Journal of Autism and Developmental Disorders, Vol. 28, No.

2, 1998

The Responses of Autistic Children to the Distress of

Others

Alyson L. Bacon,1 Deborah Fein,1,5 Robin Morris,2 Lynn Waterhouse,3 and Doris Allen4

The behavior of preschool children from five groups (developmental language disordered,
high-functioning autistic, low-functioning autistic, mentally retarded, and normally develop-
ing) were coded in three situations: presentation of a nonsocial orienting stimulus (an un-
familiar noise) and two social situations involving simulated distress on the part of an adult
with whom they were playing. Cognitive level was correlated with level of responsiveness to
stimuli only for the two retarded groups (mentally retarded and low-functioning autistic).
Girls showed more prosocial behavior than boys in both social situations, independent of
diagnosis. The language-disordered children showed only mild and subtle social deficits. The
low-functioning autistic children showed pronounced deficits in responding in all situations.
The mentally retarded and high-functioning autistic children showed good awareness of all
situations, but were moderately impaired in their ability to respond prosocially; they rarely
initiated prosocial behavior, but did respond to specific prompts. The behavioral feature that
marked both autistic groups, in contrast to all other groups, was a lack of social referencing;
they did not tend to look toward an adult in the presence of an ambiguous and unfamiliar
stimulus. Results are discussed in terms of variability between and among high- and low-
functioning autistic children, and implications for the core deficits in autism.
KEY WORDS: Preschool children; autism; prosocial behavior.

INTRODUCTION document abnormalities in the areas of social rela-

Since severe social abnormalities are central to
the disorder of autism (Wing, 1980), many researchers
have attempted to describe and/or quantify the nature
of the social deficit in autism. Although much of our
knowledge comes from detailed clinical accounts of
the behavior of autistic children (Rutter, 1984; Wing,
1980), systematic attempts have also been made to as-
sess these abnormalities under experimental condi-
tions. Reviews of autistic children's social deficits
(Howlin, 1986; Lord, 1993; Volkmar & Klin, 1993)
'University of Connecticut, Storrs, Connecticut 06268.
2Georgia State University, Atlanta, Georgia 30303.
hrenton State College, Trenton, New Jersey 08650.
4Albert Einstein College of Medicine, Yeshiva University, New
York, New York 10033.
5Address all correspondence to Deborah Fein, Department of Psy-
chology, University of Connecticut, Storrs, Connecticut 0626S.
tionships (Sigman, Ungerer, Mundy, & Sherman,
1984); recognition and comprehension of emotion in
others (Braverman, Fein, Lucci, & Waterhouse, 1989;
Fein, Lucci, Braverman, & Waterhouse, 1992; Hob-
son, 1983, 1984; Yirmiya, Sigman, Kasari, & Mundy,
1992); eye-to-eye gaze (Wing, 1980); impoverished
play (Ungerer & Sigman, 1981); lack of cooperative
play (Mchale, 1983; Mchale, Olley Marcus, & Sim-
meonsson, 1981); and lack of initiation of contact to
peers (Hauck, Fein, Waterhouse, & Feinstein, 1995;
Lord, 1984) and to adults (Capps, Sigman, & Mundy,
1994; Kasari, Sigman, & Yirmiya, 1993). Most studies
of autistic social behavior have focussed on initiations
of or responses to verbal and nonverbal communica-
tion, play, attachment, or other social behaviors.
Comparatively few studies have examined another im-
portant aspect of social behavior: attention to the af-
fective displays of others. There are many crucial

129
0162-3257/98/0400-0129$15.00/0 c 1998 Plenum Publishing Corporation
130
aspects of early normal social development that in-
volve attention to others' affect and affective interplay
between caregiver and child. These underlie all fur-
ther social development. They also bear on theoreti-
cal debates on the nature of the underlying deficit in
autism (see Discussion).
Among the most important of these behaviors
are the following:
1. the child's awareness of, or orienting to, the
affective displays of others, beginning in the
first half of the first year (Trevarthen, 1979).
Finding others' emotional displays to be of in-
trinsic interest is prerequisite to later develop-
ments.
2. the child's spontaneous seeking of emotional
information from the adult's face when faced
with a stimulus of uncertain valence (social
referencing), in the second half of the first
year. Social referencing is firmly established by
9-12 months in normal development (Fein-
man, 1982; Klinnert, Campos, Sorce, Emde, &
Svejda, 1983; Moore & Corkum, 1994), and
represents an example of "secondary intersub-
jectivity" (Trevarthen & Hubley, 1978), in
which there is coordination between the in-
fant, an adult, and an object, as in joint visual
attention ("what is the adult looking at?"),
protodeclarative gestures ("look at what I'm
looking at"), and social referencing ("how
should I feel about this object?").
3. the child's development of an appropriate be-
havioral repertoire to respond prosocially to
expressed negative affect, around age 2 (Zahn-
Waxler & Radke-Yarrow, 1990). Prosocial be-
havior is defined by Staub (1970) as behavior
that benefits another and is intended to do so.
Zahn-Waxler, Radke-Yarrow, Wagner, and
Chapman (1992) conceptualize affect as an es-
sential component of prosocial behavior and
suggested a developmental model in which
precursor behaviors such as general agitation
yield to taking of positive action, by age 2, in
response to others' distress. These simple
prosocial actions (e.g., patting) then develop
into a more varied and effective repertoire.
From the behavioral evidence, they conclude
that 2-year-olds have: "(a) the cognitive capac-
ity to interpret the physical and psychological
states of others, (b) the emotional capacity to
affectively experience the other's state, and (c)
Bacon, Fein, Morris, Water-house, and Allen
the behavioral repertoire that permits the pos-
sibility of trying to alleviate discomfort in oth-
ers" (p. 127). Prosocial behavior has indeed
been observed in preschool children (Eisen-
berg-Berg & Lennon, 1980; Yarrow, Scott, &
Waxier, 1973). Radke-Yarrow and Zahn-Wax-
ler (1976) found that 80% of young children
responded prosocially in at least one of several
experimentally created situations. Helping and
comforting along with sharing are specific as-
pects of prosocial responding that have been
found to emerge in the second year of life
(Rheingold, Hay, & West, 1976; Ross & Gold-
man, 1977). Other noted changes are in-
creased imitation of emotion and increased
negative behavior (although this is fairly low
frequency). Showing a pleased response (e.g.,
laughing, smiling) to the distressed adult was
found to be infrequent. Zahn-Waxler and
Radke-Yarrow (1990) found that by the end
of the second year of life, children initiate con-
tact with the distressed person in a variety of
positive ways, including embracing, inspecting,
sharing, and giving and using language to label
their emotions. Further, Eisenberg, Paster-
nack, Cameron, and Tryon (1984) found that
children who show only elicited prosocial be-
havior were relatively dependent and submis-
sive, with an external locus of control, and that
spontaneous prosocial acts were found in
higher frequency in children who were so-
ciable and relatively low in dependence.
