O R I G I N A L P A P E R

Social Networks and Friendships at School: Comparing ChildrenWith and Without ASD

Connie Kasari • Jill Locke • Amanda Gulsrud •

Erin Rotheram-Fuller

Published online: 30 July 2010

� The Author(s) 2010. This article is published with open access at Springerlink.com

Abstract Self, peer and teacher reports of social relation-

ships were examined for 60 high-functioning children with

ASD. Compared to a matched sample of typical children in

the same classroom, children with ASD were more often on

the periphery of their social networks, reported poorer

quality friendships and had fewer reciprocal friendships. On

the playground, children with ASD were mostly unengaged

but playground engagement was not associated with peer,

self, or teacher reports of social behavior. Twenty percent of

children with ASD had a reciprocated friendship and also

high social network status. Thus, while the majority of high

functioning children with ASD struggle with peer relation-

ships in general education classrooms, a small percentage of

them appear to have social success.

Keywords Social networks � Playground observations �Friendships � Social skills

Introduction

Despite the well-documented peer difficulties of children

with autism spectrum disorders (ASD), parents and profes-

sionals increasingly prefer inclusion of their children in

general education classrooms (Kasari et al. 1999). The

rationale is that placement of children with ASD in general

educational settings increases the involvement of these

children in the mainstream, through the behavioral modeling

of typical peers, and others’ acceptance and appreciation of

people with differences (Guralnick 1990; Villa et al. 1995).

Current research suggests that there may be both social

benefit and risk for children with ASD in inclusive settings.

Access to typical child models has been suggested as

one benefit to social outcomes for children with ASD. For

example, Sigman and Ruskin (1999) found that children

with ASD were more socially engaged at school if they had

access to typical children on the playground. Similarly,

Bauminger et al. (2003) found that high functioning chil-

dren with ASD were more likely to engage with a typical

peer on the playground than with children with special

needs. Some parents report their child’s inclusive experi-

ence as being characterized by peer acceptance, and being

able to form meaningful friendships with their non-dis-

abled classmates (Ryndak et al. 1995; Staub et al. 1994).

Mainstreamed classrooms may offer an ideal context to use

typical peers as social models, encouraging the mainte-

nance and generalization of skills often not achieved by

interventions that use an adult interventionist (Carr and

Darcy 1990; Roeyers 1996; Shearer et al. 1996).

However, other studies demonstrate that inclusion may

be insufficient to truly integrate children with ASD into the

social networks of their typical peers (Burack et al. 1997),

and may even pose social risks (MacMillan et al. 1996;

Ochs et al. 2001; Sale and Carey 1995). High-functioning

students with ASD may be at even greater risk for peer

rejection than more impaired students with ASD. Students

with severe disabilities may be more accepted in class-

rooms of mostly typical students because they readily stand

out. Different expectations can lead typical peers to play a

functional, protective role toward them instead of leading

to rejection. On the other hand, students with mild dis-

abilities receive little acceptance regardless of classroom

C. Kasari (&) � J. Locke � A. GulsrudSemel Institute, University of California Los Angeles,

68-268, Los Angeles, CA 90095, USA

e-mail: kasari@gseis.ucla.edu

E. Rotheram-Fuller

Temple University, Philadelphia, PA, USA

123

J Autism Dev Disord (2011) 41:533–544

DOI 10.1007/s10803-010-1076-x

composition. Yet both groups are more stigmatized and less

accepted than typical students (Cook and Semmel 1999).

Inclusive classrooms may also be over-stimulating and

lack specified staff and resources that students with ASD

need, causing them to grow dependent on adults in the

classroom (Mesibov and Shea 1996). From interviews with

adolescents with ASD, it appears that support staff (often

in the form of a paraprofessional aide) may mark children

as being different, hindering rather than facilitating peer

relationships (Humphrey and Lewis 2008). Researchers

observing kindergarten and school aged children note that

adults assigned to children with ASD are often unsure of

what to do on playgrounds and interfere, blocking interac-

tions between children and their peers, resulting in more

isolation from peers while increasing the child with ASD’s

interactions with adults (Anderson et al. 2004). Inclusion and

the practices implemented to facilitate inclusion (e.g.,

assignment of paraprofessionals to the child with ASD) may

not always promote social success of children with ASD.

Children spend the majority of their day at school, but

studies have rarely examined the friendships and peer

interactions of children with ASD within this context.

