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Table of Contents
ORIGINAL ARTICLE
Year : 2020  |  Volume : 52  |  Issue : 1  |  Page : 19-23

An association of imitation skills with language development in typically developing children versus children with autism spectrum disorder and developmental delay: An observational cross-sectional study


1 Department of Physical Medicine and Rehabilitation, Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, Mumbai, Maharashtra, India
2 Occupational Therapy School and Centre, TNMC and BYL Nair Charitable Hospital, Mumbai, Maharashtra, India

Date of Submission27-Sep-2019
Date of Decision23-Jan-2020
Date of Acceptance04-Feb-2020
Date of Web Publication30-Mar-2020

Correspondence Address:
Dr. Harsha Sureshlal Bhatia
B-301, New Shanti Sagar CHS, C Block Road, Ulhasnagar - 421 001, Thane, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijoth.ijoth_27_19

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  Abstract 


Background: Recent studies have shown a significant improvement in receptive and expressive language skills of children with autism spectrum disorder (ASD) using imitation skills. Thus, this study was designed to evaluate and compare imitation skills of children with ASD, children with developmental delay (DD), and developmentally age-matched typically developing (TD) children and to associate imitation skills and receptive-expressive language development in children with ASD and in children with DD. Objectives:(1) To evaluate imitation skills in children with ASD and children with DD, (2) to compare imitation skills of children with ASD and children with DD with imitation skills of TD children, and (3) to correlate imitation skills with receptive-expressive language development of children with ASD and children with DD. Study Design: This was an observational cross-sectional study. Methods: The study included 12 children with ASD of 4-6 years, 12 children with DD of 4-6 years, and 12 TD children of age that matched the developmental age of children with ASD and children with DD. Denver II Prescreening Developmental Questionnaire was used to assess the developmental age, Motor Imitation Scale to assess the imitation skills, and MacArthur-Bates Communicative Development Inventory to assess the receptive-expressive language skills in 2 sessions of 40 min each. Results: No significant difference was found between the mean developmental age of ASD and TD (P = 1; 95% confidence interval [CI]: 1.37, 17.29), ASD and DD (P = 1; 95% CI: −8.12, 7.79), and DD and TD (P = 1; 95% CI: 1.21, 17.12). This proves that the three groups were matched as per the developmental age. A significant difference was found on comparing the imitation skills of children with ASD and TD children (P = 0.005; 95% CI: −8, 0) and children with DD and TD children (P = 0.00; 95% CI: −7, −3). On correlating imitation skills with receptive-expressive language development of children with ASD, no significant correlation was found (P = 0.948; 95% CI: −0.559, 0.587 and P = 0.455; 95% CI: −0.388, 0.714, respectively), whereas a significant correlation was found between imitation skills and receptive-expressive language development of children with DD (P = 0.014; 95% CI: 0.182, 0.903 and P = 0.034; 95% CI: 0.059, 0.877, respectively). Conclusion: Imitation skills of children with ASD and children with DD are significantly affected compared to TD children. Imitation skills might not be the only contributing factor in development of language skills.

Keywords: Autism Spectrum Disorder, Developmental Disabilities, Imitative Behavior, Language Development


How to cite this article:
Bhatia HS, Vaidya PM. An association of imitation skills with language development in typically developing children versus children with autism spectrum disorder and developmental delay: An observational cross-sectional study. Indian J Occup Ther 2020;52:19-23

How to cite this URL:
Bhatia HS, Vaidya PM. An association of imitation skills with language development in typically developing children versus children with autism spectrum disorder and developmental delay: An observational cross-sectional study. Indian J Occup Ther [serial online] 2020 [cited 2020 May 25];52:19-23. Available from: http://www.ijotonweb.org/text.asp?2020/52/1/19/281638




  Introduction Top


According to child development research, the sensorimotor, cognitive, and social abilities of young children develop through imitation and observational learning.[1] Children with autism spectrum disorder (ASD) present with significant impairment in social skills. As a result, these children might not be able to adapt themselves by observational learning and tend to be at greater risk for problems with imitation skills. Severe communication deficits affecting both receptive and expressive language are one of the hallmark features of ASD. As early language development is crucial for later prognosis,[2],[3] it is necessary to understand the developmental factors that underlie, facilitate, and predict language acquisition. When occupational therapists deal with children, their primary focus is on the cognitive domain. Both imitation and language are components of early cognitive development. Thus, the study was designed to evaluate and compare imitation skills of children with ASD, children with developmental delay (DD), and developmentally age-matched typically developing (TD) children. Secondary objectives were to associate imitation skills and receptive-expressive language development in children with ASD and in children with DD to find a true correlation.