Autistic children have been found to be deficient
on a variety of tasks measuring comprehension of
others' expressed emotion on experimental cognitive
tasks. For example, they have difficulty in matching
emotional expressions and in comprehending affect
terms (Braverman et al., 1989; Yirmiya et al., 1992),
in understanding the appropriate contexts of emo-
tions (Fein et al., 1992), and in recognizing how facial
expressions, vocalizations, and gestures are related
(Hobson, 1986a, 1986b). Few studies, however, have
examined the spontaneous reactions of autistic chil-
dren to the affective displays of others in more natu-
ralistic settings that would parallel the observations
of normal children in their attending, seeking, and
responding to others' affective displays. Sigman,
Kasari, Kwon, and Yirmiya (1992) studied autistic
children's comprehension of bodily and vocal ges-
tures expressing negative emotions. They found that
 Responses of Autistic Children to Distress of Others
normal (M age 19.8 months) and mentally retarded
(M age 41.7 months) children appeared more con-
cerned than the autistic children (M age 42.4
months) with the distress of an adult, although they
noted that not many children in any group exhibited
much comforting behavior. Capps, Kasari, Yirmiya,
and Sigman (1993) found that young autistic chil-
dren's responsiveness to the emotions of others were
correlated with parental judgments of emotional ex-
pressiveness. Few autistic children were found to
look toward their parent's face when successfully
completing a task (Kasari, Sigman, Baumgartner, &
Stipek, 1993).
There is, therefore, a dearth of information on
the spontaneous behavior of autistic children relative
to the expressed affect of others, or on its relationship
to gender or cognitive level. Cognitive level often de-
termines the form that a behavioral deficit or a be-
havioral competence will take. For example, Mundy,
Sigman, and Kasari (1994) found that developmental
level partially predicted which type of joint attention
behavior, such as protodeclarative or turn-taking,
would be expressed by autistic children. It has been
suggested by several groups (Cohen, Paul, & Volkmar,
1987; Rapin, 1996; Rutter & Garmezy, 1983; Tsai,
1992) that high- and low-functioning autism may rep-
resent subtypes that are distinct with respect to not
only cognitive level, but with respect to behavior, out-
come, and possibly etiology. Therefore, it becomes im-
portant not only to examine the correlation of IQ with
behavioral measures but to treat high- and low-func-
tioning autism as possibly different groups.
The aim of the present study is to investigate
the spontaneous and elicited responses of high- and
low-functioning autistic children to the naturalistic
distress of an unfamiliar adult. The addition of a
nonsocial orienting stimulus (an unfamiliar noise) al-
lowed us to compare awareness of a social versus a
nonsocial event, and provided an opportunity to ob-
serve social referencing. The autistic children are
compared in this study to developmentally language-
disordered and mentally retarded children as well as
to normally developing children. To partially control
for the fact that many autistic children show mental
retardation, it is instructive to compare their re-
sponses to nonautistic mentally retarded children. In
addition, developmentally language-disordered chil-
dren make an appropriate comparison group for the
autistic children whose nonverbal IQs are in the nor-
mal range, and who show similar cognitive profiles,
with verbal functioning lower than nonverbal func-
131
tioning. The children in these clinical groups were
also compared to a sample of normal children
matched for chronological age.
METHOD
Participants
The children in this study were recruited for a
larger research project dealing with the classification
of developmental disorders, whose objectives and
main results are presented elsewhere (Rapin, 1996).
Children at the six geographic sites were recruited
either through clinical referral or by soliciting appro-
priate local programs. Inclusion criteria for all sub-
jects included English as a first language, no active
uncontrolled seizures, no known brain lesions, hear-
ing >25 dB binaurally, no significant motor or sen-
sory handicaps, and no high dosages of
anticonvulsants or behavior-altering medication.
Videotapes of play sessions of 233 preschool children
were available for analysis. Twenty-nine children
were excluded from the study because of inadequate
sessions (i.e., one or more of the experimental
prompts was missing). An additional 5 children were
excluded from the study because their nonverbal ra-
tio IQ scores were <10 (see below). The remaining
subjects were divided into five groups.
Group 1 consisted of 42 children diagnosed with
developmental language disorder (OLD). The diag-
nosis of OLD was given to children who showed lan-
guage deficits that could not be attributed to mental
deficiency, hearing loss, frank neurological and
neuromuscular deficit, severe emotional disorders,
and/or autism. Discrepancy criteria were employed to
establish the language deficit. Children were tested
with the Test of Early Language Development
(TELD; Hresko, Reid, & Hammill, 1981). Children
were identified as DLD if TELD scores were defi-
cient (less than 80 or 1 SD below nonverbal IQ) or
if they showed 1 SD difference between chronologi-
cal age and language age estimated from MLU
(mean length of utterance) (see Rapin, 1996, for de-
tailed methods).
Groups 2 and 3 consisted of children diagnosed
with autism according to DSM-III-R (American Psy-
chiatric Association [APA], 1987). Selection criteria
for these children included being identified by a clini-
cal professional (using the brief Wing interview) as
having significant impairment in social relatedness,
132
and meeting DSM-III-R criteria for Infantile Autism
(assessed by a child psychiatrist). The two groups dif-
fered with regard to the children's functioning level.
Group 2 consisted of 32 children diagnosed with
high-ftinctioning autism (HiAut). Their nonverbal IQ
scores were 80 or above on the Stanford-Binet-4th
ed. (Thorndike, Hagan, & Saltier, 1986). Group 3
consisted of 51 children diagnosed with low-function-
ing autism (LoAut). Their nonverbal IQ scores were
less than 80 on the Stanford-Binet. Six children who
met criteria for Pervasive Developmental Disorder,
but not for Infantile Autism, were excluded from the
analyses presented in this paper.
Group 4 consisted of 39 children diagnosed with
mental retardation. Their nonverbal IQ scores as as-
sessed by the Stanford-Binet were less than 80 and
they showed no significant signs of autism.
The fifth group of 29 children were normal con-
trols. These children were recruited from two pre-
schools in Atlanta, GA. They were identified by
teachers as having no significant cognitive or behav-
ioral difficulties. Although cognitive data was not
available for the total group of normal controls, Pe-
abody Picture Vocabulary Tests available on 19 of the
29 had a mean standard score of 110 and Stanford-
Binet Abstract Visual Reasoning scores available on
11 of the 29 had a mean Performance IQ of 104,
suggesting an average functioning group of children.
Characteristics of the sample are shown in Table I.
Additional details on exclusion and inclusion criteria
for all groups can be found in Rapin (1996).
The total autistic group was divided into high-
and low-functioning subgroups on the basis of a non-
verbal IQ of 80, so that the OLD children would
match the higher functioning autistic children in non-
verbal cognitive functioning and the mentally retarded
Table I. Sample Characteristics of Developmentally Language Disordered, High-Functioning Autistic,
Low-Functioning Autistic, Mentally Retarded, and Normal Children
DLD HiAut
(n = 42) (n = 32)
Male = 29 Male = 26
Age (months)
M 53.93 55.84
5D 12.51 14.36
Language ratio
M 81.69 59.50
SD 24.34 18.27
Nonverbal ratio
M 107,52 103.00
SD 19.60 24.40
Bacon, Fein, Morris, Waterhouse, and Allen
(MR) group would match the lower functioning autis-
tic children. Since a significant proportion of the two
retarded groups (MR and LoAut) scored below the
norms on the tests given and since it was important
to preserve the differences among these children, a
language ratio was calculated for each child by dividing
the language mental age (MA) by the chronological
age of the child and then multiplying by 100. The lan-
guage MA was derived from the TELD (Hresko et
al., 1981) or Sequenced Inventory of Communication
Development-Revised (SICD-R; Hendrick, Prather, &
Tobin, 1984). The SICD-R was used as a lower exten-
sion for children who could not perform the TELD.