Rather, most studies ask children or parents to identify

friendships without gathering corresponding reciprocity

data. As Bauminger and Kasari (2000) note, all of the chil-

dren in their sample of high functioning children with autism

identified a friend. Most children were identified from their

school setting; however, several children identified friends

that mothers later indicated was the child’s tutor, stepdad, or

other unusual choice. Without data from the nominated

friend of the child with ASD, we could not judge reciprocity

of friendships. In a later study of second and third grade

children, we found that approximately one-third of nomi-

nated friends reciprocated the friendship of children with

ASD at school compared to sixty percent for typical children

from the same class (Chamberlain et al. 2007). Thus, reci-

procity at school appears to be lower for children with ASD.

While multiple informants are important in determining

the social inclusion of children with ASD at school,

reporters do not always agree on the degree to which

children are socially included. In particular, children with

ASD experience misperception of their social involvement

at school; they may see themselves as more or less socially

involved than their peers or parents report. For example, in

one study we found that children with ASD saw themselves

as more connected than their peers saw them. Children

with ASD nominated many more children as friends at

school than peers nominated them (Chamberlain et al.

2007). In another study, children identified fewer friends

from any context or setting than their mothers identified for

them (Bauminger and Kasari 2000). In this latter study, we

did not obtain peer reports so that it was unclear if mothers

over-identified or children under-identified their friends.

Determining inclusion success appears different depending

on the reporter (e.g. peer, child with ASD, parent, teacher)

and the circumstances (e.g., observations of actual behavior

on playgrounds or survey).

One limitation to our current knowledge of children’s

experiences at school is that most studies describe the expe-

riences of only a few children and are limited in the number of

measures and reporters that they include. Thus, studies may

obtain the child’s report of relationships, and/or their tea-

cher’s or parent’s report, but rarely reports from peers and/or

observations of spontaneously occurring peer interactions. In

our previous reports of classroom peer nominations, both

peers and children with ASD agreed that children with ASD

were more often peripheral in their classroom social networks

(Chamberlain et al. 2007; Rotheram-Fuller et al. in press).

Children with ASD also reported lower quality friendships

(Bauminger and Kasari 2000; Chamberlain et al. 2007), and

their difficulties with their peer social networks were greater

at the older grades than the younger grades (Rotheram-Fuller

et al. in press). However, these studies did not include actual

observations of peer relationships, nor did they include

impressions from teachers. Teachers and independent

observers of children’s social interactions on the playgrounds

offer important additional information on the social inclusion

of children with ASD.

It is expected that the peer social network nominations of

children should be in line with observations of children on

their school playgrounds. Thus, peer reports of children with

ASD as peripheral to their classroom social networks should

predict that they would be largely unengaged on their school

playgrounds. Indeed, studies that have observed children

with ASD on playgrounds suggest that they are often unen-

gaged with peers; they make fewer attempts to interact with

other children, and are less responsive to other’s bids for

social interaction (Sigman and Ruskin 1999). One study

found that just four behaviors discriminated over 90% of

children with ASD on the playground from other children.

These behaviors included poor social engagement with

peers, lack of respect for personal space, isolation, and

inappropriate behavior (Ingram et al. 2007). The consistent

finding that children with ASD are isolated or unengaged on

the playground may be due to several possibilities, including

that children distance themselves from interactions with

others (perhaps wanting to be alone) or that they are unen-

gaged due to their own or others’ actions on the playground.

At this point, we do not know how the children themselves

(both peers and the child with ASD) and their teachers view

their relationships, and how these relationships may play out

on the school playground. To date, researchers have not

connected all of these measures together in the same study.

The goal of the current study was to connect self and

other perceptions to actual observations of children on their

playgrounds, and to teacher reports of social interactions at

534 J Autism Dev Disord (2011) 41:533–544

123

school. While we recognize that children can have friend-

ships in many different contexts, they spend the greatest

amount of time at school, and it is the context in which social

relationships can have added benefit to both social and

academic development. Moreover, for children with ASD,

school is the context in which they can feel loneliness and

isolation (Bauminger and Kasari 2000). We expected that

children with ASD would receive fewer reciprocated

friendship nominations, report poorer quality friendships,

and be viewed by their peers as more peripheral in their

classroom social networks (Bauminger and Kasari 2000;

Chamberlain et al. 2007; Rotheram-Fuller et al. in press). In

this study, however, a primary goal was to examine the

association between independent observations of children

on the school playground with teacher, peer and self reports

of peer relationships. We hypothesized that children who

were more peripheral in their social networks, would be less

engaged on the playground, have fewer friendships, and

receive poorer teacher reports of social skills.

