenbach, T. M., & Rescorla, L. A. (2001). Manual for the ASEBA school-​age forms and
profiles. University of Vermont, Research Center for Children, Youth, & Families.
Ageranioti-​Belanger, S., Brunet, S., D’Anjou, G., Tellier, G., Boivin, J., & Gauthier, M.
(2012). Behaviour disorders in children with an intellectual disability. Pediatric
Child Health, 17(2), 84–​88.
Alka, A., Martin, J., Langley, K., & Thapar, A. (2013). Intellectual disability in children
with attention deficit hyperactivity disorder. Journal of Pediatrics, 163(3), 890–​895.
doi:10.1016/​j.jpeds.2013.02.043
American Academy of Child and Adolescent Psychiatry. (2018, June). Facts for fam-
ilies: Intellectual disabilities. https://​www.aacap.org/​AACAP/​AACAP/​Fam​ilie​s_​an​
d_​Yo​uth/​Fac​ts_​f​or_​F​amil​ies/​FFF-​Guide/​Child​ren-​with-​an-​Intel​lect​ual-​Dis​abil​ity-​
023.aspx
American Association of Intellectual and Developmental Disabilities. (2010). Intellectual
disability: Definition, classification, and systems of supports (11th ed.). AAIDD.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental
disorders (5th ed.). American Psychiatric Publishing.
Anderson, L. M., Shinn, C., Fullilove, M. T., Scrimshaw, S. C., Fielding, J. E., Normand,
J., Carande-​Kulis, V. G., & Task Force on Community Preventive Services. (2003).
The effectiveness of early childhood development programs: A systematic review.
American Journal of Preventive Medicine, 24(3), 32–​46.
Arias, V. D., Gomez, L. E., Moran, M. L., Alcedo, M. A., Monsalve, A., & Fontanil, Y.
(2018). Does quality of life differ for children with autism spectrum disorder and
intellectual disability compared to peers without autism? Journal of Autism and
Developmental Disorders, 48, 123–​136. doi:10.1007/​s10803-​017-​3289-​8
Baglio, G., Blasi, V., Intra, F., Castelli, I., Massaro, D., Baglio, F., Valle, A., Zanette, M.,
& Marchetti, A. (2016). Social competence in children with borderline intellectual
functioning: Delayed development and theory of mind across all complexity levels.
Frontiers in Psychology, 7, 1604. doi:10.3389/​fpsyg.2016.01604
Baker, B. L., & Blacher, J. (2015). Disruptive behavior disorders in adolescents with
ASD: Comparisons to youth with intellectual disability or typical cognitive devel-
opment. Journal of Mental Health Research in Intellectual Disabilities, 8 (2), 98–​116.
doi:10.1007/​s10803-​017-​3347-​2
Baker, B. L., & Blacher, J. (2019). Brief report: Behavior disorders and social skills in
adolescents with autism spectrum disorder: Does IQ matter? Journal of Autism
and Developmental Disorders, 50(6), 2226–​2233. https://​doi.org/​10.1007/​s10​
803-​019-​03954-​w
Baker, B. L., & Blacher, J. (2021). Behavior disorders and social skills in adolescents with
intellectual disability: Does co-​morbid autism matter? Journal of Mental Health
Research in Intellectual Disability, 14(2), 174–​188.
Baker, B. L., Blacher, J., Crnic, K., & Edelbrock, C. (2002). Behavior problems and par-
enting stress in families of three-​year-​old children with and without developmental
delays. American Journal on Mental Retardation, 107, 433–​444.
Baker, B. L., McIntyre, L. L., Blacher, J., Crnic, K., Edelbrock, C., & Low, C. (2003).
Preschool children with and without developmental delay: Behavior problems and
38