A nonverbal ratio score was also calculated for each
child by dividing the nonverbal MA by the chronologi-
cal age of each child and multiplying by 100. The non-
verbal MA was obtained from the Stanford-Binet
subscales of Pattern Analysis and Copying. The Kent
Scoring system of the Bayley Scales of Infant Devel-
opment (Bayley, 1969; Reuter, Stancin, & Craig, 1981)
was used as a lower extension for children who could
not perform the Stanford-Binet.
The nonverbal ratios of the HiAut and OLD
children were not significantly different (t — .88), nor
were the nonverbal ratios of the LoAut and MR chil-
dren (t = 1.29). The language ratios of the HiAut
children were significantly lower than those of the
DLD children (t = 4.31, p < .001) and the language
ratios of the LoAut children were significantly lower
than those of the MR children (t = 2.37, p < .02).
Procedures
The children participated in a semistructured
play session which was videotaped (see below). The
LoAut MR Normal
(n = 51) (n = 39) (« = 29)
Male = 47 Male = 28 Male = 18
62.04 55.85 55.72
17.92 14.68 13.49
23.20 34.41 Not
20.90 23.85 avail.
45.35 50.64 Not
20.06 18.15 avail.
 Responses of Autistic Children to Distress of Others
children were also evaluated with a variety of assess-
ment instruments.
Each child was brought to the 25-minute play
session by a familiar adult (parent or teacher) who
remained with the child for the first 5 minutes. A
standardized set of developmentally varied toys, in-
cluding sensorimotor, functional and symbolic, were
made available. During these first 5 minutes, the child
was encouraged to play with any of the available toys
while the experimenter chatted with the familiar
adult. During this time an orienting stimulus was given.
The stimulus was a loud animal-like honking-braying
sound emitted from a speaker in the room.
Shortly after this, the familiar adult left the
room and the experimenter interacted with the child,
engaging him/her in play with the toys. After about
10 minutes, at an appropriate juncture to make it ap-
pear as natural as possible, the experimenter simu-
lated distress by banging his/her hand/knee/elbow on
the wall or a table, with appropriate facial expression
and exclamation (ouch!), followed by rubbing of the
injured body part. If the child showed distress or con-
cern, he/she was reassured that "everything was OK."
A third probe, the lost pen, occurred about 5
minutes after the simulated distress. The experi-
menter covertly placed a pen in a place that was vis-
ible to the child but not obvious. Soon after, the
experimenter exclaimed "Oh no! I've lost my pen. It
was my favorite pen." This was repeated with the ex-
perimenter appearing mildly upset while making an
obvious search for the pen. In the event that the child
did not respond in a prosocial manner, the child was
given an additional prompt, "can you help me find
my pen?" Regardless of the child's response, the epi-
sode was always ended with the experimenter finding
the pen and making this clear to the child.
Cognitive measures given to all of the children
in the clinical groups were: Stanford-Binet Verbal
Reasoning Standard Area Score, Stanford-Binet Ab-
stract Visual Standard Area Score, The Peabody Pic-
ture Vocabulary Test-R (Dunn & Dunn, 1981),
Vineland Adaptive Behavior Scales (Sparrow, Balla,
& Cicchetti, 1984).
Coding
Three sets of behavior were coded for each
child: their responses to the orienting stimulus, an ani-
mal-like honking-braying sound, to the simulated
physical distress, and to the lost pen episode. Coding
133
was done independently by two coders who were na-
ive with respect to diagnosis, in order to establish in-
terrater reliability. Coders were guided by a coding
manual that described how to decide if a behavior
had or had not occurred. Coders were trained and
interrater reliability was established on 30 cases.
Once established, each of the remaining tapes was
coded by one coder with 20% being checked by the
primary investigator (A.B.) to ensure that the coding
did not drift. In addition, 40 tapes selected from
across the study were coded by both coders at the
end of the study to ascertain ongoing interrater re-
liability. It should be noted that some behaviors oc-
curred too infrequently for interrater reliability to be
established. Where interesting, these results are re-
ported for descriptive purposes.
Responses to the Orienting Stimulus. The pres-
ence or absence of 7 categories of behavior was
coded (Table II). Kappas for the first and second re-
liability study, respectively, follow descriptions of the
behavior, in parentheses, for those codes where the
behavior occurred frequently enough for kappas to
be calculated.
Responses to Simulated Distress. The presence or
absence of 12 categories of behavior was coded (Table
II). Kappas for the first and second reliability study,
respectively, follow descriptions of the behavior, in pa-
rentheses, for those codes where the behavior oc-
curred frequently enough for kappas to be calculated.
Responses to the Lost Pen. The lost pen paradigm
was coded as a hierarchical mutually exclusive sys-
tem. The child's response to the first prompt was
coded according to 3 categories described in Table
II. Children who did not make the prosocial response
were given an additional prompt and were then given
one of 4 codes described in Table II. Kappas were
obtained for responses to the first prompt and were
for the first and second reliability study, respectively:
.67 and .62. Kappas for the second prompt were .88
and .52.
RESULTS
ANOVAs were run on mean responses for each
experimental variable, with diagnosis and sex as the
independent variables. Where significant results were
found, post hoc Tukey tests were carried out. Chi-
square analyses on frequencies of children showing
each response within each diagnostic group were also
run, and yielded identical patterns of significance to
134 Bacon, Fein, Morris, Waterhouse, and Allen

the ANOVAs. Because the autistic and nonautistic
comparison groups differed on their language scores,
PPVT language age was also used as a covariate in
these analyses. Because PPVT scores were not avail-
able for the normal group, and because all normal
children had been identified as having age-appropriate
language by their teachers, chronological age was used
as the best estimate of language age for this group.
Table III summarizes the significant effects
found for diagnosis on the orienting stimulus and
simulated distress paradigms.
Orienting Stimulus
There was a significant diagnosis effect for re-
sponse/no response to the orienting stimulus (F =
3.27, p < 0.02) (see Table III). Post hoc Tukey tests
revealed the significant difference to be between the
LoAut children and the normal children: 41% of the
LoAut children did not respond in any observable
way to the orienting stimulus. However, when lan-
guage age was covaried, the diagnosis effect became
nonsignificant; therefore, group differences in overall
responsivity to the orienting stimulus could be ac-
counted for by the degree of their language retarda-
tion.
