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American Journal of  
Life Science and Innovation (AJLSI)

Examining Early Communication Profiles in Preschool Children with Autism Spectrum 
Disorders in Dubai, U.A.E.: A Comparative Analysis of  Cognitive, Language and

Symbolic Play Abilities
Rajeshree Singhania1*

Volume 4 Issue 1, Year 2025
ISSN: 2833-1397 (Online)

DOI: https://doi.org/10.54536/ajlsi.v4i1.2645
https://journals.e-palli.com/home/index.php/ajlsi

Article Information ABSTRACT

Received: March 13, 2024

Accepted: April 20, 2024

Published: February 20, 2025

Effective communication skills in young children encompass a diverse range of  abilities 
crucial for early autism spectrum disorder (ASD) identification. This study aims to analyse 
communication skills in 36 preschool children (ages 1.6 to 4.6 years) diagnosed with autism 
in Dubai, employing the Early Communication Assessment (ECA) tool developed by 
Coupe O’Kane and Goldbart (1998). The ECA evaluates 13 areas of  early communicative 
functioning categorised into 3 to 5 developmental stages, ranging from Reflexive to Intentional 
Conventional. Communication abilities were assessed, and the 5 ECA levels were condensed 
into 3 for comparative analysis. Key communicative areas, such as joint referencing, social 
organisation, turn-taking, and imitation, were identified as significantly delayed in this 
cohort. Conversely, affective behavior, audio-visual behaviors, and physical production of  
sound exhibited relatively lesser impact. Contrary to common assumptions, poor eye contact 
was not the predominant indicator of  communication challenges. Comparative analyses 
were conducted between communication skills and perceptive cognitive abilities, language 
proficiency, and symbolic play. No substantial correlation was found between perceptive 
cognitive abilities and communication skills. However, a significant association was observed 
between communication abilities, language proficiency, and symbolic play. These findings 
underscore the complexity of  early communication profiles in preschool children with ASD 
in Dubai, emphasising the need for comprehensive assessment and targeted interventions 
beyond conventional indicators.

Keywords

Imitation, Joint Referencing, 
Language, Social Organisation, 
Symbolic Play, Turn-Taking 

INTRODUCTION
Autism Spectrum Disorder is a common 
neurodevelopmental disorder which prevails from early 
on in life. It is characterised by difficulty in speech, 
communication, language, and social interactions 
and restricted and repetitive patterns of  behaviours, 
interests or activities, which may vary in individuals 
(Campisi et al., 2018). Since it is a spectrum disorder, 
each person’s symptoms severity and manifestation 
will differ substantially, resulting in various clinical 
presentations(Lord et al., 2020). Over the past few decades, 
the prevalence of  ASD has increased considerably, 
drawing the attention of  researchers, clinicians, and 
policymakers worldwide.  Just under 1% of  people 
globally are thought to have autism, while estimates are 
higher in high-income nations(Lord et al., 2020).
There has been a discernible rise in the prevalence 
of  ASD worldwide, making it a major public health 
concern. Numerous studies have consistently shown an 
increased trend in the prevalence of  ASD, even though 
variances in reported rates are influenced by cultural, 
environmental, and diagnostic factors (Salari et al., 2022). 
The global prevalence of  ASD has increased four to five 
times, with a higher prevalence in boys than in girls. The 
average prevalence in Asia, Europe, and North America 
is 1%(Durkin & Wolfe, 2020). In the United States, the 
prevalence of  ASD among 8-year-old children was 1.59 
in 2014 and 1.54 in 2016, while in Italy, it was 1.15% 

(Narzisi et al., 2020). In Asia, it was 3.9%; in the Arab 
countries around the Gulf, it was 0.14 to 2.9% (Qiu et al., 
2020). As a result of  increased awareness and improved 
diagnostic techniques, the Centers for Disease Control 
and Prevention (CDC) reports that new estimates in 
the United States indicate that roughly 1 in 44 children 
have received an ASD diagnosis (Prevention, 2024). The 
fact that prevalence rates differ throughout nations and 
areas emphasises the necessity of  having an adequate 
understanding of  the disorder’s worldwide effects.
ASD is characterised by difficulties in social 
communication, restricted behaviors, and lack of  
understanding and use of  gestures. It can also lead to a 
restricted range of  interests, reliance on sameness, and 
repetitive activities. However, the diagnostic criteria for 
ASD have evolved, with the fifth edition of  the DSM-
5 consolidating several distinct disorders into a single 
term, ASD, acknowledging the diverse presentation and 
individual variability in symptomatology(Sharma et al., 
2018; Tsai et al., 2020). Many first-contact carers and 
physicians in Dubai focus on these while ignoring others, 
such as joint referencing and turn-taking. This may 
delay the diagnosis of  autism and thus hinder effective 
early intervention. Early communication is transparent 
with overt intentions, but in children with ASD, they 
remain opaque (Fuller & Kaiser, 2020). However, 
communication is a broad concept that involves multiple 
components, both lingual and para-lingual (Maljaars et al., 