38 D i f f erential D iagnosis o f A utism S pectrum D isorder

parenting stress over time. Journal of Intellectual Disability Research, 47, 217–​230.
doi:10.1046/​j.1365-​2788.2003.00484.x
Bishop, E. G., Cherny, S. S., Corley, R., Plomin, R., DeFries, J. C., & Hewitt, J. K. (2003).
Development genetic analysis of general cognitive ability from 1 to 12 years in a
sample of adoptees, biological siblings, and twins. Intelligence, 31(1), 31–​49.
Blacher, J., & Baker, B. L. (Eds.) (2002). Families and mental retardation: A collection of
notable AAMR journal articles across the 20th century. American Association on
Mental Retardation.
Blacher, J., & Baker, B. L. (2007). Positive impact of intellectual disability on families.
American Journal on Mental Retardation, 112, (5) 330–​348.
Blacher, J., & Baker, B. L. (2019). Collateral effects of youth disruptive behavior dis-
order on mothers' psychological distress: Adolescents with Autism Spectrum
Disorder, Intellectual Disability, or Typical Development. Journal of Autism and
Developmental Disorders, 49(7), 2810–​2821.
Blacher, J., Baker, B. L., & Kaladjian, A. (2013). Syndrome specificity and mother-​
child interactions: Examining positive and negative parenting across contexts and
time. Journal of Autism and Developmental Disorders, 43, 761–​774. doi:10.1007/​
s10803-​012-​1605-​x
Blasi, V., Zanette, M., Baglio, G., Giangiacomo, A., Di Tella, S., Canevini, M. P., Walder,
M., Clerici, M., Baglio, F., & BIF group (2020). Intervening on the developmental
course of children with borderline intellectual functioning with a multimodal inter-
vention: Results from a randomized controlled trial. Frontiers in Psychology, 11, 679.
Boat, T. F., & Wu, J. T. (Eds.). (2015). Mental disorders and disabilities among low-​income
children. National Academies Press.
Bradley, E. A., Summers, J. A., Wood, H. L., & Bryson, S. E. (2004). Comparing rates of
psychiatric and behavior disorders in adolescents and young adults with severe in-
tellectual disability with and without autism. Journal of Autism and Developmental.
Disorders, 34(2), 151–​161. doi:10.1023/​b:jadd.0000022606.97580.19
Bryson, S. E., Bradley, E. A., Thompson, A., & Wainwright, A. (2008). Prevalence of au-
tism among adolescents with intellectual disabilities. Canadian Journal of Psychiatry,
53(7), 449–​459.
Cai, R. Y., Richdale, A. L., Uljarević, M., Dissanayake, C., & Nathanson, A. C. (2018).
Emotion regulation in autism spectrum disorder: Where we are and where we need
to go. Autism Research, 11(7), 962–​978.
Caplan, B., Neece, C. L., & Baker, B. L. (2015). Developmental level and psychopa-
thology: Comparing children with developmental delays to chronological and
mental age matched controls. Research in Developmental Disabilities, 37, 143–​151.
Centers for Disease Control and Prevention. (2012). Prevalence of autism spectrum
disorders—​Autism and developmental disabilities monitoring network, 14 sites,
United States, 2008. Morbidity and Mortality Weekly Report: Surveillance Summaries,
61(3), 1–​19.
Constantino, J. N., & Gruber, C. P. (2012). Social Responsiveness Scale: SRS-​2. Western
Psychological Services.
Dekker, M. C., Koot, H. M., van der Ende, J., & Verhulst, F. C. (2002). Emotional and
behavioral problems in children and adolescents with and without intellectual disa-
bility. Journal of Child Psychology and Psychiatry, 43(8), 1087–​1098.
39