A significant effect was also obtained for diag-
nosis for the variable, looks at adult (F = 4.12, p <
.01) (see Table III). These results were unaffected by
covarying language age. It can be seen from Table
III that the highest percentage of looking at the adult
occurred in the normal children (76%) followed by
OLD and MR children (50 and 49%, respectively),

Table II. Response Codes and Kappas

Responses to the orienting stimulus

1. No response (.83, .94).
2. Appropriate verbalization (.87, .89); (e.g., "What was that?").
3. Inappropriate verbalization (.65, .48); (e.g., idiosyncratic verbalizations.).
4. Looks around (.47, .80).
5. Looks at adult (.67, .65).
6. Giggles/laughs (— , 1.0).
7. Other (1.0, .78).
Responses to simulated distress
1. No response (1.0, .92).
2. Looks at distressed adult (1.0, .92).
3. Appropriate verbalization (e.g., "You banged your elbow.").
4. Inappropriate verbalization (.67, .93); (e.g., idiosyncratic verbalizations or
verbalizations unrelated to event, e.g., "Can I play with the telephone?").
5. Verbal prosocial response (— , .79); (e.g., "Are you ok?").
6. Nonverbal prosocial response (— , 1.0); (e.g., kissing, hugging, patting).
7. Physical response (.47, — ) (e.g., child points to the injury).
8. Pleased response to distressed adult (— , .70) (e.g., child laughs at adult).
9. Self-concerned response (e.g., "I'm ok").
10. Withdraws (e.g., child covers ears or eyes).
11. Disruption of ongoing behavior with no other specific response.
12. Other.
Responses to the lost pen
Response to first prompt
1. No response.
2. Recognition response (e.g., child comments but doesn't begin to look for
the pen).
3. Prosocial behavioral response (e.g., chid begins to look for the pen).
Response to additional prompt
1. No response.
2. Refusal (e.g., child refused to look for pen).
3. Proforma response (e.g., child verbally acquiesces but there is no
effective behavioral response or any looking on the part of the child is
perfunctory).
4. Prosocial response (e.g., child helps to look for the pen).
 Responses of Autistic Children to Distress of Others 135

Table III. Significant Differences in Percentage of Children Making Each Response in the Orienting and Simulated Distress
Paradigms Groupa
Group"
DLD HiAut LoAut MR Norm F Post Hoc
Orienting stimulus
Response (vs. no response) 71 78 59 80 93 3.27df N>LoAut
Looks at adult 50 34 33 49 67 4.12d N>HiAut
N>LoAut
Stimulated distress
Response (vs. no response) 90 94 57 87 97 9.37e LoAut < all groups
Looks at adult 90 91 55 85 97 9.18e LoAut>all groups
Pleased response 17 0 6 10 0 2.80c DLD>HiAut
Prosocial nonverbal 14 0 4 5 0 2.84* DLD>norm, HiAut, LoAut
aDLD = Developrnentally language disordered; HiAut = high-functioning autistic; LoAut = low-functioning autistic; MR = mentally
retarded; Norm = normal.
bp < .05.
cp < .02.
Jp < .01.
<p < .001.
fa goes to nonsignificance with covariance.

followed by the HiAut and LoAut children (34 and
33%, respectively). Post hoc Tukey tests revealed the
significant differences to be between the normal and
both groups of autistic children.
No sex effects were found for any orienting
stimulus variable.
Simulated Distress
There was a significant diagnosis effect for re-
sponse/no response to the simulated distress of the ex-
perimenter (F - 9.37, p < .0001) (see Table III).
Covarying language age did not significantly affect
these results. Post hoc Tukey tests revealed the sig-
nificant difference to be between the LoAut children
and all other diagnostic groups. Most of the subjects
responded in some way to the simulated distress of
the adult, but 43% of the LoAut subjects did not re-
spond in any observable way.
There was a significant diagnosis effect for look-
ing at the distressed adult (F = 9.18, p < .0001) (see
Table III). Covarying language age did not change
this analysis. As above, post hoc Tukey tests revealed
the significant difference to be between the LoAut
children and all other diagnostic groups. The over-
whelming majority of subjects in all other groups did
in fact look at the adult but only 55% of the LoAut
subjects did so.
A trend for sex differences was found for proso-
cial verbal response in the simulated distress paradigm
(F = 2.74, p < .1). For this variable, covarying lan-
guage age increased the sex difference to a signifi-
cant one (F = 4.04, p < .05). 10% of the girls
responded in a prosocial verbal manner while only
2% of the boys responded in this way. This was,
therefore, a low-frequency behavior with only 8 chil-
dren (5 girls, 3 boys), constituting 4% of the total
sample, exhibiting this behavior.
A significant difference for diagnosis (F = 2.84,
p < .05) and the interaction of diagnosis and sex (F
= 3.01, p < .05) was also found for prosocial non-
verbal behavior. As might be expected for a nonverbal
behavior, covarying language age did not significantly
affect this analysis. Ten children exhibited this behav-
ior, 6 of whom were diagnosed with DLD. The post
hoc Tukey tests for the diagnosis effect showed that
the DLD children showed this behavior more than
the normal, HiAut, or LoAut children. The Sex x Di-
agnosis interaction derives from sex distributions of
DLD 5 boys 1 girl; MR 1 boy 1 girl; LoAut 0 boys
2 girls. Thus, prosocial nonverbal responses were also
a low-frequency behavior (5% of total sample).
A significant difference was found for diagnosis
for showing a pleased response to the distressed adult
(F = 2.80, p < .02) (Table III). Covarying language
age did not significantly affect this analysis. Post hoc
Tukey tests revealed the difference to be between the
136
DLD children (17%) and the HiAut children (0%).
This was, therefore, also a low-frequency behavior.
Lost Pen
This paradigm proved effective in detecting dif-
ferences on the basis of diagnosis (Table IV). Re-
sponses on the first part of the paradigm were
significantly different by diagnosis (F = 19.98, p <
.0001). Covarying language age left the diagnosis ef-
fect significant atp < .0005. Post hoc Tukey tests re-
vealed that both the normal and DLD groups were
responding at significantly higher levels than the Hi-
Aut, LoAut, or MR groups.
There was also a significant sex effect (F = 5.11,
p < .02) (preserved with covariance), with girls giving
significantly higher level mean responses than boys
(girls = 2.35, boys = 1.93). No Sex x Diagnosis effect
was found.
The second part of the paradigm, the additional
prompt, also showed a significant difference on the
basis of diagnosis, (F = 6.42, p < .0002) (Table V).
Tukey tests showed that the DLD and normal chil-
dren showed higher responses than the LoAut chil-
dren.
This effect, however, became nonsignificant
when language age was covaried.
A significant sex effect was found in the analysis
of covariance (F = 4.83, p < .02), with the girls giv-
ing a significantly higher mean response (girls =
2.87, boys = 2.26).
If one tabulates the percentage of children in
each diagnostic group who gave a prosocial or pro-
forma (compliant) response on either part of the lost
pen paradigm, the normal children (93%) and DLD
children (84%) are similar, as are the HiAut children
(60%) and MR children (54%), followed by the
LoAut children (29%). This pattern is similar to the
Table IV. Responses to the First Part of the Lost Pen Paradigma
Subjects giving each response (%)
No response
Recognition
Prosocial
Mean for each group
"OLD = Developmentally language disordered; HiAut = high-functioning autistic; LoAut = low-
functioning autistic; MR = mentally retarded; Norm = normal.
