Read the “Social Communication Deficits in Conduct Disorder: A Clinical and Community Survey” article in the required readings. What type of research method was used? What questions/hypotheses were being evaluated? What methods were used in the study to obtain results, and describe how they were summarized and organized?

Min 150 words with at least one in text citation

Social communication de¢cits in conduct disorder:
a clinical and community survey
J. Gilmour,1 B. Hill,2 M. Place,3 and D.H. Skuse2

1Sub-Department of Clinical Health Psychology, University College London, UK; 2Behavioural and Brain Sciences
Unit, Institute of Child Health, London, UK; 3Hartlepool CAMHS, UK

Background: Increasing numbers of children are referred to Child and Adolescent Mental Health
Services because of disruptive behaviour. Recent reviews on the origins of conduct problems indicate
that the most severe and persistent forms are found predominantly among males with a range of
neurodevelopmental vulnerabilities, which are likely to have biological substrates. In this study, we
tested the hypothesis that many children who are identified with conduct disorder actually have a
primary deficit in pragmatic language skills, of a quality and degree that is similar to children on the
autistic spectrum. We hypothesised that pragmatic difficulties may underlie the antisocial behaviour in
a proportion of children who are labelled as conduct disordered. Methods: Using the Children’s
Communication Checklist (Bishop, 1998), we surveyed 142 children who had been referred for clinical
investigation, with a predominant diagnosis of either an autistic spectrum condition (n ! 87) or conduct
disorder (n ! 55), and 60 typically developing comparison children. Among children with conduct
disorders, males predominated 9:1. Results: On the basis of parent and teacher ratings, two-thirds of
those with conduct disorders had pragmatic language impairments and other behavioural features
similar in nature and degree to those of children with autism, independent of IQ. In a further study,
we surveyed 54 children who had been excluded from elementary schools in a socio-economically
disadvantaged inner-London borough and found over two-thirds to have comparable deficits.
Conclusions: These findings have both theoretical and practical implications. First, they indicate the
presence of communicative problems in a sub-group of children in whom conduct rather than language
had been the major concern. Second, they indicate that severe deficits in pragmatic abilities and aut-
istic-like behaviours can coexist with psychiatric conditions other than autism, especially in boys.
Third, they imply that the management of many disruptive children could profitably be addressed to
ameliorating their social and communicative skill deficits. Keywords: Social communication, prag-
matics assessment, language impairment, autism, conduct disorder. Abbreviations: ADHD: Attention
deficit and hyperactivity disorder; CAMHS: Child and Adolescent Mental Health Services; CCC:
Children’s Communication Checklist; DfEE: Department for Education and Employment; 3di: The
Developmental, Dimensional and Diagnostic Interview; NUT: National Union of Teachers; PIQ:
Performance IQ; PDD: pervasive developmental disorder; SCD: social communication disorder; SLI:
Specific Language Impairment; VIQ: Verbal IQ; WHO: World Health Organisation.

Permanent exclusions from schools in England in-
creased from 3,000 in 1990–1 to 13,500 in 1996–7,
including 1,340 from primary schools in 1998–9, a
rate of .03 per cent (DfEE, 2000). Each child exclu-
ded from school costs public services over £30,000
(Bagley & Pritchard, 1998). Up to 25,000 children
are being educated outside the school environment,
and they obtain on average only 10% as much edu-
cation as their peers do (Parsons, 1996). Those at
highest risk are male, have special educational
needs, and live in areas of social deprivation. There
is great inter-school variability in reasons given for
exclusion but, in general, teachers are unsure of the
distinction between poor behaviour and behaviour
that reflects an underlying problem requiring treat-
ment (Social Exclusion Unit Report, 1998). The
management of children at risk of exclusion de-
mands a framework for assessment and treatment
that does not exist at present.

Many children with disruptive behaviour are
known to have problems with social understanding
(e.g., Milch-Reich, Campbell, Palham, Connelly, &

Geva, 1999). Previous work has focused largely on
their misinterpretation of other’s intent, especially
attributional biases (Crick & Dodge, 1996; Matthys,
Cuperus, & Van Engeland, 1999). These deficiencies
and biases are often present from early childhood,
and reasons for their development have usually been
couched in terms of social learning theory. Whilst
this may be true for a proportion, we aimed to test
the hypothesis – based on our pilot work and clinical
experience – that a sub-sample of these children
have a deficit in social communication abilities,
including pragmatic skills. Evidence has been
accumulating over many years of an association
between conduct disorders and deficits in language-
based verbal skills, which persist even after con-
trolling for potentially confounding variables such as
race and socioeconomic status (Hill, 2002). A specific
association with deficits in pragmatic skills, al-
though suspected, has never previously been invest-
igated systematically.

Pragmatics may be defined as the appropriate use
and interpretation of language in relation to the

Journal of Child Psychology and Psychiatry 45:5 (2004), pp 967–978

! Association for Child Psychology and Psychiatry, 2004.
Published by Blackwell Publishing, 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main Street, Malden, MA 02148, USA

context in which it occurs (Bishop, 1997). Some
children with severe pragmatic skill deficits also
possess autistic characteristics. In short, there ap-
pears to be blurring of boundaries between deficits in
pragmatic skills, broader deficits in social commu-
nication, and disorders on the autistic spectrum. We
will describe this clinical profile in general terms as a
social communication deficit.