Because children with ASD in this study ranged from

first to fifth grade, we were also interested in grade related

differences in our measures. In a previously completed

study involving 79 children with ASD in kindergarten

through fifth grade, grade related changes were found in

children’s social networks (Rotheram-Fuller et al. in press).

Sixty of these children are participants in the current study

and received the additional measures that are the focus of

this study (including measures of friendship quality, tea-

cher report of social relationships, and independent play-

ground observations). Thus, we can begin to examine

grade-related differences in the connections between self

and other reports and actual behaviors of children with

ASD in inclusive classrooms.

Method

Participants

A total of 243 children were prescreened for participation

in this study and 83 families signed consent from August

2003 to September 2007. The majority of families who did

not meet the prescreening criteria lived outside of our

catchment area (within 90 min of the University). Children

were included in this study if they had a diagnosis of ASD

from a licensed psychologist, if they met criteria for ASD

on the ADI-R and ADOS, were fully included in a regular

education classroom for at least 80% of the school day,

were between the ages of 6–11 years old and in grades 1–5,

and had an IQ of 65 or higher. Children were excluded

from this study if they had additional diagnoses. Of the 83

children with ASD who signed consent, 23 did not par-

ticipate for a variety of reasons (nine schools refused

participation; six parents withdrew before the assessments;

six children did not meet the IQ criteria; two children did

not meet criteria for ASD). All peers from each partici-

pating child with ASD’s classroom were then invited to

participate in the study. Both parental consent and child

assent were obtained from all participating peers.

A total of 60 children with ASD and 815 typically

developing children participated in this study. Research

clinicians not associated with the study independently

evaluated all children with ASD. Overall, 44 children

received an autism diagnosis, and 16 children received an

Asperger diagnosis. Participants were recruited from 56

classrooms in 30 different schools across the greater Los

Angeles area (53% of the schools were Title I schools). Of

the children with ASD, 15 children were in first grade, 18

children in second grade, eight children in third grade, 11

children in fourth grade, and eight children in fifth grade.

Children with ASD were from diverse ethnic backgrounds

(46.7% Caucasian, 5% African American, 21.7% Latino,

16.7% Asian, and 10% Other) and were predominantly

male (90%). All were fully included in regular education

classrooms for 80% or more of the school day and were an

average of 8.14 ± 1.56 years old, with an average IQ of

90.97 ± 16.33. One family refused the IQ test but previous

reports of IQ were in the normal range. Sixty percent of the

children with ASD were assigned a 1:1 aide in the class-

room and on the playground. Children assigned an aide had

significantly lower IQs than children without an aide,

t(1, 57) = 3.07, p = .003. Average IQ of children with NO

AIDE (N = 24) was 98.33 (SD = 19.23) and of children

WITH AIDE (N = 35) was 85.91 (SD = 11.86).

To allow for direct comparisons to the children with ASD,

a subsample of typical children was randomly selected from

each child’s classroom that matched the children with ASD

on gender, age, grade and classroom. Typically developing

children were an average of 7.86 ± 1.43 years old. Further

demographic data were not available for the matched peers.

Measures

Friendship Qualities Scale (FQS; Bukowski et al. 1994).

The FQS is a 23-item questionnaire that examined five

features of friendship quality: (a) companionship (amount

of voluntary time spent together), (b) help (encompassing

both aid and protection from victimization), (c) security

(including trust and the idea that the relationship will

transcend specific problems), (d) closeness (consisting of

both the child’s feelings toward the partner and his or her

perceptions of the partner’s feelings), and (e) conflict

(disagreements in the friendship relation). Children rated

how true a sentence description was of their best friendship

using a 5-point Likert scale (1 = never to 5 = always).

This measure has been used in previous studies of children

J Autism Dev Disord (2011) 41:533–544 535

123

with autism and their peers (Bauminger and Kasari 2000;

Bauminger et al. 2004; Chamberlain et al. 2007).