6F for diagnosis = 19.98, p < .001. Post hoc: DLD, Normal > HiAut, LoAut, MR.
Bacon, Fein, Morris, Waterhouse, and Allen
number of children showing no response at all to the
first lost pen prompt, where the normal children
(3%) are similar to the DLD children (2%), the Hi-
Aut children (25%) are similar to the MR children
(26%) groups, with the LoAut children the most un-
responsive (45%). This pattern is carried through on
failure to respond to the second prompt (DLD 19%,
normal 18%, HiAut 37%, MR 36%, LoAut 69%).
Correlational Analyses
Correlations among the experimental variables
were examined within each diagnostic group to see
whether responsiveness in one situation was predic-
tive of responsiveness in another.
For LoAut children, the two verbal measures of
appropriate verbalization to the orienting stimulus and
prosocial verbal response in the simulated distress
paradigm were correlated, (r - .38, p < .01). They
also showed correlations between responsiveness to
the simulated distress and the level of their response
to the lost pen paradigm (r = .34, p < .01). In ad-
dition, looking at the distressed adult correlated with
the level of their response to the lost pen (r = .38,
p < .01).
For the MR children, responsiveness to the
simulated distress predicted their behavior in the lost
pen paradigm (r = .43, p < .01). Looking at the dis-
tressed adult predicted the level of their behavior in
the lost pen paradigm (r = .51, p < .01). Finally,
their behavior in the first part of the lost pen para-
digm predicted their behavior in the second part of
the paradigm (F = .61, p < .0001).
For the normal children, the only significant cor-
relation was between two verbal responses (appropri-
ate verbalization to the orienting stimulus and
prosocial verbal in the simulated distress paradigm, r
= .69, p < .0001). The DLD and HiAut children
DLD HiAut LoAut MR NORM
2 25 45 26 3
60 59 51 67 35
38 16 4 7 62
2.36 1.91 1.59 1.82 2.59*
Responses of Autistic Children to Distress of Others
Table V. Responses to the Second Part of the Lost Pen Paradigm
DLD
Subjects giving each response (%)
No response 19
Refusal 8 11
Proforma 12
Prosocial 62
Mean for each group 3.16
aOLD = Developmentally language disordered; HiAut = high-functioning autistic; LoAut = low-functioning
autistic; MR = mentally retarded; Norm = normal.
hF for diagnosis = 6.42, p < .01. Post hoc: DLD, normal > LoAut covaried for language age F = 1.69, ns.
showed no significant correlations on their responses
between the experimental paradigms.
Correlations between the significant experimen-
tal variables and a variety of cognitive measures were
also obtained. Correlations were calculated for the
cognitive variables: Stanford-Binet Verbal Reasoning
Standard Area Score, Stanford-Binet Abstract Visual
Reasoning Standard Area Score, the Peabody Picture
Vocabulary Test Standard Score, the Vineland Adap-
tive Behavior Scales Standard Scores, nonverbal ra-
tio, language ratio, nonverbal mental age, and
language mental age. Given the number of correla-
tions, significance was set at p < .01 level.
The cognitive variables did not correlate signifi-
cantly with the experimental variables for normal,
HiAut or DLD children.
For the orienting stimulus, LoAut children's lan-
guage mental age correlated with looking at adult r
= 0.47, p < .001. For the simulated distress para-
digm, Stanford-Binet Verbal Reasoning correlated
with prosocial verbal response (r = .60, p < .01). Pe-
abody Picture Vocabulary Test correlated with proso-
cial verbal response (r = .51, p < .01); language ratio
correlated with prosocial verbal response (r = .41, p
< .01); language mental age correlated with Proso-
cial verbal response, (r = .47, p < .001).
For the MR children, no correlations of cogni-
tive variables with the experimental variables in the
orienting stimulus or the simulated distress paradigm
were found. Correlations with level of behavior in the
first part of the lost pen paradigm were nonverbal
ratio (r = .57, p < .0001); language ratio (r = .60,
p < .0001); nonverbal mental age (r = .55, p < .001);
language mental age (r = .50, p < .001). Correlations
with the second part of the lost pen paradigm were:
nonverbal ratio (r = .45, p < -01); nonverbal mental
137
Groupa
HiAut LoAut MR NORM
37 69 36 18
4 14 0
22 6 25 37
30 20 25 46
2,44 1.78 2.39 3.09*
age (r = .55, p < .001); language mental age (r =
.41, p < .01).
DISCUSSION
Results indicate that LoAut children were less
responsive to the orienting stimulus than normal chil-
dren, but this difference was accounted for by their
degree of language retardation. Children in both
autistic groups, however, showed the lowest rates of
responding to the uncertainty of the orienting stimu-
lus by social referencing (looking at the adult), and
this finding was not accounted for by their level of
mental development.
Similarly, in the simulated distress situation, the
LoAut children did not look at the adult (the source
of the stimulus) as much as the other groups. More
girls overall tended to respond to the adult's distress
with prosocial verbal responses, and the DLD chil-
dren gave a disproportionate number of nonverbal
prosocial responses, and "pleased" responses, per-
haps reflecting their language disability, and a so-
cially anxious or immature style. Prosocial responses,
whether verbal or nonverbal, were a low-frequency
behavior for the total sample.
The lost pen paradigm also elicited different
patterns of responses by children in the different di-
agnostic groups. Almost all of the DLD and normal
children made a response (either recognizing the
situation or a prosocial response) in the first part of
the paradigm, with approximately one third of the
DLD and two thirds of the normal children giving
prosocial responses. In contrast, the responses of the
high-functioning autistic, low-functioning autistic,
and mentally retarded children were divided between
recognition and nonresponsiveness, with only a small
138
number of children in these groups responding
prosocially. These differences were not affected by
language level. With the additional prompt, more
DLD and normal children responded appropriately
than did LoAut children (with the MR and HiAut
groups intermediate), but this group difference was
accounted for by language level differences. Pro-
fbrma or truly prosocial responses were given in the
lost pen situation, with or without the additional
prompt, by approximately 90% of the normal and
DLD children, 60% of the MR and HiAut children,
and 30% of the LoAut children, with the MR and
autistic groups responding primarily after the addi-
tional prompt, in which the adult specifically asked
the child to help. Lack of response on either part of
the lost pen situation characterized approximately
one tenth of DLD and normal children, one third of
HiAut and MR children, and two thirds of LoAut
children.
Correlation analyses revealed that a number of
behavioral measures were cross-correlated for the
two low-functioning groups (MR and LoAut). There
were almost no significant correlations among these
measures for the three high-functioning groups (nor-
mal, DLD, HiAut). Similarly, cognitive variables
were most predictive of behavioral responsiveness for
the low-functioning groups (MR and LoAut), with
the LoAut children's behavior in the orienting and
simulated distress condition predicted by language
level, and the MR children's behavior on the two lost
pen measures predicted by both language and non-
verbal level. The high-functioning groups' behavior
(normal, DLD, HiAut) was not predicted by cogni-
tive variables.