1 Singhania Clinic & Therapy Centre DMCC, Dubai, United Arab Emirates
* Corresponding author’s e-mail: rajeshris@gmail.com



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2011). Autism causes a reduction in the frequency and 
diversity of  early communication forms, which results in 
a wide range of  clinical images and challenging diagnoses, 
particularly in children under the age of  four (Bradshaw 
et al., 2021).  For instance, not all children have poor eye 
contact or dislike being cuddled. Communication skills 
include joint attention, social referencing, mutual gaze, 
imitation, communication intentions, turn-taking and 
social interaction, social organisation, communication in 
context, and audio-visual behaviour (Chung, 2020).

LITERATURE REVIEW
Joint Attention/Social Referencing
Babies learn to make eye contact, or “look,” at their 
caregiver as early as two hours after birth. Infants begin 
to display their need to share other people’s attention 
between the ages of  9 and 14 months, showing that 
they wish to join points of  reference (such as the light 
or fan). In addition to pointing out the objects, children 
simultaneously glance at other individuals to see if  they 
share their interest in the same subject. One could refer 
to this urge as social attention (Mundy, 2023; Mundy 
& Bullen, 2022). Social referencing is similar to the 
notion of  shared attention and is defined as a process 
of  emotional communication in which one’s perception 
of  another individual’s interpretation is used to form 
one’s understanding of  the event (Cornew et al., 2012). 
Four abilities (Lawson et al., 2018)have been proposed, 
including the ability to discriminate emotional expressions 
on the caregiver’s face, recognise their meaning, respond 
to them emotionally, and finally, use them to regulate 
one’s behaviour. The first level is already observable in a 
6-month-old baby (Berger & Ingersoll, 2013).

Imitation
Imitation is crucial in understanding others and is the 
earliest form of  social-communicative interaction (Berger 
& Ingersoll, 2013) . Imitation starts with adults attributing 
imitation to the infant’s undifferentiated behaviour, 
then imitating the baby, stimulating the child to copy. 
Imitation then progresses from sporadic imitation through 
immediate and systematic copying to deferred imitation, 
which is not automatic but involves cognitive processes, 
and the child chooses what to copy (McAuliffe et al., 2020).
A child’s decision about what to imitate and cognitive 
processes play a key role in the process of  imitation, 
which is essential to language development. Adults begin 
by assuming that a baby’s actions are imitations and move 
from intermittent to delayed imitation. The inability of  
people with ASD to pay attention to and form an internal 
representation of  behavior makes it difficult for them to 
mimic it. They display “parasitic” aberrant imitation, which 
is predictive of  children with autism having poor expressive 
abilities  (McAuliffe et al., 2020; Mundy & Bullen, 2022).

Mutual Gaze
It is proposed that mutual gazing is a basic type of  human 
communication behavior that provides a foundation for 

other communication modes. The adult and youngster 
look at each other for extended periods. There is a great 
deal of  face-to-face and eye-to-eye communication during 
these times. Gaze coupling, a turn-taking exchange that 
mimics later gaze patterns observed in mature discourse, 
modifies the reflexive gaze (Wiklund, 2023). Intentional 
communication occurs in the setting of  mutual gaze, 
which develops into mutual orientation or attention. The 
behavior consists of  looking, making an interested facial 
expression, and positioning oneself  with movement and 
posture. Throughout early infancy, people with ASD 
exhibit disruption of  mutual gaze, regardless of  their 
intellectual ability. One of  the main areas of  difficulty 
associated with ASD is mutual gazing (Rollins et al., 2021; 
Wiklund, 2023). 