  Methods Top


The research was an observational cross-sectional study. The study was initiated after receiving an approval from the Institute Ethics Committee and the Maharashtra University of Health Sciences Review Board. The study population comprised three groups which included children diagnosed with ASD of age group 4-6 years, children diagnosed with DD of age group 4-6 years recruited from hospital outpatient department, and TD children of age group 2-4 years that matched the developmental stage of children with ASD and children with DD recruited from the community.

Inclusion Criteria

  1. Children diagnosed with ASD of age group 4-6 years
  2. Children diagnosed with DD of age group 4-6 years, with mild neurological involvement
  3. TD children of age that matched the developmental stage of children with ASD and children with DD
  4. Subject's parents who can read or write in English with education level ≥5th standard.


Exclusion Criteria

  1. Children with ASD with auditory and visual impairments and other neurological and orthopedic disorders
  2. Children with DD with auditory and visual impairments, orthopedic disorders, and moderate-severe neurological involvement.


Test Battery

Assessment tools used

  1. Denver II Prescreening Developmental Questionnaire
  2. Motor Imitation Scale
  3. MacArthur-Bates Communicative Development Inventory.


Denver II Prescreening Developmental Questionnaire

It is the revision of the Denver Developmental Screening Test. It is a parent-completed questionnaire and is used to monitor the development of infants and preschool-aged children. The test covers four general functions: gross motor, fine motor, social, and language.[4]

Motor imitation scale

It is used to assess motor imitation skills in young children. It consists of 16 single-step actions that are modeled by an adult. Half of the items require imitation of actions with objects, and the other half requires imitation of body movements.

MacArthur-Bates Communicative Development Inventory

It is used to assess language development of infants between 8-30 months and toddlers with 16-36 months. The infant scale is used to evaluate comprehension, word production, and communicative gestures. The toddler scale examines word production and early phases of grammar. It is a parent/caregiver report measure. In this study, infant scale was used. Since the age criteria for infant scale are lower than the study population, the raw scores of receptive and expressive language skills are used for comparison and correlation.[5]

Procedure

The study population that was included in the study was by purposive sampling. The study includes three groups

  • Group A: Children with ASD of age group 4-6 years
  • Group B: Children with DD of age group 4-6 years
  • Group C: TD Children of age 2-4 years that matched the developmental stage of Children with ASD and Children with DD.


As the aim of the study was to find a correlation between imitation skills and receptive-expressive language skills, Group B was included in the study along with Group A to find a true correlation. Group C was included in the study to compare the level of imitation skills of Group A and Group B with that of TD children at similar developmental age.

Sample size for the study was calculated based on the parent article using the Spearman's rank order correlation coefficient of the two variables: imitation-receptive language and imitation-expressive language for ASD at 80% power and 95% confidence interval (CI) (5% α error). It was calculated to be minimum 8 and 11, respectively. Hence, the study included 12 children in each group.

Ethics committee clearance for conducting the study was obtained.

The assessment was done in two sessions each of 40 min duration.

Parents and children were explained about the details of the study and were assured about the confidentiality. Written informed consent forms were signed by parents of these children.

The case record form which included demography and the medical records of the child was filled. Initially, parents of children with ASD and children with DD were given Denver II Prescreening Developmental Questionnaire to find out the developmental stage of Group A and Group B, which in turn helped determine the age of children in Group C. The questionnaire was explained to parents in the language best understood by them and the therapist was there to assist in case of any queries. Based on this, the mean developmental stage range was determined using the formula mean + 1.96 × standard deviation, which was calculated to be 2-4 years and then TD children of 2-4 years were included.

Children from each group were assessed for imitation skills using Motor Imitation Scale. The scoring was done by a therapist and comparison was done between:

  • Imitation skills of children with ASD and TD children
  • Imitation skills of children with DD and TD children.


Parents of children in Groups A and B were administered MacArthur-Bates Communicative Development Inventory to assess receptive-expressive language development of their child. The scoring was done by a therapist and raw scores of receptive and expressive language skills were used to establish a correlation between motor imitation skills and language development of children with ASD and children with DD.

Data Analysis

The data were recorded in Microsoft Excel and analysis was conducted using IBM SPSS statistics for windows, Version 19.0. (Armonk, NY; IBM Corp.). Nonparametric tests were used for calculating the results of this study as the data were not normally distributed. Chi-square test was used for comparing imitation skills and Spearman's rank correlation coefficient for correlating the imitation skills and language skills. The level of significance was set at P < 0.05 and 95% CI was calculated.