Based on our clinical experience, we predicted that
pragmatic deficits (and perhaps broader social
communication deficits) would commonly be found
among children with conduct disorders. We were
particularly concerned about the social commun-
ication skills of children excluded from mainstream
education, and those at risk of exclusion, in the early
years at school. Specific and general cognitive defi-
cits have been described among children with dis-
ruptive behaviour. Moffitt, Caspi, Rutter, and Silva
(2001) reviewed findings relevant to sex differences
in antisocial behaviour, identified from a population
birth-cohort followed up from 3 to 21 years (the
Dunedin study). The authors discuss the relevance
of neurodevelopmental problems to the origins of
persistent and severe antisocial behaviour, which
affects males more frequently than females. These
risk factors are couched in terms of neuro-cognitive
deficits (visuospatial as well as verbal in nature),
undercontrolled temperament, a personality trait
they term ‘weak constraint’, and hyperactivity. Weak
constraint implies that the individual has low self-
control, is unconcerned about harm-avoidance, and
has little regard for traditional values such as high
moral standards and a conservative social environ-
ment. These personality descriptors may be more
applicable to individuals in late adolescence than to
children in elementary school, but their origins
probably lie in temperamental variables that could
be measured in early life. They do not simply result
from acculturation. Family risk factors cannot, as
Moffitt et al. (2001) rightly point out, account for the
great preponderance of antisocial behaviour among
males. They do not discuss the relevance to the onset
of antisocial behaviour of autistic-like deficits in so-
cial cognitive skills, but they do acknowledge that
the male preponderance in pervasive disorders such
as autism may share the same neurodevelopmental
explanation as a ‘relatively rare’ form of early onset,
persistent antisocial behaviour.

Aggression and ‘insolent’ and ‘uncooperative’
behaviour with adults are the most common reasons
for exclusion from school (National Union of
Teachers (NUT), 1992). We hypothesised that such
behavioural problems could be linked in some cases
to social communication deficits. Children with such
deficits do not tend to use language in a way that
takes account of a social hierarchy (peer, teaching
assistant, headteacher). Consequently, their failure
to treat school staff with due deference makes them
appear to be ‘insolent’. They may publicly point out
their teacher’s mistakes in class. Children who make

such errors are not necessarily aware of them; typ-
ically they are bewildered by the adverse reaction of
teachers. The fact that the underlying reason for
their solecism is not identified means they are only
too likely to repeat it.

Significant numbers of children with disorders on
the autistic spectrum remain undetected in the
general population. Characteristically, they have
undue difficulty with social aspects of communica-
tion, in both verbal and non-verbal modes. They lack
social reciprocity, and restricted interests, social
isolation and repetitive rituals characterise a pro-
portion. There is an increasing recognition of the
extent of the problem by child health professionals,
both in the UK (General Practice Research Database;
Kaye, del Mar Merelo-Montes, & Jick, 2001) and in
the USA (California Department of Developmental
Services; Fombonne, 2001). Even so, the number
coming to clinical attention is significantly lower
than the true population prevalence (2–5/1000),
as estimated from community surveys that have
actively sought out cases (Baird et al., 2000;
Fombonne, 1999; Gillberg & Wing, 1999; see
Fombonne, 2001). Patterns of comorbidity have not
been investigated, largely because standardised
case-finding psychiatric interviews are not suitable
for this purpose.

We hypothesised that pragmatic difficulties would
be associated with antisocial behaviour in a pro-
portion of children who are labelled as conduct dis-
ordered. There were two phases to our investigation.
In Phase One, we aimed to assess the pragmatic
competence of children who had been referred to
child and adolescent mental health services with
conduct disorders. We compared them with children
whose primary problem was a disorder on the aut-
istic spectrum. In Phase Two, we asked the same
question of a sample of inner-city children who had
been excluded from school, or who were at high risk
of exclusion, but who had not been referred to a
clinical service.

Method
Phase One: Participants referred to Child
and Adolescent Mental Health Services

All the children in Phase One were clinically referred
cases. There were two clinic populations from which
children with conduct or pervasive developmental dis-
orders were selected. The first sample consisted of all
new referrals during the period January 1999 through
October 2001 to the Social and Communication Disor-
ders Clinic at Great Ormond Street Hospital (GOSH),
London. This is a tertiary referral centre, which spe-
cialises in the evaluation of children with behavioural
problems that are thought to have a neurodevelop-
mental origin. Whilst most of these children are sus-
pected of having an autistic-like condition, a minority
are referred because of persistent behaviour problems
of a less specific nature. Referrals are sent from a wide

968 J. Gilmour et al.

geographical area, throughout the southeast of Eng-
land, and are heterogeneous with regard to socioeco-
nomic background. Those with global learning
difficulties, according to clinical evaluation and/or
psychometric evaluation (a Full Scale IQ of 70 or below),
were excluded, as were children who did not possess
sufficient language skills to enable a formal test of their
pragmatic abilities to be completed. Cognitive ability
was assessed in a proportion of children who attended
the clinic at Great Ormond Street Hospital. While IQ
data are not available on the whole sample, the sub-
group on whom data exist is representative as it was a
consecutive series of clinic attendees. Cognitive ability
data were not routinely collected in the Sunderland
sample. Wherever possible, IQ was assessed using the
Wechsler Intelligence Scales for Children (Wechsler,
1992) or Verbal IQ was estimated using the British
Picture Vocabulary Scales (Dunn, Dunn, Whetton, &
Burley, 1997).

The second clinical population comprised a con-
secutive series of children with miscellaneous dis-
orders, who had been referred to clinics providing Child
and Adolescent Mental Health Services in Sunderland,
a city in the north of England with a population of ap-
proximately 300,000. According to the Government In-
dex of Deprivation 2000, approximately 50% of wards in
Sunderland rank in the lowest 10% nationally in terms
of multiple indices of income, unemployment, health,
education, housing, access to services and child poverty
(Department of Transport, Local Government and the
Regions, 2000). Exclusion criteria were similar to those
in the GOSH sample.

Typically developing comparison children were
recruited from paediatric outpatient clinics in Sunder-
land. A consecutive clinical sample was chosen which
was similar to the psychiatric clinic attendees in terms
of age and socioeconomic status. These children were
referred for physical complaints such as asthma but
were subject to the same structured psychiatric inter-
view evaluation as the case children; thus children with
a psychiatric condition were excluded from the com-
parison group.

Diagnostic procedures. In both the GOSH and the
Sunderland sample, diagnoses were made primarily by
clinical judgement, by clinicians who were experienced
in making diagnoses within the autistic spectrum. The
data on which such judgements were based were col-
lected by a computerised interview, which has good
psychometric properties in terms of both reliability and
validity (Skuse et al., 2004). Diagnoses were assigned
according to ICD-10 criteria (World Health Organiza-
tion, 1996). Identical protocols of assessment and the
application of diagnostic criteria were applied to the
Great Ormond Street Hospital sample (N ! 103) and
the Sunderland sample (N ! 39).