Social Organisation
Various organisational strategies are used for 
communication. These are needed to initiate, maintain, 
or terminate communication (Baron-Cohen, 1988).   
Strategies required to initiate communication include 
eye contact, proximity, and vocalisation. Maintaining 
communication needs strategies like question/answer 
and statement and reply. Breaking off  or terminating a 
communication entails strategies like moving away or 
breaking eye contact (Erturk et al., 2021). Skills acquired 
through infancy through interpersonal interactions 
underpin the skills needed for conversational and 
discourse management. Individuals with ASD lack 
strategies to organise communication. It is probably more 
evident in high-functioning verbal individuals capable of  
conversation (Loukusa, 2021).

Turn-Taking and Social Interaction
Turn-taking, seen in social interaction or dialogue, starts 
with the adult leaving space for children to fill their turn 
with sounds or actions. The adult utilises the child’s 
existing repertoire of  behaviours by imitating them. This 
produces reciprocation behaviours in the child.   These 
reciprocal behaviors are imitations of  various adult and 
altered and novel responses. Hence, the adult allows the 
child to take turns, but the child also gives reinforcing 
feedback to maintain and change adult responses (Ramey 
et al., 1978).
Individuals with ASD have difficulty taking turns at a very 
early age, both in vocal interactions and physical tasks 
(Baren-Cohen, 1988).

Communicative Intentions
Intention is the speaker’s motivation for communication, 
often expressed through gestures and vocalisations. Early 
communication, such as proto-imperative and proto-
declarative, involves using another person to obtain 
something or draw attention. By 9 months, infants can 
express intention using gestures and vocalisations. Other 
behaviors include gaining attention, drawing attention, 
and regulating social contact. Communication intentions 
include greeting, protesting, rejecting, naming, and 



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informing. Individuals with ASD lack communication 
intentions due to impairment in perception and 
mentalising ability (Schütz et al., 2020).

Comprehension in Context
Autism disrupts the normal development of  language, 
leading to delayed and deviant language development. The 
primary reason for learning a language is communication, 
which is the primary reason for communication. Neonatal 
infants are biologically tuned to person-mediated events, 
responding more to speech than non-speech sounds. 
In the first six months, infants start to read signals and 
expressions of  others’ behavior, gradually developing 
into a highly developed area of  expertise. Individuals with 
ASD have difficulty in early communicative behaviors, 
affecting their language development, socialisation, and 
self-expression(Elbeltagi et al., 2023).

Language Problems
ASD often affect communication rather than language, 
with around half  of  all children failing to develop 
functional speech. Spoken language ability in ASD ranges 
from muteness to apparent facility, with a persistent 
impairment in communicative use and understanding 
of  complex concepts. Autism-related speech is non-
productive, echolalic, pedantic, and monotone, with 
limited use for sharing experiences or conversing. Early 
communication trajectory demonstrates a relationship 
to language acquisition, and studies on symbolic play in 
children with ASD vary. Some children show cognitive 
abilities in symbolic play, while others show less interest 
and ability(Vogindroukas et al., 2022).
ASD greatly impacts preschool-aged children’s 
communication abilities; therefore, early identification 
and intervention are essential. These children frequently 
display distinctive communication profiles, including 
delayed language learning, unusual language use, and 
trouble interacting with others on a reciprocal basis. Early 
indications of  ASD usually show up in toddlerhood, when 
parents and other caregivers notice changes in their child’s 
communication style. These include a lack of  interest in 
social relationships, restricted gesture use, delayed or absent 
language milestones, and issues with shared attention. 
This study aimed to investigate children with autism 
and their communication profiles. To ascertain which 
components of  preschoolers’ communication are more 
likely to be impacted, the study examined various aspects 
of  their communication. In addition to inadequate eye 
contact and aversion to making physical contact, other 
communication issues were investigated. The relationship 
between communication and children’s cognition, 
symbolic play, and language development was explored.

MATERIALS AND METHODS
Study Participants
The study included children aged from 1.6 to 4.6 years 
diagnosed with autism spectrum disorder (ASD) at 
a Dubai clinic between 1998 and 2008. Diagnoses 

were made based on DSM IV criteria, considering 
communication, cognition, symbolic play, and language 
assessments. Cases with incomplete assessments were 
excluded, resulting in the analysis of  36 children.