Playground Observation of Peer Engagement (POPE)

(Kasari et al. 2005). Designed for this study, the POPE is a

time-interval behavior coding system. Researchers recor-

ded children’s engagement with peers on the playground,

and frequency of initiations and responses (see Table 1 for

description). Independent observers watched the target

child on the playground for 40 consecutive seconds and

then coded for 20 s for at least ten minutes during the

recess or lunch play period on two separate occasions

within 1 week. The observers noted the child’s engagement

with peers on the playground (solitary, proximity,

onlooking, parallel, parallel aware, involved in games with

rules and joint engaged with peers) in each interval.

Playground engagement states were summed for a total

proportion of intervals in each engagement state.

Coders also noted two types of children’s initiations

toward other children. First, observers coded for successful

initiations to peers where the child directs communication

to a peer/peers (e.g. offers toy, greets, asks to play game,

comments, states facts, etc.) and the peer responds with a

nonverbal gesture (e.g. head nod/shake, follows the child,

laughs, etc.) or verbal language. Second, observers rated

children’s failed initiation attempts where the target child

directs communication to a peer/peers and the peer does

not respond or ignores the child. Coders also noted two

types of child responses to others including the children’s

appropriate responses to a peer’s initiation (e.g. child says

yes when a peer asks him/her to play) as well as the child’s

missed responses to a peer’s initiation (e.g. a peer asks him/

her to play and the child does not respond). Playground

observations included a comment section where the

observer qualitatively documented whether or not the child

had a 1:1 aide and the type of activity he/she engaged in

with the child on the yard.

Playground engagement states were summed into total

interval counts that yielded a total percentage of intervals

in each engagement state, and frequency of social behav-

iors (e.g., initiating to others and responding to peers’

social overtures) within each observed interval. To correct

for varying intervals per observation, the number of

intervals children spent in each engagement state was

divided by the total number of observed intervals for that

observation period.

Prior to beginning the study, all observers were trained

and considered reliable with percent agreement [.80.Observers then overlapped on 15% of all observations

distributed over the course of the study to assess coder

reliability and drift. When conducting reliability two

observers overlapped on sessions and began their stop-

watches at the same time, but coded independently. Reli-

ability was estimated with Kappa statistic, and averaged

.91 (range .83–.96).

Teacher Perception Measure. The Teacher Perception

Measure was a 26 item questionnaire completed by teachers

and adapted from the Personal Maturity Scale (Alexander

and Entwisle 1988), the Child Behavior Checklist for Pre-

school-Aged Children, Teacher Report (Achenbach et al.

1987) and the Behavior Problems Index (Zill 1990) by the

Early Head Start FACES program. The adapted measure

used a 3-point Likert scale to rate 12 items regarding

teachers’ perceptions of students’ social skills (1 = never,

2 = sometimes, 3 = very often) and 14 items regarding the

teacher’s perceptions of children’s classroom conduct

(1 = not true, 2 = somewhat or sometimes true, 3 = very

true or often true). The social skills domain described the

child’s strengths, such as adaptability to the school class-

room and environment, quality of interactions with peers,

and popularity or likeability among peers. The classroom

conduct domain described problems, such as disruptive,

impulsive, withdrawn, and depressive behaviors; problems

in school-related skills and motivation; and difficulty fol-

lowing directions. The Early Head Start FACES program

reported good internal consistency for this measure, ranging

from .72 to .88.

Table 1 Engagement states from the playground observation of peer engagement

Solitary/

isolated

Child plays alone, with no peers within 3 feet, and no mutual eye gaze with other children

Proximity Child plays alone within 3-foot range of peer

Onlooker Child has one-way awareness of child who is farther away than 3 feet. It appears the child is watching another child or group of

children or a game with interest or the intent to participate

Parallel Child and peer are engaged in a similar activity but there is no social behavior

Parallel aware Child and peer engaged in similar activity and mutually aware of each other during activity

Joint

engagement

Child and peer direct social behavior, e.g., offering objects, conversing, toy-taking, and other activities with a turn- taking

structure

Games with

rules

Child participates in organized sports such as 4-square, basketball, or handball and/or engages in fantasy or pretend play OR a

fantasy game that the child or his/her peers have created provided all children are playing by a set of rules that the children

have specified. A game has to be with another child

536 J Autism Dev Disord (2011) 41:533–544

123

Social Networks and Friendship Survey. Children were

asked to identify who they like to hang out with in their

classroom. From this list the children generated, they were

instructed to circle their top 3 friends, and place a star next to

their best friend from among the 3 names that were circled.