Eligible cases were subdivided according to their
primary diagnosis into the following groups:

i) Conduct disorder (49 boys, 6 girls). The diagnosis of
conduct disorder excluded the category of ‘conduct
disorder confined to the family context’. Our dia-
gnostic criteria required evidence of behavioural
disturbance at home and at school. Information
concerning the latter context was obtained from

teachers, on the basis of a score ‡4 on the Strengths
and Difficulties Questionnaire (Goodman, 1997),
followed by interviews where the diagnosis was
suspected. We have subsumed both socialised and
unsocialised conduct disorders under this heading.
We also subsumed ODD within the category ‘con-
duct disorder’ for the purposes both of simplifying
the analysis and increasing group size.

ii) Autistic Spectrum Disorder (34 boys, 8 girls). These
children met diagnostic criteria on two of the three
domains of the triad of autistic impairments,
according to the Multiaxial Classification of Child
and Adolescent Psychiatric Disorders (WHO, 1996).

iii) Autism (40 boys, 5 girls). This group included chil-
dren clinically described as both ‘Asperger syn-
drome’ and autism, according to ICD-10 criteria.
There is little evidence (e.g., Miller & Ozonoff, 2000)
that there are any meaningful differences between
high-functioning autistic and Asperger’s groups.

iv) Typically developing comparisons (29 girls, 31 boys).

Comorbidity. Some children had more than one dia-
gnosis. The primary diagnosis was assigned following
team discussions of all clinical material. This was de-
fined as the condition that dominated the clinical pic-
ture, and it was usually the condition associated with
the symptom profile that prompted referral. In some
cases one or more additional psychiatric diagnoses
were made. Diagnostic evaluations for comorbidity in
association with a primary diagnosis of conduct disor-
der were based on clinical judgement and ICD-10
guidelines, using as a data source information gathered
by means of a standardised psychiatric interview (the
3di; Skuse et al., 2004). Data describing comor-
bidity were available for the GOSH clinical samples
only. Comorbidity rates in the CD (n ! 29) group were
as follows: none of the CD group showed evidence of
generalised anxiety disorder, phobias, panic disorder,
depression, hypomania or bipolar affective disorder.
One child (3%) had a separation anxiety disorder and 6
(20%) had hyperkinetic disorder. In the Autism group
(n ! 34) there was no comorbidity for generalised
anxiety disorder, phobia, panic disorder, hypomania,
bipolar affective disorder or eating disorders. One child
(3%) had separation anxiety disorder, three (9%) had a
depressive disorder and 4 (12%) had hyperkinetic dis-
order. None of the children in the ASD group (n ! 35)
showed evidence of generalised anxiety disorder, panic
disorder, depression, hypomania, bipolar affective dis-
order or eating disorders. Two children (6%) had fea-
tures of separation anxiety disorder, two (6%) had
a specific phobia, and 6 (17%) had had hyperkinetic
disorder.

Phase Two: Participants identified
from community survey of excluded children

Children were identified with the assistance of the Local
Educational Services in the London Borough of Hack-
ney. Hackney Borough has a population of nearly
200,000 of which almost a quarter is under 16 years of
age. A third of the borough’s population is from ethnic
minority groups. Several key contributory factors to
antisocial behaviour and crime, such as high unem-

Social communication deficits in conduct disorder 969

ployment, family breakdown, low levels of education
and high levels of disaffected young people, are wide-
spread in Hackney. According to the Government Index
of Deprivation (Department of Transport, Local Gov-
ernment and the Regions, 2000), Hackney rates as the
second most deprived Borough in the country. All wards
are in the worst 10% nationally and nine wards are in
the worst 3%. Other indicators of social deprivation in
the Borough show that 58% of residents live in social
housing; 50% of all children receive free school meals,
and long-term illness and disability are the highest in
London. Hackney experiences high levels of mental
health problems and has amongst the highest admis-
sions rates to psychiatric hospitals in the country.

Our sample of antisocial children from this source
comprised children between the ages of 5 and 10 years
old who had been excluded or were at risk of exclusion
from schools in the Borough in June 2001. Of the 57
primary schools in the Borough we received information
from 51; 16,000 pupils who were within this age range
attended school in the Borough. The total of children in
the age range excluded from school on whom we re-
ceived information comprised 5 girls and 49 boys at
that time. So far as we could ascertain, none was
attending CAMHS services at the time of the survey. No
diagnostic interviews have been conducted with parents
in this sample. We were unable to identify the total
number of children in the Borough who were at risk of
exclusion at the time of this survey.

Assessment of pragmatic competence

The Children’s Communication Checklist (CCC; Bish-
op, 1998) was used for the purpose of assessing prag-
matic skills in both the clinical and the community
samples. This instrument was developed with the spe-
cific goal of distinguishing between those children who
have impairments in their social use of language, or
pragmatic skills, and those with Specific Language
Impairment (SLI), where the principal problems are
with language structure. Pragmatic competence is
intrinsically dependent on the specific situation in
which it is assessed, whereas structural language
problems are pervasive. For each item, the rater is
presented with a statement and has to check whether
this ‘definitely applies’, ‘applies somewhat’, or ‘does not
apply’.