Early Communication Assessment (ECA)
Communication abilities were assessed using the Early 
Communication Assessment (ECA) developed by Coupe 
O’Kane and Goldbart (1998). The ECA comprises 
13 areas of  early communicative functioning, which 
are categorised into five levels: Reflexive, Reactive, 
Pre-intentional, Primitive Intentional, and Intentional 
Conventional levels. The 13 regions include Affective 
Communication, Mutual Gaze, Social Organization, 
Joint Reference, Turn-taking and Social Interaction, 
Comprehension in Context, Communicative Intentions, 
Cognitive Roles, First Meaning, Imitation, Auditory 
and Visual Behaviors, Vocal Production, and Physical 
Production.
The 5 levels were condensed into 3 for comparison 
purposes: Group 1 (not developed), Group 2 (growing), 
and Group 3 (developed). Each child’s ability was assessed 
concerning these groups for the 13 areas.

Cognitive Abilities
Perceptual cognitive abilities were evaluated using the 
Munich Functional Developmental Test, specifically 
focusing on concepts like object permanence, copying, 
matching, and sorting. This individually administered test 
assessed gross motor, fine motor, perceptual, cognitive, 
language expression, comprehension, social skills, and 
self-reliance abilities.

Language Skills
The Reynell Developmental Language Scales (Reynell, 
1978) were employed to measure oral expressive and 
receptive language skills in children aged 1 to 7. Language 
categorised into severe delay, moderate delay, mild delay, 
or no delay was determined based on the difference from 
chronological age.

Symbolic Play
The Lowe-Costello Play Test assessed the symbolic play 
(Lowe & Costello, 1998), focusing on early concept 
formation symbolisation. They utilised four sets of  toys 
in free play, which were scored according to guidelines, 
and the raw score was converted to play age in months. 
Play age was categorised into severe delay, moderate 
delay, mild delay, or no delay based on the difference from 
chronological age.

Data Analysis
Demographic data, symbolic playtest results, language 
age, non-verbal development, and communication 
assessments were comprehensively analysed. Descriptive 
statistics and comparative analyses were performed to 
discern patterns and relationships among variables.



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RESULTS AND DISCUSSION
The study investigated the relationship between 
communication, language development, and non-verbal 
cognitive and perceptual development in children with 
ASD. The total number of  children investigated was 36, 
of  which 25 were boys and 11 were girls. Table 1 shows 
the distribution of  children in the study, ranging from 1.6 

to 4.6 years. The largest age group had 13 children aged 
1.6 to 2 years, while the smallest group contained 2-4 
children aged 4.1 to 4.6 years.   The study also categorises 
children into three main groups: Asians, Arabs, and 
Europeans. The majority of  the children are of  Asian 
nationality (22 children), followed by Arabs (10 children) 
and a smaller representation of  Europeans (4 children).

Table 1: Age distribution and nationality profile in the cohort
Age bands (in years) Number of  children
1.6  to 2 13
2.1 to 2.6 3
2.7 to 3 10
3.1 to 3.6 4
3.7 to 4 4
4.1 to 4.6 2
Nationality Profile in the Cohort
Nationality Number of  children
Asians 22
Arabs 10
European 4

Table 2: The difference between chronological age and ability in symbolic play in months
Difference between the chronological age and the play age in months Number of  children
Severe delay - a difference of  more than 12 months 17
Moderate delay - a difference of   6 to 12 months 12
Mild delay - difference of  less than 6 months 3
No delay 0
Missing data 4

Symbolic Play
The study used the Lowe-Costello Play Test to evaluate 
the pretend play abilities of  children with ASD. The 
results showed that 17 children had a play age more than 
12 months behind their chronological age, indicating 
a significant delay in their play skills. 12 children had a 
play age 6-12 months behind their chronological age, 

showing some delay, while 3 children had a play age less 
than 6 months behind their chronological age, showing 
minimal delay. No children showed no delay, and data was 
unavailable for 4 children.
Symbolic and most delayed communication skills showed 
no significant difference between the delayed and not 
delayed groups, as shown in Table 3.

Table 3: Symbolic play and communication
Symbolic play Most Delay Communication skills P value 
Symbolic Play Social organisation 1.246
Symbolic Play Joint Referencing 1.000
Symbolic Play Imitation 0.4016
Symbolic Play Turn-taking 0.0003*
Symbolic skills and most delayed of  communication skills showed no significant difference between the delayed and 
not delayed group hence were not correlated.