They were also asked to list any children they did not like to

hang out with (rejects). Next, participating students were

asked: ‘‘Are there kids in your class who like to hang out

together? Who are they?’’ Children listed the names of other

children who hung around together in groups; they were

reminded to include themselves in groups as well as to

remember to include students of both genders. Children

circled the groups of children who they identified as hanging

out together. This method has been used in various studies

from early childhood through adolescence to assess the

social structure of individual classrooms for both typical and

atypical populations (Cairns and Cairns 1994; Farmer and

Farmer 1996; Chamberlain et al. 2007; Locke et al. 2010).

Coding Indegrees, Outdegrees, Connects, and Rejects.

These variables were coded from the Friendship Survey.

Indegrees were coded as the total number of received

friendship nominations – the number of classmates that

listed the child as ‘‘someone they like to hang out with,’’

whereas outdegrees were coded as the total number of

outward friendship nominations by the child—the number

of classmates the child listed as ‘‘someone they like to hang

out with.’’ Children’s connects score was calculated as the

total number of children that were significantly linked on

the social network map. Each line segment from the social

network map indicated a significant connection to a

classmate from that child (See Fig. 1). Lastly, rejects were

coded as the total number of times children were identified

as someone other children ‘‘did not like to hang out with’’.

Coding Friendship Reciprocity. Children were consid-

ered to have reciprocal friendships if they selected each

other as their top 3 or best friends within the classroom. A

conservative method of determining reciprocal friendships

was used, such that when one of the students nominated

was absent, or did not complete the measure, it was coded

as missing data instead of a non-reciprocal friendship.

Coding Social Network Centrality (Cairns and Cairns

1994). Following Cairns and Cairns (1994), social network

analyses were conducted in order to obtain each child’s

social network centrality score. Social network centrality

refers to the prominence of an individual in the overall

classroom social structure. Three related scores were cal-

culated in order to determine a student’s level of involve-

ment in the classroom’s social networks: (1) the student’s

‘‘individual centrality,’’ (2) the ‘‘cluster centrality’’ of each

social group within the class, and (3) the student’s combined

‘‘social network centrality’’ score. Using methods developed

by Cairns and Cairns (1994), the first two types of centrality

were used to determine the third (Cairns et al. 1990; Farmer

and Farmer 1996). Based on categorizations by Farmer and

Farmer (1996), four levels of social network centrality were

possible. These four levels of involvement (i.e. isolated,

peripheral, secondary, and nuclear) in the classroom’s social

structure were coded from 0 to 3, to provide a system for

describing how well the child with ASD was integrated into

the informal peer networks. Children that were considered

‘isolated’ received a score of 0 for their social network

centrality and were not considered part of any cluster of

children within their classroom. Children that were consid-

ered ‘peripheral’ received a score of 1 for their social net-

work centrality and were considered on the outskirts of their

classroom’s social structure. These children may have a few

connections to other children within the classroom but are

not salient members of their classroom’s social network.

Children that were considered ‘secondary’ received a score

of 2 on their social network centrality and were considered

well connected members of their classroom social structure.

Lastly, children that were considered ‘nuclear’ received a

score of 3 on their social network centrality and were con-

sidered ‘popular’ and central members of their classroom

social structure. These children were individually salient

(nominated frequently) and were also significantly con-

nected to other children who were very salient on an indi-

vidual level. Children’s total social network centrality status

could only be as high as their lowest centrality score derived

from their individual or cluster centrality score.

Procedures

Once families completed the informed consent process,

they were assessed by independent evaluators to validate

the clinical diagnosis of ASD via the ADI-R (Lord et al.

1994) and ADOS (Lord et al. 2000) evaluations. Inde-

pendent evaluators also administered the Wechsler

Fig. 1 Sample social network map where the target child is anisolate. All other lines stemming from children’s ID numbers indicate

significant classroom connections. Numbers in parenthesis next to theID number represent children’s individual scores. Numbers within thecluster are children’s group scores (*** denotes the target child with

autism)

J Autism Dev Disord (2011) 41:533–544 537

123

Intelligence Scale for Children (WISC-III; Weschler 1991)

to obtain a developmental quotient. Children with an IQ of

65 or higher and who had a diagnosis of ASD were

included in the study.