The general population scores from Bishop and
Baird’s (2001) typically developing group and the
maximum score are given as follows for each subscale.
Speech (mean 35.1 SD 1.5; maximum score: 38)
measures intelligibility and fluency, concerning matters
such as whether speech is clearly articulated and flu-
ent. Syntax (31.7 SD .7; maximum score: 32) measures
the child’s ability to produce developmentally appro-
priate length of utterances in a grammatically correct
manner. Inappropriate Initiation (27.2 SD 2.1; max-
imum score: 30) is a subscale that measures impulsive
behaviour, such as interrupting conversations. The
Coherence (35.2 SD 1.3; maximum score: 36) subscale
measures the child’s ability to tell a story, or to talk
about past or future events in an appropriate temporal
context, aimed at increasing intelligibility to the lis-
tener. Stereotyped Language (28.0 SD 2.1; maximum
score: 30) measures a tendency to engage in conversa-

tions that are allied to the interests of the child, con-
taining favourite but inappropriate themes, and
stereotyped phrases. Use of Context (30.5 SD 1.9;
maximum score: 32) assesses different aspects of the
use of conversational context, such as the child’s
understanding of sarcasm or non-literal remarks. In
general, children with poor understanding of contextual
cues will interpret another’s remarks over-literally.
Rapport (32.8 SD 1.4; maximum score: 34) describes a
child’s ability to start a conversation, use gestures to
facilitate meaning, interpret non-verbal gestures and
facial expressions, and to use eye contact appropriately.
Social Relationships (32.7 SD 1.9; maximum score: 34)
concerns the child’s ability to make and to maintain
friendships. There are questions specifically targeted at
identifying children who are loners, or perceived as odd
by others, or who are deliberately aggressive. The
Interests subscale (31.5 SD 2.1; maximum score: 34)
concerns aspects of social behaviour as well as a tend-
ency to have overriding specific interests (such as
dinosaurs). It also records unusual repertoires of fac-
tual knowledge, including obscure words. The Prag-
matic Composite (153.6 SD 6.5; maximum score: 162)
score is derived from the following subscales: Inappro-
priate Initiation, Coherence, Stereotyped Language, Use
of Context and Rapport.

Lower scores on the CCC scales indicate greater
impairment. A child who obtains a profile indicating
average or typical development, with no items describ-
ing communication difficulties scored as applying
‘somewhat’ or ‘definitely’, would score 30 on each sub-
scale. Scores greater than 30 are possible for those
scales that include positive items that describe com-
municative strengths. In consultation with Dorothy
Bishop, we defined significant clinical impairment to be
associated with CCC scores that lay at least 2.0 SD
below the population mean, on subscales or the Com-
posite score. Population data were determined from
data provided by Bishop and Baird (2001). Most items
are based on clinical descriptions of a subtype of Spe-
cific Language Impairment known as semantic-prag-
matic disorder (Bishop & Rosenbloom, 1987). Bishop
(1998) predicted that children whose problem was
purely a semantic-pragmatic one might be identified by
a poor Pragmatic Composite total score, but their Social
Relationships and Interests subscale scores would be
normal. Children with autistic features in addition to a
semantic-pragmatic disorder would obtain abnormal
scores on the latter subscales as well.

Specificity of the CCC

In order to investigate the prevalence of pragmatic dis-
orders in conditions other than conduct disorder and
autism spectrum disorders, we evaluated scores ob-
tained from parent ratings of other clinically identified
samples, diagnosed according to ICD-10 criteria, from
the Sunderland sample of consecutive referrals to
CAMHS. We found no evidence that pragmatic skill
deficits are a non-specific correlate of significant psy-
chiatric disorders in samples of children of approxi-
mately the same mean ages and abilities. The mean
Pragmatic Composite score for our typically developing
group (N ! 60) was 151.9 (SD 8.7). Comparable scores
were found for children with moderate depression

970 J. Gilmour et al.

(N ! 6; mean 151.7; SD 6.8); severe depression (N ! 5;
mean 156.8; SD 2.6); and generalised anxiety (N ! 14;
mean 150.6; SD 12.9).

Results
Phase One: CCC ratings and diagnostic categories
for clinically referred sample

Table 1 shows parent CCC ratings in relation to
diagnostic category for the clinical samples and the
comparisons. Table 2 shows corresponding data for
teacher ratings from the clinically referred sample.
Each table gives the proportion of children in each
diagnostic group with scores more than 2 SD below
the CCC subscale (and Pragmatic Composite) popu-
lation means (data from Bishop & Baird, 2001). Such
scores are described as being in the ‘clinical range’,
indicating that they are sufficiently low that they
would be typical of children requiring clinical inter-
vention (Bishop, 1998). Children in the diagnostic
categories ‘Conduct Disorder’, ‘Autism Spectrum
Disorder’ and ‘Autism’ are compared with a typically
developing comparison sample. The main effect of
diagnostic group was tested in analyses of variance for
differences in means, based on each CCC subscale

and the Pragmatic Composite score. We undertook an
analysis of variance, with Bonferroni corrections to
avoid the possibility of type 1 errors. The highly sig-
nificant main effects of group, according to data on
communication skills obtained from parent-rated
CCC (see Table 1), were largely attributable to the
contrasts between typically developing and clinically
referred children (irrespective of whether they were in
the conduct disordered, autistic spectrum or autistic
groups). We did not have a normal comparison group
for teacher data (see Table 2). There were no group
differences in pragmatic skills, by diagnostic cat-
egory. Age was not significantly related to CCC sub-
scale score in the typically developing group (r values
ranged between –.16 and .19). There was no signific-
ant gender difference in the typically developing
group on any of the subscale scores of the CCC
(p < .05) (Speech t ! 1.76. Syntax t ! .76, Inappro- priate Initiation t ! 1.1, Coherence t ! .18, Stereo- typed Speech t ! .71, Context t ! .07, Rapport t ! .98, Social Relationships t ! .11, Interests t ! .65 and Pragmatic Composite t ! .10) according to parent report. We also re-examined the comparisons de- scribed in Table 1 using an exclusively male sample across all four groups. These results are detailed further in the table.