Autism Spectrum Disorder Versus Intellectual Disability39

Einfeld, S. L., Ellis, L. A., & Emerson, E. (2011). Comorbidity of intellectual disability
and mental disorder in children and adolescents: A systematic review. Journal of
Intellectual Disability Research, 36, 137–​143.
Einfeld, S. L., Piccinin, A. M., Mackinnon, A., Hofer, S. M., Taffe, J., Gray, K. M., & Tonge,
B. (2006). Psychopathology in young people with intellectual disability. Journal of
the American Medical Association, 296(16), 1981–​1989.
Eisenhower, A. S., Baker, B. L., & Blacher, J. (2009). Children’s delayed development and
behavior problems: Impact on mothers perceived physical health across early child-
hood. Social Science & Medicine, 68, 89–​99. doi:10.1016/​j.socscimed.2008.09.033
Ellingsen, R., Baker, B. L., Blacher, J., & Crnic, K. (2013). Resilient parenting of pre-
school children at developmental risk. Journal of Intellectual Disability Research, 58,
664–​678. doi:10.1111/​ jir.12063
Elliott, C. D., Salerno, J. D., Dumont, R., & Willis, J. O. (2018). The differential ability
scales (2nd ed.). In D. P. Flanagan & E. M. McDonough (Eds.), Contemporary intel-
lectual assessment: Theories, tests, and issues (pp. 360–​382). Guilford Press.
Emerson, E., & Hatton C. (2007). Mental health of children and adolescents with intel-
lectual disabilities in Britain. British Journal of Psychiatry, 191, 493–​499.
Emerson, E. (2003). Prevalence of psychiatric disorders in children and adolescents with
and without intellectual disability. Journal of Intellectual Disability Research, 47, 51–​
58. doi.org/​10.1046/​j.1365-​2788.2003.00464.x
Emerson, E., Blacher, J., Einfeld, S., Hatton, C., Robertson, J., & Stanclliffe, R. J. (2014).
Environmental risk factors associated with the persistence of conduct difficulties in
children with intellectual disabilities and autistic spectrum disorders. Research in
Developmental Disabilities, 35(12), 3508–​3517. doi:10.1016/​j.ridd.2014.08.039
Farber, B., & Kirk, S. A. (1959). Effects of a severely mentally retarded child on family in-
tegration. Monographs of the Society for Research in Child Development, 24(2), 1–​112.
Farber, B., & Rowitz, L. (1986). Families with a mentally retarded child. International
Review of Research in Mental Retardation, 14, 201–​224.
Farmer, C., Butter, E., Mazurek, M. O., Cowan, C., Lainhart, J., Cook, E. H., . . . Aman,
M. (2015). Aggression in children with autism spectrum disorders and a clinic-​
referred comparison group. Autism, 19(3), 281–​291.
Fenning, R. M., Baker, J. K., Baker, B. L., & Crnic, K. A. (2007). Parenting children with
borderline intellectual functioning: A unique risk population. American Journal on
Mental Retardation, 112, 107–​121. https://​doi.org/​10.1352/​0895-​80172
Fenning, R. M., Baker, J. K., Baker, B. L., & Crnic, K. A. (2014). Parent-​child interaction
over time in families of young children with borderline intellectual functioning.
Journal of Family Psychology, 28(3), 326.
Fung, S., Lunsky, Y., & Weiss, J. A. (2015). Depression in youth with autism spectrum
disorder: The role of ASD vulnerabilities and family–​ environmental stressors.
Journal of Mental Health Research in Intellectual Disabilities, 8(3-​4), 120–​139.
Gallagher, S., Phillips, A. C., Oliver, C., & Carroll, D. (2008). Predictions of psycholog-
ical morbidity in parents of children with intellectual disabilities. Journal of Pediatric
Psychology, 33(10), 1129–​1136.
Gerstein, E., & Crnic, K. (2016). Family interactions and developmental risk associated
with early cognitive delay: Influences on children’s behavioral competence. Journal
of Clinical Child & Adolescent Psychology, 47(Suppl. 1), 1–​13.
40