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Cognitive Delay
Non-verbal cognitive and perceptual development was 
measured using the Munich Functional Development 
Test. The difference between the chronological and 

cognitive ages was calculated and tabulated. Severe delay 
was found in 13 children, while no delay was seen in 11 
children in their chronological and cognitive age, as seen 
in Table 4.

Table 4: The difference between the chronological age of  each child with cognitive-perceptual development in months
Difference between the chronological age and the cognitive age in months Number of  children
Severe delay - a difference of  more than 12 months 13
Moderate delay - a difference of  6 to 12 months 9
Mild delay - difference of  less than 6  months 3
No delay 11

The study found no significant correlation between 
perceptual cognition and communication areas in children 
with ASD. The children struggled with joint referencing, 
social organisation, turn-taking, and imitation. However, 

their development was not significantly linked to their 
non-verbal cognitive skills. This suggests that despite 
having typical cognitive abilities, they still had significant 
delays in specific communication areas.

Language Delay
The child’s language was assessed in their mother 
tongue on the Reynell Language Development Test. 
The difference between the chronological and language 
ages was calculated and tabulated. Results showed that 

25 children had a language age 18 months behind their 
chronological age, 8 had a 12-17 month delay, 2 had a 
3-12 month delay, and 1 had no delay. Most children had 
some language delay, with severe delay affecting over two-
thirds of  them.

Table 6: The difference between the chronological age of  each child with language age in months
Difference between the chronological age and the language age in months Number of  children
Severe delay- a difference of   more than 18 months 25
Moderate delay - a difference of   12 to 17 months 8
Mild delay - a difference of   3 to 12 months 2
No delay 1

Table 5: Perceptual Cognition versus Communication
Perceptual Cognition Most Delay Communication skills P value 
Perceptual Cognition Social organisation 0.0913*
Perceptual Cognition Joint Referencing 0.0179*
Perceptual Cognition Imitation 0.2322
Perceptual Cognition Turn-taking 0.7795
Perceptual Cognition and most delayed of  communication skills showed significant difference between the delayed 
and not delayed group hence were not correlated.

Table 7: Language and communication  
Language Most Delay Communication skills P value 
Language Social organisation 0.4
Language Joint Referencing 0.1
Language Imitation 0.2
Language Turn-taking 0.025*
Language skills and most delayed of  communication skills showed no significant difference between the delayed and 
not delayed group hence were not correlated. 



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The figure shows that Language and most delayed 
communication skills showed no significant difference 
between the delayed and the most delayed groups.

Analysis of  Communication
To facilitate analysis, the levels in each communicative 
area were divided into three categories once each child’s 
abilities were determined to be one of  the three to five 

levels: In Group 1, the child was at level 1 or lower, 
meaning that the communication area was not developed. 
In Group 2, the child was at levels 2 to 3 (when there were 
five levels in that region) and level 2 (when there were three 
levels in that area), indicating that the communication area 
was developing. In Group 3, the child reached the highest 
level (either 3 or 5) in that communication area, indicating 
that the communication area had been developed. 

Table 8: Analysis of  each of  the 13 communication abilities on the ECA in the cohort
Communication area Not developed Developing Developed Missing data
Communication in context 7 18 6 5
Communicative intentions 6 14 7 8
Cognitive Roles 5 14 6 11
Meaning 5 9 4 18
Mutual Gaze 6 23 1 6
Social Organisation 18 8 4 6
Joint Reference 18 9 2 7
Turn-taking 13 10 7 6
Imitation 15 9 4 8
Affective Communication 0 16 20 0
Audio-visual behaviour 0 14 13 9
Physical production 0 13 8 15

*A lack of  information in that area in the records causes discrepancies in the numbers.

Figure 1: Analysis of  each of  the 13 communication abilities on the ECA in the cohort as developed, developing, or 
not developed

The communicative areas that were most delayed or 
affected were joint referencing, social organisation, turn-
taking, and imitation, as seen in Table 9.

Table 9: Further Analysis of  each of  the most delayed of  the 13 communication abilities on the ECA in the cohort
Communicative areas Developed Not developed
Joint Referencing 2 18
Social Organisation 4 18
Turn-taking 7 13
Imitation 4 15



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The communicative areas that were least affected were 
affective behaviour, audio-visual behaviours, and physical 
production, as seen in Table 10.