Table 1 Parental Children’s Communication Checklist ratings in relation to diagnostic category

Scale

Diagnostic group
ANOVA (Bonferonni-

corrected)+
p < .05

v2 p > .05″

A – Conduct
Disorder
(n ! 55)

B – Autistic
Spectrum

Disorder (n ! 42)
C – Autism
(n ! 45)

D – Typically
developing
(n ! 60)

Mean age in yrs mths (SD) 10.2 (2.70) 9.7 (2.7) 10.2 (3.7) 10.1 (2.4) ns
% male 89% 81% 89% 51%
Speech Mean (SD) 32.1 (4.0) 29.9 (5.5) 30.9 (4.9) 34.8 (1.6) D > ABC
% in clinical range! 40% 55% 53% 10% ns
Syntax Mean (SD) 30.8 (1.8) 30.3 (1.9) 29.6 (3.9) 31.5 (1.3) D > C
% in clinical range! 42% 52% 47% 18% ns
Inappropriate Initiation Mean (SD) 23.2 (3.4) 22.3 (2.9) 24.5 (3.9) 27.2 (2.7) D > ABC
% in clinical range! 54% 63% 40% 12% ns
Coherence* Mean (SD) 28.9 (4.2) 26.7 (4.6) 27.1 (4.2) 34.4 (2.6) D > ABC
% in clinical range! 78% 89% 89% 21% ns
Stereotyped Language* Mean (SD) 22.9 (4.2) 20.8 (4.1) 23.2 (4.3) 26.9 (2.3) D > ABC

C > B
% in clinical range! 68% 82% 56% 15% B >> C
Use of Context* Mean (SD) 22.8 (3.7) 21.5 (3.5) 22.9 (3.7) 29.9 (2.7) D > ABC
% in clinical range! 88% 97% 86% 14% ns
Rapport* Mean (SD) 26.2 (4.2) 25.9 (4.1) 24.5 (3.1) 33.2 (1.3) D > ABC
% in clinical range! 83% 84% 97% 4% ns
Social Relationships” Mean (SD) 25.5 (4.1) 24.1 (4.4) 23.9 (4.6) 32.6 (2.4) D > ABC
% in clinical range! 82% 90% 87% 7% ns
Interests” Mean (SD) 29.3 (2.8) 28.4 (2.5) 27.6 (2.7) 31.1 (2.4) D > ABC

A > C
% in clinical range! 24% 40% 46% 8% C >> A
Pragmatic Composite Mean (SD) 127.3 (16.4) 117.29 (2.5) 124.5 (15.1) 151.9 (8.7) D > ABC
% in clinical range! 78% 95% 89% 8% B >> A

*Contributes to the Pragmatic Composite score.
“Subscales considered by Bishop (1998) to distinguish children with autism from those with ‘pure’ pragmatic disorder.
!Proportion of children with scores at least 2 SDs below typically developing mean were considered to have scores in the same range
as those seen for clinical evaluation in specialised language units (Bishop, 1998). The TD group was excluded from these analyses.
+These analyses were similar using a male only sample in the same sub-groups, with three exceptions: Coherence: A > C. The C > B
finding in Stereotyped Language and the A > C in Interests finding no longer hold.

Social communication deficits in conduct disorder 971

We tested the hypothesis that the Pragmatic Com-
posite score was related to intellectual ability. In our
clinical sample, IQ data from the Wechsler (1992)
scales were available for 48 children on whom we
had parental CCC information and 41 on whom we
had teacher-reported CCC data. Thus it was possible
to look separately at relationships between Verbal
(VIQ) and Performance IQ (PIQ), and pragmatic
competence for each group. In these analyses, age
was not entered as a covariate, because neither the
parent nor the teacher Pragmatic Composite score
correlated significantly with age. Neither VIQ nor PIQ
was significantly related to the parent-rated Prag-
matic Composite (VIQ: for the Autism group:
r ! (9) ! .35, ns, ASD group r (14) ! .26 ns and CD
group r (25) ! .16, ns. PIQ: for the Autism group:
r (9) ! ).05, ns, for the ASD group r (14) ! .26, ns
and CD group r (25) ! ).02, ns). The Pragmatic
Composite score rated by teachers was not signific-
antly correlated with either VIQ or PIQ (VIQ: for the
Autism group r (7) ! ).09, ns, for the ASD group
r ! (12) ! ).17, ns, and for the CD group r (22) !
.21, ns. PIQ: Autism group r (7) ! ).62, ns, for the
ASD group r ! (12) ! ).26, ns and for the CD group
r (22) ! .08, ns. This finding contrasted with the
positive association between these variables re-
ported by Bishop and Baird (2001).

We had both teacher and parent CCCs for 84
children who were drawn from the clinically identi-
fied samples only. Within this group as a whole, the
correlation between teacher and parent scores on the
Pragmatic Composite was only .18, which failed to

reach a conventional level of significance. In con-
trast, teachers and parents did agree reasonably well
on specific aspects of speech and language disorder
as measured by CCC subscales. These included
Speech (r ! .56, p < .001) Syntax (r ! .57, p < .001), and Coherence (r ! .38, p < .001). They were less likely to agree about whether the child used Con- textual Cues appropriately (r ! .06, n.s.) or whether a child’s speech was Stereotyped (r ! .22, p < .05). Good agreement was found for Interests (r ! .41, p < .001) and Inappropriate Initiation (r ! .36, p < .001), but there was poor agreement on Social Relationships (r ! .16, ns) and Rapport (r ! .11, ns).

We had expected agreement in Pragmatic com-
posite scores rated by teachers and parents to differ
by diagnosis. For example, distinct impairments in
pragmatic skills should be obvious in cases of aut-
ism, whether the rater was a parent or a teacher. In
fact, the value of the correlation coefficient was very
similar within each of the four diagnostic categories.
In general, teachers tended to rate children with
disorders on the autistic spectrum as less language-
disordered than did their parents. This is clear from
a comparison of the proportions of children who
obtain scores that are more than 2 SDs below the
population mean. Further analyses indicates there
was 60% agreement between parent and teacher in
their allocation of individual children to the clinical
range status on the Pragmatic Composite scale, 58%
agreement for Speech, 73% agreement for Syntax,
77% agreement for Coherence, 78% agreement for
Use of Context, 55% agreement for Stereotyped

Table 2 Teacher CCC ratings in relation to diagnostic category

Scale
Diagnostic group
ANOVA (Bonferonni-

corrected)
p < .05

v2 p < .05

A – Conduct
Disorder
(n ! 29)

B – Autistic
Spectrum

Disorder (n ! 31)
C – Autism
(n ! 24)