  Results Top


[Table 1] shows the comparison of developmental age of children with ASD, children with DD, and TD children. The result shows that there is no significant difference between the mean developmental age of the children with ASD and TD children (P = 1; 95% CI: 1.37, 17.29), between children with ASD and children with DD (P = 1; 95% CI: −8.12, 7.79), and between children with DD and TD children (P = 1; 95% CI: 1.21, 17.12).
Table 1: Comparison of Developmental Age of Children with Autism Spectrum Disorder, Children with Developmental Delay and Typically Developing Children

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Comparative results of imitation skills of children with ASD and TD children and imitation skills of children with DD and TD children show a statistically significant difference (PASD and TD = 0.005; 95% CI: −8, 0 and PDD and TD = 0.00; 95% CI: −7, −3) [Table 2] and [Figure 1].
Table 2: Comparison Of Imitation Skills of Children with Autism Spectrum Disorder, Children with Developmental Delay and Typically Developing Children

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Figure 1: Comparison of Imitation Skills of Children with ASD, Children with DD, and Typically Developing Children

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[Table 3] represents Spearman's correlation coefficient test used to find the correlation between imitation skills and receptive-expressive language skills in ASD. There was a very weak correlation between the imitation skills and receptive and expressive language skills in ASD (ρ = 0.021; 95% CI: −0.559, 0.587 and ρ = 0.239; 95% CI: −0.388, 0.714, respectively) and the difference between them is not statistically significant (P = 0.948 and P = 0.455, respectively).
Table 3: Correlation between Imitation Skills and receptive-expressive language skills in autism spectrum disorder and in developmental delay

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[Table 3] also represents correlation between imitation skills and receptive-expressive language skills in DD. There was a strong positive correlation between the imitation skills and receptive and expressive language skills in DD (ρ = 0.684; 95% CI: 0.182, 0.903 and ρ = 0.612; 95% CI: 0.059, 0.877, respectively) and the difference between them is statistically significant (P = 0.014 and P = 0.034, respectively).


  Discussion Top


Infants begin with motor and vocal imitation during the 1st year of life. [6,7] Motor imitation ability has been associated with the development of cognition and social communication behaviors such as language, play, and joint attention.[8] Children with ASD exhibit severe communication and social interaction deficits. As language is crucial in developing social relationships, it is important to know the underlying causes for problems with language. The unusual combinations of sensory, communication, and behavioral characteristics seen with ASDs significantly affect the child's ability to participate in home, school, and community activities.[9] The promotion of the child's social participation within the contexts of family, friendships, classmates, caregivers, and teachers is an essential domain of occupational therapy in all practice settings.

In this study, an effort has been made to assess the levels of imitation skills in children with ASD as compared to TD children and to correlate the imitation skills with the receptive-expressive language skills of these children. To find the true correlation between imitation skills and receptive-expressive language skills, children with DD are also assessed as these children may have difficulty in imitation skills due to failure to meet the expected age-related milestones.

This study included three groups comprising 12 children in each group of ASD, DD, and TD children, respectively. As the study was designed to know the level of imitation skills in comparison with age in each of the groups, it was necessary to match the age of the three groups. Children aged 4-6 years in ASD and DD were included in the study, out of which for ASD 10 were male and 2 were female and for DD 6 were male and 6 were female. Denver II Prescreening Developmental Questionnaire was implemented on them to know the developmental age in these groups. The third group included TD children of age group 2-4 years, matching the developmental age of the first two groups, out of which 4 were male and 8 were female.

On comparing the developmental age between these three groups, there was no difference between the mean developmental age of the three groups and also no statistically significant difference was seen in the developmental age of three groups. This proves that the three groups matched as per the developmental age [Table 1].

Once the age was matched, Motor Imitation Scale was implemented on all the three groups. The Motor Imitation Scale is used to assess motor imitation skills in young children. It consists of 16 single-step actions that are modeled by an adult. Half of the items require imitation of actions with objects, and the other half requires imitation of body movements. On comparing the scores of the imitation skills of children with ASD with TD children, there was statistically significant difference (P = 0.005) [Table 2]. These imitation skills are important during the early developmental period as a component of cognitive, social, and language development and may be affected due to problems with sensory processing, fundamental social processes (e.g., acknowledging presence of others), joint attention, and perception in ASD. Similar findings were seen in the study by Turan and Ökçün Akçamuş and Rogers et al.[10],[11] The study done by Stone et al., 1997, showed that children with ASD had difficulty in imitating behaviors with and without objects and pretending facial expressions.[12] On comparing the scores of imitation skills of children with DD and TD children, there was statistically significant difference (P = 0.000) [Table 2]. The imitation skills of children with DD might be affected due to delay in achieving age-related milestones and difficulty in well-coordinated dissociated movements of the limbs.