Figure 2: Further Analysis of  each of  the most delayed of  the 13 communication abilities on the ECA in the cohort

Figure 6: Further analysis of  each of  the least delayed of  the 13 communication abilities on the ECA in the cohort 
– Group C

Table 10: Further Analysis of  each of  the least delayed of  the 13 communication abilities on the ECA in the cohort 
– Group C
Communicative areas Not Developed Developing Developed
Affective behaviour 0 16 20
Audio-visual behaviour 0 14 13
Physical Production 0 13 8

Those communicative areas that were moderately affected 
were – communicative intentions, communication in 
context, mutual gaze, and cognitive roles, as seen in Table 11.

Table 11: Further Analysis of  each of  the moderately delayed 13 communication abilities on the ECA in the cohort 
– Group B
Communicative areas Not Developed Developing Developed
Communicative Intentions 6 14 7
Communication in context 7 18 6
Mutual gaze 6 23 1
Cognitive Roles 5 14 6
Physical production 0 13 8



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Figure 4: Further analysis of  each of  the moderately delayed 13 communication abilities on the ECA in the cohort 
– Group B

The total number of  ‘not developed’ and “developed” 
levels in Groups A, B, and C were scrutinised and 
compared, as shown in Table 12. The Table compares 
the communication abilities of  both parameters in 

three groups (A, B, C) based on ECA. Group A has 
the most affected communicative areas, Group B has 
moderately affected areas, and Group C has the least 
affected areas.

Table 12: Comparison of  ‘Not Developed’ and ‘Developed’ Communication Abilities in Groups A, B, C
Communication Area Group A (Most 

Affected)
Group B (Moderately 
Affected)

Group C (Least 
Affected)

Total 'Not Developed' Levels 64 29 0
Total 'Developed' Levels 17 24 41

Comparing Communication to Language Development 
and Non-Verbal Cognitive and Perceptual Development
Communication in children with normal or mildly 
delayed non-verbal cognitive and perceptual development 
on the MFT was investigated. Table 13 presents a 
comprehensive analysis of  communication levels in 
12 children with normal to near normal cognitive and 

perceptual development categorised into three groups (A, 
B, C) based on their communication abilities. The results 
show that the most affected group has not developed 
communication levels, while the moderately affected group 
has not developed communication levels but is showing 
progress. The least affected group has not developed 
communication levels but has reached the developing stage. 

Table 13: Number of  ‘developed,’ ‘developing,’ and ‘not developed’ communication abilities in Group A, B, and C 
in the 12 children with normal to near normal cognitive perceptual ability on the MFT

Group A 
Communicative 
areas

Group B 
Communicative 
areas

Group C 
Communicative 
areas

Number of   children with ‘Not developed’ levels 6 3 2
Number of   children with ‘developing’ levels 2 5 6
Number of   children with ‘developed’ levels 0 0 0

Table 14: Comparison of  ‘Not Developed’ and ‘Developing’ Communication Levels in Children of  Varying Non-
Verbal Cognitive Perceptual Development
Cognitive Development Communicative Areas Group A (No 

to Mild Delay)
Group B 
(Moderate Delay)

Group C 
(Severe Delay)

'Not Developed' Levels Group A 6 3 2

The communication in children of  different non-verbal, 
cognitive, and perceptual development groups was 
accessed. There were 3 groups – the severely delayed, the 
moderately delayed, and mildly delayed + the no delay. 
Table 14 compares ‘not developed’ and ‘developing’ 
communication levels in children with autism across 

various non-verbal, cognitive, and perceptual development 
groups. The study found that Group A has the highest 
number of  ‘not developed’ levels, while Group C has a 
substantially less number. Developing levels are more 
prominent in Groups B and C, indicating progress in 
communication abilities despite cognitive delays.



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Group B 5 3 4
Group C 6 6 5

'Developing' Levels Group A 2 5 6
Group B 2 5 4
Group C 0 0 0

Communication among children of  different language 
development groups was accessed as well. There were 3 
groups – the severely delayed, the moderately delayed, 
and mildly delayed + the no delay. Table 15 compares 
‘not developed’ and ‘developing’ communication levels in 
children with autism across different language development 

groups. Severe language delay (Group C) has the highest 
number of  ‘not developed’ levels. Groups A and B show 
more pronounced ‘developing’ levels, indicating progress 
in communication abilities despite language delays. Group 
A, representing no to mild language delay, has no children 
with ‘not developed’ communication levels.