Mean age Mths (SD) 120 (33) 109 (32) 125 (50) ns
% male 92% 84% 87%
Speech Mean (SD) 32.0 (3.3) 32 (5.5) 30.3 (4.7) ns
% in clinical range! 46% 41% 58% ns
Syntax Mean (SD) 30.7 (2.3) 30.8 (1.08) 29.8 (2.3) ns
% in clinical range! 31% 29% 54% ns
Inappropriate Initiation Mean (SD) 25.5 (3.4) 24.7 (3.4) 26.6 (3.3) ns
% in clinical range! 31% 39% 17% ns
Coherence* Mean (SD) 29.3 (4.9) 29.1 (4.9) 28.1 (4.6) ns
% in clinical range! 76% 74% 83% ns
Stereotyped Language* Mean (SD) 25.2 (3.9) 23.9 (4.1) 24.8 (3.6) ns
% in clinical range! 31% 58% 46% ns
Use of Context* Mean (SD) 25.0 (3.5) 24.5 (3.8) 24.1 (6.0) ns
% in clinical range! 79% 80% 67% ns
Rapport* Mean (SD) 26.8 (4.4) 27.6 (4.2) 26.1 (3.5) ns
% in clinical range! 79% 68% 82% ns
Social Relationships Mean (SD) 26.3 (4.1) 25.7 (4.3) 25.1 (5.1) ns
% in clinical range! 69% 80% 74% ns
Interests Mean (SD) 28.5 (3.3) 29.4 (2.6) 27.3 (2.8) ns
% in clinical range! 31% 23% 48% ns
Pragmatic Composite Mean (SD) 131.7 (15.1) 129.9 (15.1) 130.1 (13.1) ns
% in clinical range! 69% 68% 77% ns

*Contributes to the Pragmatic Composite score.
!Proportion of children with scores at least 2 SDs below typically developing mean.

972 J. Gilmour et al.

Speech, 60% agreement for Interests, 64% agree-
ment for Inappropriate Initiation, 70% agreement
on Social Relationships and 71% agreement for
Rapport.

Table 3 provides data for both the parent- and
teacher-rated Pragmatic Composite, in specified
ranges of scores, by diagnostic group. Scores are
divided into approximately 1.0 SD categories below
the population mean (Scores in band 133–139 are
>1.0 SD below mean, 123–132 are >2.0 SD, and
those less than 122 are >3.0 SD. The values we have
taken are conservative, and derived from our own
sample of typically developing children and com-
parable data collected by Bishop (Bishop, personal
communication). With very low Pragmatic Composite
scores on the CCC (below 122) there is a trend for
parents and teachers to disagree, insofar as parents
are more likely to give lower ratings. Nevertheless,
the proportion of children with conduct disorders in
this lowest banding is very similar to the proportion
of children with autism scoring in that band,
whether the rating is made by teachers or by
parents. Parent ratings indicate about 50% of
clinically identified conduct disordered children are
in this lowest category, compared with 51% of those
with childhood autism. Teachers rate 27% of autistic
children in the lowest category, compared with 34%
of those with clinically defined conduct disorder.

Comorbidity. We specifically examined the extent to
which evidence existed of comorbid conduct disorder
in children assigned diagnoses of autism or an aut-
ism spectrum disorder. We looked separately at co-
morbidity between these conditions in the two
clinical samples referred to the Social Communica-
tion Disorders Clinic and the CAMHS service in
Sunderland. The proportions of conduct disordered
children who were clinically significantly impaired
on two of the three aspects of the autism triad (i.e.,
had an autism spectrum disorder) were 38% (13 of
34) in the Social Communication Disorders Clinic
and 19% (4 of 21) in the CAMHS services, a non-
significant difference (v2 ! 2.2, ns, effect size ! .20).
Table 4 compares the CCC subscale scores for the

CD group comorbid for an ASD and without. As
expected, in general, parents and teachers reported
a trend for the ASD affected group to have lower
scores (poorer functioning). The same table also
shows the proportion of children who fall into the
clinical range according to parents and teachers.

Phase Two: Children excluded from school
for disruptive behaviours

In Phase Two we selected the conduct-disordered
sample of children from elementary schools in the
London Borough of Hackney, on the basis that they
were so disruptive they were at risk of permanent
exclusion from mainstream education. In Table 5,
Teacher CCC ratings for the 54 excluded children are
given for individual subscales, showing the propor-
tions of those children rated as having a degree of
pragmatic disorder that falls more than 2.0 SDS
below the population mean (see p. 8) (Bishop &
Baird, 2001). In the Hackney excluded children
sample, the proportion with a Pragmatic Composite
score which is >2.0 SDs below the mean is 69%. In
the clinically ascertained sample of conduct disor-
dered children, the equivalent proportion as rated by
teachers is 48% (scores less than 132 are equivalent
to )2.0 SDS), and the proportion with low scores
rated by parents (total N ! 55) is 65%. The equival-
ent proportions in the autism spectrum disorder
sample are 55% and 88% respectively. These pro-
portions do not differ significantly from one another.

We tested the hypothesis that there would be
similar mean scores in respect of each of the CCC
subscales and the pragmatic composite for the clin-
ical and the community samples, in respect of con-
duct disordered children. Teacher ratings on the
CCC for the 54 excluded children are reported in
Table 5, and should be compared with equivalent
data for the clinically referred sample, shown in
Table 2. We undertook a further set of analyses,
comparing the teacher CCC scores for the excluded
children with those in the diagnostic categories
shown in Table 2. The mean values for the CCC
subscales and the Pragmatic Composite score are

Table 3 Numbers (percentage) of children in relation to range of score on the Pragmatic Composite Score of Children’s Com-
munication Checklist. Parent and teacher ratings

Parent rating
A – Conduct Disorder

(N ! 55) n (%)
B – Autistic Spectrum
Disorder (N ! 42) n (%)

C – Autism (N ! 45)
n (%)

D – Typically Developing
(N ! 60) n (%)

140 or more 12 (22%) 2 (5%) 5 (11%) 56 (93%)
133 to 139 7 (13%) 3 (7%) 7 (16%) 2 (3%)
123 to 132 8 (14%) 6 (14%) 10 (22%) 1 (2%)
Below 122 28 (51%) 31 (74%) 23 (51%) 1 (2%)

Teacher rating
A – Conduct Disorder

(N ! 29) n (%)
B – Autistic Spectrum
Disorder (N ! 31) n (%)

C – Autism (N ! 24)
n (%)

140 or more 9 (31%) 10 (32%) 6 (27%)
133 to 139 6 (21%) 4 (13%) 3 (14%)
123 to 132 4 (14%) 5 (16%) 7 (32%)
Below 122 10 (34%) 12 (39%) 6 (27%)

Social communication deficits in conduct disorder 973

T
a
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is
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g
ro
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ic
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p
in
g
m
e
a
n
.