Then, MacArthur-Bates Communicative Development Inventory was implemented on children with ASD and children with DD to assess receptive-expressive language skills. In this study, the infant scale of MacArthur-Bates Communicative Development Inventory was used to evaluate comprehension and word production.

The aim of the study was to determine the effect of level of imitation skills on receptive-expressive language skills of children with ASD and children with DD. Hence, the level of imitation skills was correlated with receptive and expressive language skills in children with ASD and children with DD. Imitation skills of children with ASD did not correlate with their receptive-expressive language skills (ρ = 0.021 and ρ = 0.239, respectively) [Table 3]. Similar findings were noted in the study done by Susan Weismer (2010).[13] Studies done by Susan Weismer (2010) and Toth have shown that development of language and communication skills are associated with some early abilities such as joint attention, imitation, toy play, and nonverbal cognition.[13],[14] As in this study imitation skills are not correlated with receptive-expressive language skills, there might be other factors influencing the language development. The present study observed moderate positive correlation between imitation skills and receptive-expressive language skills (ρ = 0.684 and ρ = 0.612, respectively) in children with DD [Table 3]. Similar findings were noted in a study done by Susan Weismer (2010).[13]

The above-mentioned results show that imitation skills are affected in both children with ASD and children with DD. Hence, we reject the null hypothesis which states that imitation skills will not be affected in children with ASD and children with DD. These results also show that there is no correlation between imitation skills and receptive-expressive language skills of children with ASD and a moderate positive correlation between imitation skills and receptive-expressive language skills of children with DD.

Limitations

  • Since the screening of imitation skills and language skills in ASD and DD was done on a small sample size, as calculated according to parent article, generalization of the results is not possible
  • Apart from imitation, other factors such as nonverbal cognition, joint attention, and toy play may have influenced the development of language.


Recommendations

  • Factors other than imitation can be considered to see the effect on language development
  • A study can be conducted to compare level of imitation skills and receptive-expressive language development between males and females.



  Conclusion Top


The results of the study suggest that the children with autism and children with developmental delay have impaired imitation skills. These skills are impaired in both imitating body movements and imitation of object use.

Imitation skills significantly contribute to the development of receptive-expressive language skills in children with DD. However, imitation skills did not have a relation with the development of receptive-expressive language skills in children with ASD. Thus, imitation skills may not be the only contributing factor for development of language skills.

Financial Support and Sponsorship

Nil.

Conflicts of Interest

There are no conflicts of interest.



 
  References Top

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Fenson L, Marchman VA, Thal DJ, Dale PS, Reznick JS, Bates E. Macarthur-Bates Communicative Development Inventories: User's Guide and Technical Manual. 2nd ed. Baltimore, MD: Brookes; 2007. p. 30.  Back to cited text no. 5
    
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Meltzoff AN, Moore MK. Imitation of facial and manual gestures by human neonates. Science 1977;198:74-78.  Back to cited text no. 6
    
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Masur EF, Ritz EG. Patterns of gestural vocal and verbal imitation performance in infancy. Merrill Palmer Q 1984;30:369-392.  Back to cited text no. 7
    
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Rogers SJ, Pennington B. A theoretical approach to the deficits in infantile autism. Dev Psychopathol 1991;3:137-162.   Back to cited text no. 8
    
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Rogers SL. Common conditions that influence children's participation. In: Falk K, editor. Occupational Therapy for Children. 6th ed. St Louis: Elsevier – Health Sciences Division; 2010. p. 170.  Back to cited text no. 9
    
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Rogers SJ, Young GS, Cook I, Giolzetti A, Ozonoff S. Imitating actions on objects in early-onset and regressive autism: Effects and implications of task characteristics on performance. Dev Psychopathol 2010;22:71-85.  Back to cited text no. 10
    
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Turan F, Ökçün Akçamuş MÇ. An investigation of the imitation skills in children with autism spectrum disorder and their association with receptive-expressive language development. Turk Psikiyatri Derg 2013;24:111-116.  Back to cited text no. 11
    
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Stone WL, Ousley OY, Littleford CD. Motor imitation in young children with autism: What's the object? J Abnorm Child Psychol 1997;25:475-485.  Back to cited text no. 12
    
13.
Ellis Weismer S, Lord C, Esler A. Early language patterns of toddlers on the autism spectrum compared to toddlers with developmental delay. J Autism Dev Disord 2010;40:1259-1273.  Back to cited text no. 13
    
14.
Toth K, Munson J, Meltzoff AN, Dawson G. Early predictors of communication development in young children with autism spectrum disorder: Joint attention, imitation and toy play. J Autism Dev Disord 2006;36:993-1005.  Back to cited text no. 14
    


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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