Upon entry into the study, research personnel contacted

the target child’s school and obtained a letter of school

participation for the study. Once school approval was

obtained, consent forms were distributed to all children in

the class. Children were informed that their classroom was

selected to participate in a research study examining chil-

dren’s friendships and social skills. Children, who returned

informed consent from their parents, as well as offered

assent to join the study, completed the social network

measures (including brief demographic information) and the

Friendship Qualities Scale. To ensure understanding of the

measures, research personnel provided verbal instructions

on how to complete the instruments and individually assis-

ted children who had difficulty reading and/or writing and/or

were in the youngest grades. Children in the older grades

independently completed the measures after instructions

were given. In addition, teachers were asked to complete the

Teacher Perceptions Scale for the child with ASD during

this visit. Within the same week of distributing classroom

measures, research personnel gathered behavioral observa-

tions on the playground during two separate recess periods.

Results

Analyses below are based on 120 children, 60 children with

ASD and a paired sample of 60 typically developing peers

(children matched on age and gender from the same

classroom). There were no differences on outcome mea-

sures between children diagnosed with Asperger syndrome

(n = 16) and autism (n = 44); therefore, the following

analyses included all 60 children with ASD. We first report

descriptive data for the groups on measures of peer nom-

ination and friendship ratings: social network centrality,

friendship nominations (indegrees, outdegrees, connec-

tions, rejects, reciprocity of best and top 3 friends), and

friendship quality ratings. In each case, we tested for group

and grade-related differences. Next we report the descrip-

tive data for the playground observations of children with

ASD, and finally report individual differences in measures

for the children with ASD.

Descriptive Data: Self-and Other Perceptions of Social

Connections for Children With and Without ASD

Social Network Centrality. For the group of children with

ASD, 8 children were isolated, 25 had peripheral status, 22

had secondary status, and five had nuclear social status. In

contrast, none of the typically developing children were

isolated, six had peripheral status, 35 had secondary status

and 19 had nuclear status. See Fig. 2.

Consistent with our earlier studies, an ANOVA indi-

cated that there was a significant group difference for social

network centrality, F(1, 116) = 38.57, p .0001. Childrenwith ASD had significantly poorer social network centrality

(1.38 ± .09) compared to typically developing matched

peers (2.20 ± .09). There was a significant main effect of

grade level, F(1, 116) = 4.87, p = .03 where children in

the older grades (3rd–5th) had lower social network cen-

trality (1.65 ± .10) than children in the younger grades

(1st–2nd; 1.93 ± .09). There was no significant interaction

between grade and diagnostic group.

Friendships, Connections, and Rejections. A MANOVA

with grade and diagnostic group as independent variables

was used to compare the number of children’s friendships,

connections, and rejections within his/her classroom

between typically developing children and children with

ASD. Of the 120 children, 114 children were used in this

analysis because three children with ASD did not complete

the rejections portion of the friendship survey, as it was

added after the study began; thus, these students (and their

matched peers) were excluded from this analysis.

The multivariate result was significant for group, Wilks

Lambda = .79, F(1, 106) = 7.13, p B .001, indicating a

difference in friendships between children with ASD and

their typically developing peers. The univariate F tests

showed a significant difference between children with ASD

and their matched peers for the number of friends they

nominated within the classroom (outdegrees; F(1, 106) =

8.57, p = .004), the number of received friendship nomi-

nations by other children (indegrees; F(1, 106) = 18.84,

p B .001), and the number of classroom connections (con-

nects; F(1, 106) = 14.61, p B .001). Children with ASD

nominated fewer peers as friends (3.76 ± .34), were nom-

inated fewer times as a friend by peers (1.48 ± .24) and had

Fig. 2 Bar graph of the frequency of social network centrality statusfor children with ASD and their typically developing matched peers

538 J Autism Dev Disord (2011) 41:533–544

123

fewer overall classroom connections (i.e., smaller social

networks; 2.76 ± .33) than their typically developing mat-

ched peers (5.17 ± .34; 2.92 ± .24; 4.54 ± .33, respec-

tively). Children with ASD did not differ from typically

developing children in their percentage of connections to

peers by gender. Boys were more often connected to boys

and girls to girls for both groups. Lastly, when examining

children’s number of rejections, there was no significant

difference in the number of rejection nominations received

by children with ASD relative to their matched peers. There

was no main effect of grade or a group by grade interaction

for these outcomes (see Fig. 3).