40 D i f f erential D iagnosis o f A utism S pectrum D isorder

Gillberg, C., & Fernell, E. (2014). Autism plus versus autism pure. Journal of Autism and
Developmental Disorders, 44, 3274–​3276. doi:10.1007/​s10803-​014-​2163-​1
Gjevik, E., Eldevik, S., Fjæran-​Granum, T., & Sponheim, E. (2011). Kiddie-​SADS reveals
high rates of DSM-​IV disorders in children and adolescents with autism spectrum
disorders. Journal of Autism and Developmental Disorders, 41(6), 761–​769.
Goldin, R. L., Matson, J. L., Konst, M. J., & Adams, H. L. (2014). A comparison of
children and adolescents with ASD, atypical development, and typical develop-
ment on the Behavioral Assessment System for Children, Second Edition (BASC-​
). Research in Autism Spectrum Disorders, 8(8), 951–​957. https://​doi.org/​10.1016/​
j.rasd.2014.04.005
Gottfried, A. W., Gottfried, A. E., & Guerin, D. W. (2009). Issues in early prediction
and identification of intellectual giftedness. In F. D. Horowitz, R. F. Subotnik, & D.
J. Matthews (Eds.), The development of giftedness and talent across the life span (p.
43–​56). American Psychological Association.
Greenspan, S., Switzky, H. N., & Woods, G. W. (2011). Intelligence involves risk-​
awareness and intellectual disability involves risk-​unawareness: Implications of a
theory of common sense. Journal of Intellectual and Developmental Disability, 36(4),
246–​257.
Guralnick, M. J. (2005). Early intervention for children with intellectual disabil-
ities: Current knowledge and future prospects. Journal of Applied Research in
Intellectual Disabilities, 18(4), 313–​324.
Guralnick, M. J. (2017). Early intervention for children with intellectual disabilities: An
update. Journal of Applied Research in Intellectual Disabilities, 30(2), 211–​229.
Harrison, P., & Oakland, T. (2015) Adaptive Behavior Assessment System (ABAS-​3). The
Psychological Corporation.
Jess, M., Totsika, V., & Hastings R. P. (2018). Maternal stress and functions of posi-
tivity in mothers of children with intellectual disability. Journal of Child and Family
Studies, 27, 3753–​3763.
Kanner, L., & Kessler, L. (1953). Early infantile autism. Pediatric Clinics of North America,
5(3), 711–​730.
Karande, S., Kanchan, S., & Kulkarni, M. (2008) Clinical and psychoeducational profile
of children with borderline intellectual functioning. Indian Journal of Pediatrics, 75,
795–​800.
Keith, K. D., & Keith, H. E. (2020). Lives and legacies of people with intellectual disa-
bility. AAIDD.
Lake, J. K., Perry, A., & Lunsky, Y. (2014). Mental health services for individuals with
high functioning autism spectrum disorder. Autism Research and Treatment, 2014,
50420. https://​doi.org/​10.1155/​2014/​502​420
Lord, C., Rutter, M., DiLavore, P. C., Risi, S., Gotham, K., & Bishop, S. (2012). Autism
Diagnostic Observation Schedule (2nd ed.). Western Psychological Services.
Lovaas, O. I. (1987). Behavioral treatment and normal educational and intellectual func-
tioning in young autistic children. Journal of Consulting and Clinical Psychology,
55(1), 3.
Maenner, M. J., Shaw, K. A., & Baio, J. (2020). Prevalence of autism spectrum disorder
among children aged 8 years—​autism and developmental disabilities monitoring
network, 11 sites, United States, 2016. MMWR Surveillance Summaries, 69(4), 1–​12.
41