It therefore appears that the behavioral meas-
ures fall into three groups: (a) those on which only
the LoAut children are impaired; (b) those on which
the DLD and normal children are approximately
equal, followed by the MR and HiAut children, fol-
lowed by the LoAut children; and (c) those on which
both autistic groups are selectively impaired.
The LoAut children were alone in their impair-
ment on three variables: responding to the orienting
stimulus, responding to the simulated distress, and
looking at the adult (who was the source of the
stimulus) in the simulated distress paradigm. Their
failure to respond to the orienting (but not simulated
distress) stimulus was accounted for by the severity
of their language retardation. Children in all other
groups showed a very high preponderance of re-
Bacon, Fein, Morris, Waterhouse, and Allen
sponding to both the nonsocial (orienting) and social
(simulated distress) stimuli.
The variables following the second pattern were
found in the lost pen paradigm. These included mean
level of response to both prompts, failure to respond
to first prompt or second prompt, and prosocial or
proforma responses with either prompt. On all of
these variables, the DLD and normal children per-
formed at the highest level, the MR and HiAut chil-
dren performed at very similar, intermediate levels,
and the LoAut children performed at the lowest
level. This pattern of responses was also found on
many complex cognitive variables in the larger pro-
ject from which these subjects were drawn (Rapin,
1996). It suggests that the moderate retardation char-
acteristic of our MR subjects, and the social-lan-
guage deficit characteristic of our nonretarded HiAut
subjects can produce the same level of impairment
on complex cognitive or social tasks, while the mul-
tiple deficits shown by the LoAut subjects produce a
much greater impairment.
That the impairments of the MR and HiAut
subjects, although at the same level, stem from dif-
ferent sources, is confirmed by the fact that cognitive
variables correlated significantly with behavioral vari-
ables for the MR but not for the HiAut subjects. The
deficit of the HiAut subjects in responding coopera-
tively in the lost pen situation must stem from some
source other than their failure of comprehension.
Some of them may not have known how to help the
experimenter look for her pen, but since many of
them failed not only to assist in the search for the
pen but to respond at all, and since the majority of
them failed to initiate prosocial behavior spontane-
ously, but did respond to a prompt, an obvious can-
didate is a factor related to their lack of social
motivation or attention.
One variable strikingly showed a pattern of defi-
cit primarily for the two autistic groups; this was so-
cial referencing (looking at the adult during the
orienting stimulus). While the HiAut children did
look at the adult when that adult was the source of
the sound to which they were orienting (in the simu-
lated distress paradigm), children in both autistic
groups (equally) failed to look at the adult as a
source of information about the ambiguous and un-
familiar orienting stimulus.
The rates of prosocial behavior of the normal
children on the simulated distress paradigm were low
compared to what might be expected from some
studies in the literature, but were consistent with the
 Responses of Autistic Children to Distress of Others
findings of Sigman et al. (1992). The low rates of
prosocial behavior in the current study and the Sig-
man et al. study may be due to the age of the chil-
dren in these studies. Many studies have documented
prosocial behavior by the age of 2 (Zahn-Waxler &
Radke-Yarrow, 1990). The Sigman et al. (1992) sub-
jects had a mean age of 19 months, and might have
been somewhat too young to evidence consistent
prosocial behavior in their experimental setting. In
the current study, the children were older than 3.
The majority of the normal children looked at the
adult; it is probable that their comprehension was so-
phisticated enough for them to realize that nothing
serious was wrong, that no action was required, or
that there was little they could do.
The lost pen paradigm proved more powerful in
discriminating among the higher functioning diagnos-
tic groups, and in eliciting prosocial behavior, than
the simulated distress paradigm. This is probably due
to the fact that a simple, effective course of action
was available to solve the problem. The sex differ-
ence extended to both distress situations, however,
with girls responding with more prosocial behavior
than boys, across diagnostic groups, in the simulated
distress episode and in response to both lost pen
prompts; this difference was unaffected, or even ac-
centuated, by covarying language level. This gender
difference is consistent with what has been found in
normal toddlers (Zahn-Waxler, Robinson, & Emde,
1992); it is interesting that even in groups of children
with impaired social awareness and skills, these gen-
der differences persist.
Behavior in some situations was partly predict-
able from cognitive variables, but only for the low-
functioning groups (MR, LoAut). For these children,
it appears that their level of language or overall men-
tal age was a limiting factor; some of them probably
did not have high enough developmental levels to en-
able them to verbalize or to fully comprehend the
language that was part of the eliciting situation. Once
a threshold of cognitive or linguistic competence was
reached, language level appeared to have nothing to
do with the children's behavioral responses.
Although the DLD children showed no statisti-
cal impairment relative to the normal children, their
overall responsiveness to orienting and simulated dis-
tress stimuli, social referencing, and prosocial re-
sponse to the lost pen situation was mildly but very
consistently lower. They also showed significantly
higher rates of immature and nonverbal behavior in
the social situation. Thus, it appears likely that these
139
children, as a group, showed subtle and mild social
deficits relative to the normal children, even in a situ-
ation involving only one friendly adult.
The LoAut children, as might be expected, were
impaired not only on prosocial initiation, response to
a prompt for prosocial behavior, and social refer-
encing, but also on apparent awareness of the social
and nonsocial events. How can the response profile
of the HiAut children across these situations be char-
acterized? They overwhelmingly responded to the
nonsocial orienting stimulus, usually by looking
around the room, and to the distressed adult, usually
by looking at the adult. They were moderately im-
paired in their responding appropriately to a social
demand situation; most of those who did engage in
some form of prosocial behavior did not spontane-
ously initiate this behavior, but responded to an ex-
plicit prompt. In all of these behaviors, they were at
the level of the normal and DLD children, or inter-
mediate between them and the LoAut children. On
the social referencing variable, however, they were
as impaired as the LoAut children; furthermore, lan-
guage age explained a significant part of the variance
(22%) in social referencing for the LoAut children
but not for the HiAut children.
The different behaviors (except for social refer-
encing) and different patterns of correlation among
behavioral and cognitive variables also confirms the
conclusion drawn by Rapin (1996), that high- and
low-functioning autism appear to be behavioral dis-
tinct entities. The deficit in social referencing seen
in both autistic groups may relate more directly to
the core social deficit that characterizes both high-
and low-functioning autistic children. Social refer-
encing occurs when the child confronts an object of
uncertain significance, and turns to an adult present,
presumably to use the adult's facial expression to
guide their evaluation of, and behavior toward, the
object (Moore & Corkum, 1994). Autistic children's
deficiencies in similar types of intersubjective behav-
ior, such as protodeclarative gestures (Mundy et al.,
1994) have been taken as evidence of their deficiency
in developing a "theory of mind" (Baron-Cohen,
1991). Moore and Corkum (1994), however, present
a convincing analysis of possible fallacies in the rea-
soning that connects secondary intersubjectivity to
prior development of at least a rudimentary theory
of mind. As they point out, the "commonsense view"
of joint attention and social referencing is that the
infant who exhibits such behavior must have a rep-
resentation of the psychological relationship between
140
the adult and the object, and must, in a clear exam-
ple of metarepresentation, understand "that another
person represents an object as interesting or unin-
teresting" (Baron-Cohen, 1991, p. 246). But as
Moore and Corkum (1994) elaborate, this view of 9-
to 12-month-olds as capable of metarepresentations
that are derived from simultaneously comparing sev-
eral different models of reality and experience con-
tradicts most current developmental cognitive theory.