Reciprocal Friendships. Both reciprocated top 3 friends

and best friendships were examined using an ANOVA. For

their top 3 friends, the overall model was significant,

F(3, 99) = 13.12, p .0001 with a significant main effectfor group, F(1, 99) = 39.22, p .0001.The percentage ofchildren’s reciprocal friendships with their nominated top

three best friends was significantly lower for children with

ASD (17.91% ± 5.32) in comparison to their typically

developing matched peers (63.91% ± 5.07). There was no

main effect of grade or a group by grade interaction.

The overall model was significant for reciprocal best

friends, F(3,61) = 3.94, p = .0123, with a significant main

effect of group, F(1, 61) = 10.82, p = .0017. Children

with ASD had fewer reciprocal best friends than did typical

children, (11.33% ± 8.4 compared to 44.97% ± 7.08),

respectively. There was no main effect of grade or a group

by grade interaction. See Fig. 4.

In addition, there was no difference between children

with ASD and typically developing children in whether they

selected a same-sex best friend (v2(1, N = 116) = 3.42,p = .09). The majority of both groups chose same sex best

friends, 56 out of 60 typically developing children and 46

out of 56 children with ASD. Four children with ASD did

not list any peer as a friend.

Friendship Quality Scale. A MANOVA with grade and

diagnostic group as independent variables was used to

compare the five domains of child-rated friendship quality

(i.e. companionship, help, security, conflict, and closeness)

between typically developing children and children with

ASD. Of the 120 children in the matched sample, 116

children were used in this analysis. Four children with ASD

did not list a best friend and therefore did not complete the

FQS; therefore, they were excluded from the analysis.

The multivariate result was significant for group, Wilk’s

Lambda = .84, F(1, 108) = 4.13, p = .002, indicating a

difference in friendship quality between children with ASD

and their typically developing peers. The univariate F tests

showed there was a significant difference between chil-

dren with ASD and their matched peers for closeness,

F(1, 108) = 17.87, p B .001, security, F(1, 108) = 4.45,

p = .04, helpfulness F(1, 108) = 15.00, p B .001, and

companionship, F(1, 108) = 8.60, p = .004, in that chil-

dren with ASD reported poorer friendship quality in all four

domains (see Table 2). Children’s perceptions of conflict

with respect to their best friendships were not significantly

different between the two groups. There was no main effect

of grade or a group by grade interaction for any domain of

friendship quality (see Fig. 5).

Within the Autism Group Analyses: Playground

Observations of Children with ASD

On the playground, children with ASD were engaged with

their peers for just over a third of the observed intervals on

the playground (38.6% of the total intervals). Children

engaged in structured games with rules for approximately

Fig. 3 Bar graph of children’s social network variables betweenchildren with ASD and their typically developing matched peers

(*** p .001; ** p .01)

Fig. 4 Bar graph of children’s reciprocal friendships betweenchildren with ASD and their typically developing matched peers

(*** p .001; * p .05)

J Autism Dev Disord (2011) 41:533–544 539

123

20% of the observed intervals, and 18.6% of the observed

intervals in joint engaged activities, such as having a

conversation. For the remaining percentage of observed

intervals, children were either solitary/unengaged (33.4%),

or in lower levels of engagement: parallel play (6%); in

proximity to other children (8%); parallel aware (engaging

in similar activities with mutual social awareness; 7%); and

onlooking (watching another group of children engaged in

a game or activity; 7%). The rate of initiations to peers

was, on average, once every 3 intervals (mean of 5.13

initiations during 15.79 observed playground intervals).

Peers responded to the child with ASD in approximately

66% of the opportunities observed. Peers also initiated to

the child with ASD an average of once every four intervals

and the child with ASD responded to the peer in 75% of the

opportunities observed.

Children with ASD who had a higher percentage of

intervals observed in joint engagement and games on the

playground also initiated to other children more often on the

playground, r = .45, p B .001, and responded more to peers’

initiations, r = .57, p B .001. In addition, children with ASD

who were more engaged on the playground were significantly

less likely to have a 1:1 aide, r = -.27, p = .04.