Autism Spectrum Disorder Versus Intellectual Disability41

Majnemer, A. (1998). Benefits of early intervention for children with developmental dis-
abilities. Seminars in Pediatric Neurology, 5(1), 62–​69.
Marquis, W. A., Norona, A.N., & Baker, B. L. (2017). Developmental delay and emotion
dysregulation: Predicting parent-​child conflict across early to middle childhood.
Journal of Family Psychology, 31, 327–​335. doi:10.1037/​fam0000267.
Matson, J. L. (Ed.). (2019). Handbook of intellectual disabilities: Integrating theory, re-
search, and practice. Springer Nature.
Matson, J. L., & Shoemaker, M. (2009). Intellectual disability and its relationship to au-
tism spectrum disorders. Research in Developmental Disabilities, 30, 1107–​1114.
McKenzie, K., Milton, M., Smith, G., & Ouellette-​Kuntz, H. (2016). Systematic review of
the prevalence and incidence of intellectual disabilities: Current trends and issues.
Current Developmental Disorders Reports, 3, 104–​115.
Munir, K. M. (2016). The co-​occurrence of mental disorders in children and adolescents
with intellectual disability/​intellectual developmental disorder. Current Opinion in
Psychiatry, 29(2), 95–​102.
Neece, C. L., Green, S. A., & Baker, B. L. (2012). Parenting stress and child behavior
problems: A transactional relationship across time. American Journal of Intellectual
and Developmental Disabilities, 117(1), 48–​66.
Norona, A. N., & Baker, B. L. (2017). The effects of early positive parenting and develop-
mental delay status on child emotion dysregulation. Journal of Intellectual Disability
Research, 61(2), 130–​143.
Olsson, M. B., & Hwang, C. P. (2001). Depression in mothers and fathers of children
with intellectual disability. Journal of Intellectual Disability Research, 45, 535–​543.
Ouyang, L., Grosse, S. D., Riley, C. Bolen, J., Bishop, E., Raspa, M., & Bailey, D. B. (2014).
A comparison of family financial and employment impacts of fragile X syndrome,
autism spectrum disorders, and intellectual disability. Research in Developmental
Disabilities, 35(7), 1518–​1527. doi:10.1016/​j.ridd.2014.04.009
Patel, D. R., Apple, R., Kanungo, S., & Akkal, A. (2018). Intellectual disability: Definitions,
evaluation and principles of treatment. Pediatric Medicine, 1, 1–​11.
Petalas, M. A., Hastings, R. P., & Nash, S., Lloyd, T., & Dowey, A. (2009). Emotional and
behavioural adjustment in siblings of children with intellectual disability with and
without autism. Autism, 13(5), 471–​483. doi:10.1177/​1362361309335721
Peters-​Scheffer, N., Didden, R., Korzilius, H., & Sturmey, P. (2011). A meta-​analytic study
on the effectiveness of comprehensive ABA-​based early intervention programs for
children with autism spectrum disorders. Research in Autism Spectrum Disorders,
5(1), 60–​69.
Polyak, A., Kubina, R. M., & Girirajan, S. (2015). Comorbidity of intellectual disability
confounds ascertainment of autism: implications for genetic diagnosis. American
Journal of Medical Genetics Part B: Neuropsychiatric Genetics, 168(7), 600–​608.
Rai, D., Heuvelman, H., Dalman, C., Culpin, I., Lundberg, M., Carpenter, P, &
Magnusson, C. (2018). Association between autism spectrum disorders with or
without intellectual disability and depression in young adulthood. JAMA Network
Open, 1(4), e181464.
Reynolds, C. R., & Kamphaus, R. W. (2015). Behavior Assessment System for Children
(3rd ed.). Pearson.
Roid, G. H., Miller, L. J., & Koch, C. (2013). Leiter International Performance Scale.
Stoelting.
42

42 D i f f erential D iagnosis o f A utism S pectrum D isorder

Russell, G., Mandy, W, Elliott, D., White R., Pittwood, T., & Ford, T. (2019). Selection
bias on intellectual ability in autism research: A cross-​sectional review and meta-​
analysis. Molecular Autism, 10. https://​doi.org/​10.1186/​s13​229-​019-​0260-​x
Rutter, M., Le Couteur, A., & Lord, C. (2003). Autism Diagnostic Interview-​Revised.
Western Psychological Services.
Saunders, B., Tilford, J. M., Fussell, H. J., & Schulz, E. G., Casey, P. H., & Kuo, D. Z. (2015).
Financial and employment impact of intellectual disability on families of children
with autism. Families Systems and Health, 33(1), 36–​45. doi:10.1037/​fsh0000102
Schalock, R. L., Verdugo, M. A., Gomez, L. E., & Reinders, H. (2016). Moving us to-
wards a theory of individual qualify of life. American Journal of Intellectual and
Developmental Disabilities, 121(1), 1–​12. doi:10.1352/​1944-​7558-​121.1.1
Shaffer, D., Fisher, P., Lucas, C. P., Dulcan, M. K., & Schwab-​Stone, M. E. (2000).
NIMH Diagnostic Interview Schedule for Children Version IV (NIMH DISC-​
IV): Description, differences from previous versions, and reliability of some
common diagnoses. Journal of the American Academy of Child and Adolescent
Psychiatry, 39(1), 28–​38.
Simonoff, E., Pickles, A., Charman T., Chandler, S., Loucas, T., & Baird, G. (2008).
Psychiatric disorders in children with autism spectrum disorders: Prevalence co-
morbidity, and associated factors in a population-​derived sample. Journal of the
American Academy of Child and Adolescent Psychiatry, 47(8), 921–​929.
Sparrow, S., Cicchetti, D., & Saulnier, C. A. (2016). Vineland Adaptive Behavior Scales
(3rd ed.) (Vineland-​3). Pearson.
Srivastava, A. K., & Schwartz, C. D. (2014). Intellectual disability and autism spectrum
disorders: Causal genes and molecular mechanisms. Neuroscience and Biobehavioral
Reviews, 46(2), 161–​174. doi:10.1016/​j.neubiorev.2014.02.015
Strang, J. F., Kenworthy, L., Daniolos, P., Case, L., Wills, M. C., Martin, A., & Wallace, G.
L. (2012). Depression and anxiety symptoms in children and adolescents with au-
tism spectrum disorders without intellectual disability. Research in Autism Spectrum
Disorders, 6, 406–​412.
Taheri, A., Perry, A., & Minnes, P. (2016). Examining the social participation of children
and adolescents with intellectual disabilities and autism spectrum disorder in rela-
tion to peers. Journal of Intellectual Disability Research, 60(5), 435–​443. doi:10.1111/​
jir.12289
Thurm, A., Farmer, C., Salzman, E., Lord, C., & Bishop, S. (2019). State of the
field: Differentiating intellectual disability from autism spectrum disorder. Frontiers
in Psychiatry, 10, 526.
Tonge, B. J., & Einfeld, S. L. (2003). Psychopathology and intellectual disability: The
Australian child to adult longitudinal study. International Review of Research in
Mental Retardation, 26, 61–​91.
Tonnsen, B. L., Boan, A. D., Bradley, C. C., Charles, J., Cohen, A., & Carpenter, L. A.
(2016). Prevalence of autism spectrum disorders among children with intellectual
disability. American Journal on Intellectual and Developmental Disabilities, 121, 6,
487–​500. doi:10.1352/​1944-​7558-​121.6.487
Totsika, V, Hastings, R. P., Emerson, E., Lancaster, G. Q., & Berridge, D. M. (2011). A
population-​based investigation of behavioural and emotional problems and ma-
ternal mental health: Associations with autism spectrum disorder and intellectual
disability. Journal of Child Psychology and Psychiatry, 52(1), 91–​99.
43