974 J. Gilmour et al.

very close indeed in the two samples. There were just
two significant differences between the excluded
children and others, on the basis of CCC scores. On
both the Speech and Coherence subscales ‘excluded’
children obtained higher (indicating better func-
tioning) scores than children with autism, but they
did not differ significantly from clinically referred
conduct disordered children, nor from autistic
spectrum disorders.

Discussion
Social communication deficits in children with
conduct disorders

In this investigation we have shown that a substan-
tial proportion of children with conduct disorders, in
both clinically referred and community-ascertained
samples, have deficits in their pragmatic skills that
are as severe as those of children with clinical dia-
gnoses on the autistic spectrum. Our data show that
a sub-set of children presenting as CD actually have
an unidentified ASD. There are still further children
with CD who do not reach a formal ASD diagnosis
but who nonetheless have pragmatic problems. It
may be that pragmatic problems we have described
in the CD group have the same origins as ASD but
this remains untested. The primary neuro-cognitive
impairments in children with pragmatic problems
remain poorly understood, though executive

dysfunction (e.g., McDonald & Pearce, 1996) is one
likely candidate. For these high-functioning chil-
dren, their pragmatic difficulties are not simply a
function of intelligence; as there is no significant
correlation between these abilities and either Verbal
IQ or Non-Verbal IQ in our study. While we
acknowledge we have measured cognitive ability on
only a sub-sample of children, we are confident it is
representative of the whole clinic population as it
was a consecutive series of children from the GOSH
clinic.

We considered the possibility that a systematic
bias may have been introduced in the clinical sam-
ples, insofar as parents who brought their children
to the CAMHS service in Sunderland, or to the
service at Great Ormond Street Hospital (which
specialises in treating children with social commu-
nication problems), may have exaggerated their
child’s pragmatic deficits. This seems unlikely. First,
the profile of CCC subscale and pragmatic composite
scores for both conduct-disordered and other dia-
gnostic groups was similar in both parent- and
teacher-rated data. Second, teacher ratings of the
conduct-disordered excluded sample of children
from inner-city schools (who had not attended
CAMHS services, so far as we could ascertain) yiel-
ded almost identical mean scores for CCC subscales
and the Pragmatic Composite to the clinically re-
ferred samples. Third, although Great Ormond
Street Hospital (GOSH) is a Tier 4 service, there were

Table 5 Teacher CCC ratings for school excluded sample

Scale

Group

F – Children excluded from Hackney
schools* (n ! 54)

Significant difference from groups A-C on Table 2
(Bonferroni-corrected p < .05)

Age yrs.mths Mean (SD) 9.4 (2.0) ns
Sex ratio (M:F) 49:5
Speech Mean (SD) 32.2 (3.7) F > C
% in clinical range! 44
Syntax Mean (SD) 30.4 (4.0) ns
% in clinical range! 33
Inappropriate initiation Mean (SD) 24.5 (3.5) ns
% in clinical range! 35
Coherence Mean (SD) 30.5 (4.4) F > C
% in clinical range! 72
Stereotyped Language Mean (SD) 26.6 (5.0) ns
% in clinical range! 28
Use of Context Mean (SD) 24.7 (4.0) ns
% in clinical range! 78
Rapport Mean (SD) 27.7 (4.2) ns
% in clinical range! 67
Social Relationships ” Mean (SD) 23.8 (3.6) ns
% in clinical range! 94
Interests” Mean (SD) 29.5 (3.0) ns
% in clinical range! 20
Pragmatic Composite Mean (SD) 131.5 (14.2) ns
% in clinical range! 69

*Two children from Hackney school exclusion children sample were omitted from analysis because their quality of language was
insufficient to compute a Pragmatic Composite score.
“Subscales considered by Bishop (1998) to distinguish children with autism from those with ‘pure’ pragmatic disorder.
!Proportion of children with scores at least 2 SDs below typically developing mean were considered to have scores in the same range
as those seen for clinical evaluation in specialised language units (Bishop, 1998).

Social communication deficits in conduct disorder 975

no substantial differences in the proportions of
conduct disordered children with severe pragmatic
deficits seen at GOSH, compared with the sample
from the Royal Sunderland Hospital Tier 3 CAMHS
service. Because of small numbers, statistical com-
parisons between the two sub-samples were inap-
propriate.

This is not the first study to indicate that the
division between pervasive and specific develop-
mental disorders is not a sharp one (e.g., Norbury &
Bishop, 2002), although it is the first to find such a
substantial comorbidity for autistic features among
children with conduct disorder. Indeed, increasing
evidence is emerging to indicate that there is con-
siderable continuity between disorders that have
traditionally been regarded as quite distinct from one
another. An overlap between conduct disorders and
autistic traits was suspected by Moffitt et al. (2001).
Other evidence more directly implies that there are
links between the relatively poor verbal abilities of
children with conduct problems and emotion pro-
cessing skills. For example, Speltz, DeKlyen, Cald-
eron, Greenberg, and Fisher (1999) reported that
preschool boys with oppositional defiant disorder
had poorer vocabularies for describing affective
states than comparison boys. The result held after
general vocabulary knowledge and test behaviour
were controlled.