Furthermore, they present two alternative explana-
tions of the infant capacity for secondary intersub-
jectivity, one a learning theory, and one a nativist
theory. Crucially, they point out that social refer-
encing behavior, for example, establishes only that
the infant has made a link between the adult expres-
sion and their expectancies concerning the object,
possibly via their contagious experience of the adult's
displayed emotion. They present evidence that this
link may be in part an innate one, and that this be-
havior predates by a considerable period a true
metarepresentational theory of mind. The striking
failure of both autistic groups in the present study
to demonstrate normal social referencing, therefore,
rather than support a "theory-of-mind" deficit as the
underlying process, suggests that a deficit common
to both high- and low-functioning autistic children is
in a process that predates the development of "the-
ory of mind," such as affect attunement, or finding
facial expressions intrinsically interesting or reward-
ing. This type of deficit is consistent with social at-
tention or affective approaches to autism (Fein,
Pennington, Markowitz, Braverman, & Waterhouse,
1986; Garfin & Lord, 1986; Hobson, 1989; Mundy &
Sigman, 1989) and may be consistent with early lim-
bic dysfunction, in structures related to the amygdala
(Bachevalier, 1994; Bauman & Kemper, 1994). The
fact that both high- and low-functioning autistic chil-
dren showed this deficit to an equal degree is con-
sistent with the hypothesis that the neurological basis
of this dysfunction is common to both types of chil-
dren.
A final point is that the current sample of HiAut
children, as is typically the case, exhibit significant
within-group variability. Although the social refer-
encing deficit is the most striking finding for both
groups of autistic children, it still must be recognized
that a third of the children in both groups did exhibit
this behavior. Although language level explains some
variance for the LoAut children, it is unrelated to
social referencing for the HiAut children. Whether
consistent deficits in social referencing characterizes
Bacon, Fein, Morris, Waterhouse, and Allen
specific HiAut children (and how such a deficit cor-
relates with early development and current behavior)
is not known; observation of behavior over multiple
situations and trials is necessary to answer this ques-
tion.
ACKNOWLEDGMENTS
This project was supported by Program Project
NS 20489 from the National Institute of Neurologic
Disorders and Stroke, U.S. Public Health Service,
Ronald David, M.D., P.I., on which authors Deborah
Fein, Lynn Waterhouse, Robin Morris, and Doris Al-
len were investigators. We are grateful for this sup-
port and for the dedicated and capable help of
research assistants, as well as for the participation of
the children and their families.
REFERENCES
American Psychiatric Association. (1987). Diagnostic and statistical
manual of mental disorders. (3rd ed., rev.). Washington, D.C.:
Author.
Bachevalier, J. (1994). The contribution of medial temporal lobe
structures in infantile autism: A neurobehavioral study in pri-
mates. In M. Bauman & T. L, Kemper (Eds.), The neurobi-
ology of autism (pp. 146-169). Baltimore: Johns Hopkins
Press.
Baron-Cohen, S. (1991). Precursors to a theory of mind: Under-
standing attention in others. In A. Whiten (Ed.), Natural theo-
ries of mind. Evolution, development, and simulation of
everyday mindreading. Oxford, U.K.: Blackwell.
Bauman, M., & Kemper, T. L. (1994) Neuroanatomic observations
of the brain in autism. In M. Bauman & T. L. Keraper (Eds.),
The neurobiology of autism (pp. 119-145). Baltimore: Johns
Hopkins Press.
Bayley, N. (1969). Bayley Scales of Infant Development, Berkeley,
CA: The Psychological Corp.
Braverman, M., Fein, D., Lucci, D., & Waterhouse, L. (1989). Af-
fect comprehension in children with pervasive developmental
disorders. Journal of Autism and Developmental Disorders, 19,
301-316.
Capps, L, Kasari, C, Yirmiya, N., & Sigman, M. (1993). Parental
perception of emotional expressiveness in children with
autism. Journal of Consulting and Clinical Psychology, 61, 475-
484.
Capps, L., Sigman, M., & Mundy, E (1994) Attachment security
in children with autism. Development and Psyckopathology, 6,
249-261.
Cohen, D. J., Paul, R., & Volkmar, F. (1987). Issues in the clas-
sification of PDD and associated conditions. In D. J. Cohen,
A. M. Donnellan, & R. R. Paul (Eds.), Handbook of autism
and pervasive developmental disorders (pp. 20-40). New York:
Wiley.
Dunn, L. M., & Dunn, L. (1981). Peabody Picture Vocabulary—Re-
vised. Circle Pines, MN: American Guidance Service.
Eisenberg, N., Pasternack, J. E, Cameron, E., & Tryon, K. (1984).
The relation of quantity and mode of prosocial behavior to
 Responses of Autistic Children to Distress of Others
moral cognition and social style. Child Development, 55, 1479-
1485.
Eisenberg-Berg, N., & Lennon, R. (1980). Altruism and the as-
sessment of empathy in the preschool years. Child Develop-
ment, 51, 552-557.
Fein, D., Lucci, D., Braverman, M., & Waterhouse, L. (1992).
Comprehension of affect in context in children with pervasive
developmental disorders. Journal of Child Psychology and Psy-
chiatry, 33, 1157-1167.
Fein, D., Pennington, B., Markowitz, R, Braverman, M., & Water-
house, L (1986). Towards a neuropsychological model of in-
fantile autism: Are the social deficits primary? Journal of the
American Academy of Child Psychiatry, 25, 198-212.
Feinman, S. (1982) Social referencing in infancy. Merrill-Palmer
Quarterly, 28, 445470.
Garfin, D. G., & Lord, C. (1986). Communication as a social prob-
lem in autism. In E. Schopler & G. B. Mesibov (Eds.), Social
behavior and autism (pp. 103-131). New York: Plenum Press.
Hauck, M., Fein, D., Waterhouse, L., & Feinstein, C. (1995). Social
initiations by autistic children to adults and other children.
Journal of Autism and Developmental Disorders, 25, 579-595.
Hobson, R. R (1983). The autistic child's recognition of age-re-
lated features of people, animals and things. British Journal
of Developmental Psychology, 1, 343-352.
Hobson, R. P. (1984). Early childhood autism and the question of
egocentrism. Journal of Autism and Developmental Disorders,
14, 85-104.
Hobson, R. P. (1986a). The autistic child's appraisal of expressions
of emotion. Journal of Child Psychology and Psychiatry, 27,
321-342.
Hobson, R. P. (1986b). The autistic child's appraisal of expressions
of emotion: A further study. Journal of Child Psychology and
Psychiatry, 27, 679-680.