Table 15: Comparison of  ‘Not Developed’ and ‘Developing’ Communication Levels in Children of  Varying 
Language Development
Language Development Communicative Areas Group A (No 

to Mild Delay)
Group B 
(Moderate Delay)

Group C 
(Severe Delay)

'Not Developed' Levels Group A 0 0 0
Group B 2 1 1
Group C 16 10 10

'Developing' Levels Group A 0 6 6
Group B 4 4 5
Group C 1 1 1

Communication and language delay are related. The 
number of  non-developers is highest in all 3 with severe 
language delay. Group A had the highest number of  non-
developers and had no developing communicators in the 
severe language delay group.

Analysis of  Communication
The EC categorised communication skills into three 
groups: underdeveloped, developing, and developed. The 

analysis found that the most affected communication 
areas were social organisation, joint referencing, turn-
taking, and imitation. The least affected areas were 
affective communication, audio-visual behavior, and 
physical production. Moderately affected areas were 
communication intentions, context, mutual gaze, and 
cognitive roles. The study used a Fisher Chi-Square Test 
to assess the relationship between a child’s ASD diagnosis 
and communication skills, as seen in Figure 5. 

Figure 5: Analysis of  communication P value from Fishers’ Chi-square Test



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The study results reveal that mutual gaze is a 
communication area where children with ASD show 
some developmental delay but to a lesser extent than 
other social communication skills. Children with ASD 

show more difficulty with mutual gaze than expressing 
emotions or using gestures but less difficulty compared 
to skills like initiating shared focus or taking turns in 
conversation.

Figure 6: Analysis of  communication- Mutual gaze vs. Least and most delayed communicative skills- P-value

Figure 7: Communication vs language, symbolic play, and perceptual Cognition

No significant difference was found between the 
developed and not-developed groups regarding the most 
delayed skills as they were summed up and compared to 
the developed and not-developed aspects of  symbolic 

language play. However, a significant difference was 
found between the developed and not developed groups 
regarding the most delayed skills and perceptual cognition, 
as seen in Figure 7.

Discussion
In this analysis of  a preschool cohort with ASD at a Dubai 
clinic, substantial results were gathered. Boys dominated 
the cohort. Asians were the most common race, followed 
by Arabs and Europeans. Most children showed delays in 
language and symbolic play, with most showing significant 
delays, while about half  demonstrated normal to mild 
cognitive-perceptual abilities. Most cases showed marked 
delays in language development, and different areas of  
communication showed varying degrees of  growth. 
In particular, the least developed behaviors were joint 

reference, social organisation, turn-taking, and imitation; 
in contrast, the most developed behaviors were reciprocal 
gaze, comprehension in context, communication aims, and 
cognitive roles. The two most advanced communication 
behaviors were found to be affective and audio-visual. 
Crucially, language and symbolic play correlate strongly 
with the development of  all communication components, 
although perceptual-cognitive capacity did not show any 
significant correlation.
Most of  the pre-school children with ASD who came 
to the clinic were boys with ages ranging from 1.6 to 2 