To our knowledge, this is the first study to
investigate pragmatic communication deficits in an
unreferred sample of antisocial children who were
excluded, or about to be excluded, from school. Our
findings indicate that such deficits are characteristic
of a significant proportion, perhaps as many as two-
thirds, of children excluded or at risk of exclusion
from school during their first few years of education.
We aim to establish if there is a causal relationship
between social communication problems and
exclusion in forthcoming investigations, as we sus-
pect there is. However, it is important to acknow-
ledge that social, cognitive, psychological and
neurobiological factors may play a part in engen-
dering disruptive behaviour at school. These factors
almost certainly interact with one another and con-
tribute in a complex manner to that outcome. Fu-
ture studies might aim to include full psychosocial
investigations in order to explore the relationship
between psychosocial issues and the type of social
communicative difficulty we describe in the current
study.

Autism and autistic spectrum disorders are highly
heritable conditions, with a strong genetic predis-
position (Bailey et al., 1995). We do not at this stage
know to what extent the pragmatic communication
deficits we have described have a similar aetiology,
and to what extent circumstances of upbringing
contribute to the measured behaviours and skills. To
date, genetic research on conduct disorder has
raised more questions than it has answered, and
basic issues such as the heritability of childhood

antisocial behavior have not yet been clarified
(Simonoff, 2001).

Parent-professional agreement on pragmatic
deficits

In the age range under investigation the CCC is not
merely acting as an alternative way of identifying
verbal ability: rather it picks up communicative dif-
ficulties that may not be detected by conventional
psychometric assessments. As in the Bishop and
Baird (2001) investigation, our study showed that
parental ratings of children’s pragmatic competence
have discriminant validity. Previous studies have
also found that parent–teacher agreement on many
aspects of child behaviour is not necessarily good.
This issue has been most extensively studied in
relation to the parent-rated Child Behavior Checklist
and the Teacher Report Form (Achenbach 1991a &
b). Parent-teacher correlations for ratings of beha-
vior/emotional problems are typically in the range of
.2 to .4 (e.g., Verhulst & Akkerhuis, 1989). There are
various reasons for the lack of agreement in our own
investigation of the CCC. It is possible that the verbal
and non-verbal communicative behaviours in ques-
tion are insufficiently well defined to allow for ob-
jective assessment. However, it is notable that the
parent–teacher agreement on CCC subscales was
good for Interests and for Inappropriate Initiation.
Perhaps the subscales measuring Social Relation-
ships and Rapport are relatively less well specified.
For subscales specifically concerned with speech
and language competence, there was good agree-
ment about Speech, Syntax and Coherence, which
may be rather more obvious than the more subtle
behaviours that contribute to the Pragmatic Com-
posite score. Nevertheless, in both the teacher and
parent ratings we did find a relationship between
CCC scores and clinical diagnoses. Disagreements
between raters may in part reflect the fact that
communicative abilities are context dependent. This
latter interpretation, which is discussed by Bishop
and Baird (2001), is suggested by the fact that higher
parent–teacher correlations were found for scales
assessing language structure (such as Speech and
Syntax), which tends not to vary much with context.
We concluded that parental ratings may be more
valid than teacher ratings, insofar as they correlate
rather better with the child’s diagnostic status in the
clinical samples studied, although the instrument
was originally devised to be rated by teachers and
speech-language therapists (Bishop, 1998).

Sex ratio

There is a striking sex ratio, with a preponderance of
males in our clinically referred conduct-disordered
population (just 11% were female). This ratio is very
similar to that found among ASD and autistic
groups. The number of females with conduct prob-

976 J. Gilmour et al.

lems in both the clinic and the excluded children
samples was too small to warrant separate analysis.
The very small number of girls engaging in antisocial
behaviour at elementary school is in keeping with
previous reports, such as the Dunedin study (Moffitt
et al., 2001) which found that antisocial activities
involving girls usually do not commence until early
adolescence. However, the 9:1 male to female ratio
we report is very high, greater than was found in that
investigation at any stage. It is likely to reflect the dif-
fering characteristics of a clinically referred sample,
compared with an epidemiologically ascertained one.

Conclusions
We are aware that these surprising findings require
replication. The results indicate that a significant
minority of children with disruptive behaviour
in the community have significant, previously
unidentified, social communication difficulties. Our
findings could have particular significance for chil-
dren identified as having conduct disorder early in
their school careers. The findings from our inner-
London schools survey are of potential importance
for service planning. We caution that our prelimin-
ary finding will have to be followed by a detailed
evaluation of the children concerned. This should
include not only a formal evaluation of psychiatric
morbidity, but also a neurological examination, and
detailed cognitive testing. Whether these excluded
children would meet diagnostic criteria for an aut-
istic spectrum disorder is at present an open
question, but one that is clearly accessible to
empirical verification. We do not intend to imply
that psychosocial and family factors play an insig-
nificant role in engendering antisocial behaviour
(see Hill, 2002).

With accurate identification comes the possibility
of a new approach to the management of many
excluded children and an opportunity to ameliorate
their social communication skill deficits. Tradition-
ally, interventions for children with antisocial beha-
viour draw from social learning theory models (e.g.,
Miller & Prinz, 1990). The long-term efficacy of such
models of intervention has been questioned (Kazdin,
1997). Because we suspect such social commun-
ication problems could be causally related to the
onset of behaviours that put children at risk of ex-
clusion, a window of opportunity may exist among
those in their early years at primary school, for pre-
vention. There are a number of effective intervention
strategies developed specifically for children with
social communication deficits of this nature,
particularly children with average range general in-
telligence, such as those we are targeting. Special-
ised social skills groups, peer tutoring (Kamps,
Leonard, Vernon, Dugan, & Delquadri, 1992; Ozo-
noff & Miller, 1995) and pivotal response training
(Koegel, Koegel, Hurley, & Frea, 1992; Pierce &

Schreibman, 1997) increase socially appropriate
behaviour, which, in turn has positive secondary
gains in competence and adjustment.

Acknowledgements
The authors would like to thank Dorothy Bishop,
Margaret Dimmock, Jessica Hulsmeier, Susan
Woollacott, Tony Charman, Nichola Baboneau and
the families and teachers who took time to complete
our questionnaires and interviews.

Correspondence to
Jane Gilmour, Sub-Department of Clinical Health
Psychology, University College London, Gower
Street, London WCIE 6BT, UK; Email: Jane.Gilmour@
ucl.ac.uk

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Manuscript accepted 29 September 2003

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