Hobson, R. P. (1989). On sharing experiences. Development and
Psychopathology, 1, 197-203.
Hendrick, D. L, Prather, E. M., & Tobin, A. R. (1984). Sequenced
inventory of communication development (rev. ed.). Seattle:
University of 'Washington Press.
Howlin, P. (1986). An overview of social behavior in autism. In E.
Schopler & G. B. Mesibov (Eds.), Social Behavior and Autism
(pp. 103-131). New York: Plenum Press.
Hresko, W P., Reid, D. K., & Hamill, D. D. (1981). The test of
early language development. Austin, TX: Pro-Ed.
Kasari, C., Sigman, M., Baumgartner, R, & Stipek, D. (1993).
Pride and mastery in children with autism. Journal of Child
Psychology and Psychiatry, 34, 353-362.
Kasari, C. Sigman, M., & Yirmiya, N. (1993). Focused and social
attention of autistic children in interactions with familiar and
unfamiliar adults: A comparison of autistic, mentally retarded,
and normal children. Development and Psychopathology, 5,
403-414.
Klinnert, M., Campos, J., Sorce, J., Emde, R., & Svejda, M. (1983).
Emotions as behavior regulators: Social referencing in in-
fancy. In R. Plutchik & H. Kellerman (Eds.), Emotions in
early development: Vol. 2. The emotions. New York: Academic
Press.
Lord, C. (1993). The complexity of social behavior in autism. In
S. Baron-Cohen, H. Tager-FIusberg, & D. Cohen (Eds.), Un-
derstanding other minds: Perspectives from autism. Oxford,
U.K.: Oxford University Press.
Lord, C. (1984). Development of peer relations in children with
autism. In F. Morrison, C. Lord, & D. Keating (Eds.), Allied
developmental Psychology (Vol. 1). New York: Academic Press.
Mchale, S. (1983). Social interactions of autistic and non-handi-
capped children during free play. American Journal of Ortho-
psychiatry, 53, 81-91.
141
Mchale, S., Olley, J., Marcus, L., & Simeonssen, R. (1981). Non-
handicapped peers as tutors for autistic children. Exceptional
Children, 48, 263-265.
Moore, C, & Corkum, V (1994). Social understanding at the end
of the first year of life. Developmental Review, 14, 349-372.
Mundy, R, & Sigman, M. (1989). Theoretical implications of joint
attention deficits in autism. Development and Psychopathology,
1, 173-183.
Mundy, P., Sigman, M., & Kasari, C. (1994). Joint attention, de-
velopmental level, and symptom presentation in autism. De-
velopment and Psychopathology, 6, 389-401.
Radke-Yarrow, M., & Zahn-Waxler, C. (1976). Dimensions and
correlates of prosocial behavior in young children. Child De-
velopment, 47, 118-125.
Rapin, I. (Ed.). (1996). Preschool children with inadequate com-
munication: Developmental language disorder, autism, low
IQ. In Clinics in Developmental Medicine (No. 139). London:
Mac Keith.
Rheingold, H. L., Hay, D. F., & West, M, J. (1976). Sharing in
the second year of life. Child Development, 47, 1148-1158.
Reuter, J., Stancin, T, & Craig, P. (1981). Kent scoring adaptation
of the Bayley Scales of Infant Development. Kent, OH: Kent
Developmental Metrics.
Ross, H. S., & Goldman, B. D. (1977). Establishing new social
relationships in infancy. In T. Alloway, P. Pliner, & L. Krames
(Eds.), Advances in the study of communication and affect: Vol.
3. Attachment behavior (pp. 61-79). New York: Plenum Press.
Rutter, M. (1984). Infantile autism and other pervasive develop-
mental disorders. In M. Rutter and L Hersov (Eds.), Child
and Adolescent Psychiatry. Modem Approaches (Vol 2). Oxford,
U.K.: Blackwell.
Rutter, M., & Garmezy, N. (1983). Developmental psychopathol-
ogy. In E. M. Hetherington (Ed.), Handbook of child psychol-
ogy (Vol. 4). New York: Wiley.
Sigman, M. D., Ungerer, J., Mundy, P., & Sherman, T. (1984). Cog-
nitive functioning in autistic children. In D. Cohen, A. Don-
nellan, & R. Paul (Eds.), Handbook of autism and atypical
Development. New York: Wiley.
Sigman, M. D., Kasari, C., Kwon, J. H., & Yirmiya, N. (1992).
Responses to the negative emotions of others by autistic, men-
tally retarded, and normal children. Child Development, 63,
796-807,
Sparrow, S. A., Balla, D. A., & Cicchetti, D. V (1984). Vineland
Adaptive Behavior Scales. Circle Pines, MN: American Guid-
ance Service.
Staub, E. (1970). A child in distress: The influence of age and
number of witnesses on children's attempts to help. Journal
of Personality and Social Psychology, 14, 130-140.
Thorndike, R. L, Hagen, E. P, & Sattler, J. M. (1986). Stanford-
Binet Intelligence Scale (4th ed.). Chicago: Riverside.
Trevarthen, C. (1979). Communication and cooperation in early
infancy: A description of primary intersubjectivity. In M. Bul-
lowa (Ed.), Before speech: The beginnings of interpersonal com-
munication. Cambridge, U.K.: Cambridge University Press.
Trevarthen, C, and Hubley, P. (1978). Secondary Intersubjectivity:
Confidence, confiding, and acts of meaning in the first year.
In A Lock (Ed.), Action, gesture, and symbol The emergence
of language. New York: Cambridge University Press.
Isai, L. (1992). Diagnostic issues in high-functioning autism. In E.
Schopler & G. Mesibov (Eds.), High-functioning individuals
with autism. New York: Plenum Press.
Ungerer, J., & Sigman, M. (1981). Symbolic play and language
comprehension in autistic children. Journal of the American
Academy of Child Psychiatry, 20, 318-337.
Volkmar, F. R., & Klin, A. (1993). Social development in autism:
Historical and clinical perspectives. In S. Baron-Cohen, H.
Tager-FIusberg, & D. Cohen (Eds.), Understanding other
142
minds: Perspectives from autism. Oxford, U.K.: Oxford Uni-
versity Press.
Wing, L (1980). Early childhood autism. Oxford, U.K.: Pergamon.
Yarrow. M. R., Scott, E M, & Woler, C. Z. (1973). Learning
concern for others. Developmental Psychology, 8, 240-260.
Yirmiya, N., Sigman, M., Kasari, C, & Mundy, E (1992). Empathy
and cognition in high-functioning children with autism. Child
Development, 63, 150-160.
Bacon, Fein, Morris, Waterhouse, and Allen
Zahn-Waxler, C., & Radke-Yarrow, M. (1990). The origins of em-
pathic concern. Motivation and Emotion, 14, 107-130.
Zahn-Waxler, C, Radke-Yarrow, M., Wagner, E., & Chapman, M.
(1992). Development of concern for others. Developmental
Psychology, 28, 126-136.
Zahn-Waxler, C, Robinson, J. L., & Emde, R. (1992). The devel-
opment of empathy in twins. Developmental Psychology, 28,
1038-1047.