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years and then from 2 years 7 months to 3 years. The 
sex ratio corresponds to that found by other studies. 
Various studies consistently observed a male-to-female 
ratio of  4:1 in classical autism, a trend also reflected in 
relatives exhibiting a broader autistic phenotype (Loomes 
et al., 2017; Maenner, 2021). Studies with expanded 
definitions indicated a linear variation in gender ratio with 
IQ, approaching 2:1 in individuals with severe cognitive 
impairment. However, cognitively capable girls faced 
challenges in diagnosis due to milder social impairments 
compared to boys (Doi et al., 2022; McQuaid et al., 2021). 
However, According to a study, there is no significant 
correlation between gender, race and severity of  ASD. 
It is reported that girls are better at masking their ASD 
symptoms and imposing delayed diagnosis (Napolitano 
et al., 2022). 
Autism, though a highly heritable disorder, predisposing 
loci on the sex chromosomes have not been found. A 
genetic mechanism hypothesises that an imprinted 
X-linked gene(s) influences the threshold for phenotypic 
expression of  many autistic characteristics and is thus 
protective (May et al., 2019). The gene is expressed only 
on the X-chromosome inherited from the father, raising 
the threshold for phenotypic expression. It is normally 
silenced when transmitted maternally. Because only 
females have a paternal X chromosome, the threshold 
for phenotypic expression is higher in them than in 
males (Ferri et al., 2018). The ``extreme male brain’’ 
theory suggests that the behaviours seen in autism are an 
exaggeration of  typical sex differences. Evidence supports 
female superiority in humans in the ability to read non-
verbal signals, specific language-related skills, and theory 
of  mind. Prenatal and neonatal testosterone exposures 
impact social development and are risk factors for autism 
spectrum conditions (van Eijk & Zietsch, 2021).
Most of  the children in the study belonged to the Asian 
ethnicity, mirroring the demographic distribution of  
Dubai, where Asians constituted the largest group, 
followed by Arabs and Europeans/Americans. However, 
race showed no correlation with the severity of  autism. 
Additionally, nearly half  of  the children exhibited 
normal to mild delays in cognitive perceptual ability, 
indicating that their non-verbal skills mostly fell within 
the normal range. This aligns with findings from other 
studies suggesting that children with autism tend to excel 
in tasks involving perceptual-motor organisation and 
rote memory skills (Sodano, 2022). A study discovered a 
substantial connection between IQ and ASD, especially 
among people with above-average intellect. Significant 
cognitive deficits are present in high-IQ individuals 
with ASD, especially in the areas of  social cognition, 
verbal working memory, and visual pattern recognition 
(Rommelse et al., 2015).  In children with autistic spectrum 
disorder, symbolic or representational play exhibited 
considerable delay, with the majority experiencing severe 
delays. However, 50 percent of  the children demonstrated 
some evidence of  symbolic play, with three showing only 
mild delays. Language delay was prevalent among nearly 

all children, with most experiencing delays ranging from 
12 to 18 months. This is in line with the findings of  
other studies as well. A study found that children with 
ASD have significant impairments in their spontaneous 
expressive language abilities, with syntax and narrative 
skills increasing with age. Pragmatic skills improved from 
toddler to preschool but remained stable.
Longitudinal data showed significant improvements 
in Observation of  Spontaneous Expressive Language 
(OSEL) syntax scores over time (Thomas et al., 2021). The 
least developed aspects of  communication, including joint 
reference, social organisation, turn-taking, and imitation 
(Group A), were most affected by autism. Conversely, 
affective behavior, audio-visual behavior, and sound 
production (Group C) were the best-developed aspects. 
Another study found that an initial imitation deficit in 
toddlers with ASD at age 2 improved gradually until age 5. 
These skills were linked to cognitive and language abilities, 
and addressing early imitation deficits, joint reference, 
and social organisational skills could improve the broader 
competence of  young children (Pittet et al., 2022). These 
communication aspects demonstrated varying degrees of  
development, emphasising the heterogeneous nature of  
communication difficulties in children with autism.
Additionally, communication challenges were strongly 
associated with language development, with Group A 
showing a clearer relationship to language delay than 
Groups B and C. However, communication difficulties 
were not significantly related to non-verbal ability, 
indicating that even the most able children faced 
similar challenges in certain aspects of  communication, 
particularly those in Group A. Another study examined 
language profiles in 104 children with ASD and found 
that Nonverbal cognition and joint attention significantly 
predicted receptive and expressive language scores, 
suggesting the importance of  multiple assessment 
methods and joint attention as an intervention target 
(Nevill et al., 2019). 
The study indicates that while assessing young children 
with ASD, several aspects of  early communication should 
be kept in mind. Poor eye contact and dislike of  cuddling 
may not be seen in all these children. The most sensitive 
indicators were poor joint referencing, turn-taking, social 
organisation, and imitation.

CONCLUSION
In conclusion, the study evaluates the communication 
abilities of  children with ASD and reveals distinct 
patterns across different cognitive and language 
development levels. The study categorised children into 
three groups (A, B, C) with varying levels of  nonverbal 
cognitive, perceptual, or language development. Group A 
showed the most complications, including joint reference, 
social organisation, taking and imitation. Communication 
difficulties in group A are strongly associated with 
language delay, highlighting the complex relationship 
between these parameters.



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