Autism Spectrum Disorder Versus Intellectual Disability43

van Asselt-​Goverts, A. E., Embregts, P. J. C. M., Hendriks, A. H. C., Wegman, K. M.,

& Teunisse, J. P. (2015). Do social networks differ? Comparison of the social net-
works of people with intellectual disabilities, people with autism spectrum disorders
and other people living in the community. Journal of Autism and Developmental
Disorders, 45(5), 1191–​1203.
Viecilli, M. A., & Weiss, J. A. (2015). Reliability and validity of the pediatric quality
of life inventory with individuals with intellectual and developmental disabilities.
American Journal of Intellectual Developmental Disabilities, 120(4), 289–​301. https://​
doi.org/​10.1352/​1944-​7558-​120.4.289
Vivanti, G., Barbaro, J., Hudry, K., Dissanayake, C., & Prior, M. (2013). Intellectual de-
velopment in autism spectrum disorders: New insights from longitudinal studies.
Frontiers in Human Neuroscience, 5, 1–​8. https://​doi.org/​10.3389/​fnhum.2013.00354
Wechsler, D. (2008). Wechsler Adult Intelligence Scale (4th ed.). Pearson.
Wechsler, D. (2012). Wechsler Preschool and Primary Scale of Intelligence-​Fourth Edition
(WPPSI-​IV): Administration and scoring manual. The Psychological Corporation.
Wechsler, D. (2014). Wechsler intelligence scale for children (5th ed.). Pearson.
Weiss, J. A., & Riosa, P. B. (2015). Thriving in youth with autism spectrum disorder
and intellectual disability. Journal of Autism and Developmental Disorders, 45, 2474–​
2486. doi:10.1007/​s10803-​015-​2412-​y
Yorke, I., White, P., Weston, A., Rafla, M., Charman, T., & Simonoff, E. (2018). The asso-
ciation between emotional and behavioral problems in children with autism spec-
trum disorder and psychological distress in their parents: A systematic review and
meta-​analysis. Journal of Autism and Developmental Disorders, 48(10), 3393–​3415.
Zablotsky, B., & Black, L. I. (2020). Prevalence of children aged 3–​17 years with de-
velopmental disabilities by urbanicity: United States, 2015–​2018. National Health
Statistics Reports, Number 139, 1–​5.
Zaidman-​Zait, A., Yechezkiely, M., & Regev, D. (2020). The quality of the relationship
between typically developing children and their siblings with and without intel-
lectual disability: Insights from children's drawings. Research in Developmental
Disabilities, 96, 103537 doi:10.1016/​j.ridd.2019.1035