Qualitative notes from observations: In order to deter-

mine if children with an aide were more likely to be inter-

acting with their aide rather than with other children, we

examined the qualitative comments made by the indepen-

dent coders for each observation. During the playground

observations the observer noted if the child was interacting

with their aide or with peers. Two raters further coded the

qualitative comments about what the child was doing during

recess. These raters agreed 100% on the statements about the

child’s behavior and the role of the aide. Categories included

child unengaged but peers nearby, completely unengaged

with peers or adults, wandering or unfocused, engaged with

the aide or engaged with peers. Half of the children assigned

an aide were observed as unengaged on the playground (18/

36 children or 50%), 12 were wandering or unfocused and 6

were unengaged with peers but other children were nearby

(e.g., eating nearby, or digging in the sand nearby). Another

14% (5 children) were observed interacting with their aide

only. The rest of the sample (13/36 or 36%) was observed

interacting with peers or engaged in games. Children with an

aide were most often unengaged on the playground, neither

interacting with peers or with the aide.

Connections Between Playground Observations, Peer,

Self and Teacher Reports for Children with ASD

Correlations were run to determine if playground variables

(engagement/games, unengaged/solitary, initiations, respon-

ses) were associated with peer nominations (indegrees, out-

degrees, rejects, connects), social network centrality (SNC),

and friendship quality for the children with ASD. None of the

correlations reached significance.

We then explored whether children with ASD who were

more engaged on the playground differed by teacher report

of social skills. Using chi square statistics, we found that

teachers rated children who were more engaged on the

playground as having higher social skills, although the

association was only marginally significant, v2(1, N = 56) =3.78, p = 06.

Next we tested whether the children who had a reci-

procal friendship were more engaged on the playground,

and whether peers rated these children differentially.

Twenty percent of the children with ASD (N = 12) had at

least one reciprocal friendship. These children had signif-

icantly higher social network centrality scores (2.17 ± .20)

as compared to children with ASD who did not have a

reciprocal friendship (1.24 ± .11; v2(1, N = 49) = 11.59,p = .001). Having a reciprocal friendship, however, was

not associated with being more engaged on the playground

(v2(1, N = 49) = .67, p = 1.00).

Discussion

Children with ASD in general education classrooms are

most often on the periphery of their classroom social

Table 2 Estimated mean differences and standard errors in friend-ship quality between children with autism and their matched controls

Friendship quality Autism Matched control

Closeness 19.35 (.51) 22.35 (.49)

Conflict 8.38 (.48) 8.19 (.46)

Security 16.25 (.51) 17.74 (.49)

Companionship 13.35 (.49) 15.34 (.47)

Helpfulness 16.87 (.63) 20.25 (.47)

Fig. 5 Bar graph of children’s friendship quality between childrenwith ASD and their typically developing matched peers

(*** p .001; ** p .01; * p .05)

540 J Autism Dev Disord (2011) 41:533–544

123

networks. Their social networks are smaller than typical

classmates, the friendships they identify are less often

reciprocated, and the quality of their friendships is poorer.

These data for children in first through fifth grade are con-

sistent with a previous report on second and third graders

(Chamberlain et al. 2007), and further document the sig-

nificant social impairment that these children experience at

school. However, the current data go beyond our earlier

report in three main ways.

First, our previous study was limited to a small number

of high functioning children with ASD (N = 17) and a

more cohesive set of classrooms in which schools partici-

pating tended to have more services available, and may

have been motivated to participate because ‘things were

going well’ (Chamberlain et al. 2007). We found that none

of the children in our previous study were isolated, but they

were more often peripheral in their social networks.

Moreover, a gender effect was noted, with mostly boys

with ASD connected to social networks of girls (Cham-

berlain et al. 2007). In the current study, a larger sample of

60 children with ASD was recruited from a diverse set of

classrooms (half were from Title I schools). We found

again that children with ASD were mostly peripheral in

their classroom social networks, but there were also iso-

lated children (approximately 13% of the sample). The

gender effect we found previously was not noted in the

current study. Thus, consistent with typical peer social

interactions, boys were connected to boys and girls to girls,

and these findings were consistent for younger and older

children with ASD (Fein 1981; Pellegrini et al. 2007).

Reciprocity of friendships was particularly low for this

sample of children, 18% compared to 64% of their typical

classmates, and also lower than a previous study of 34% of

second and third graders with ASD (Chamberlain et al.

2007). Friendships of children with ASD may be better

characterized as unilateral rather than reciprocal. Because

friendships in the school context are important given the

amount of time children spend in school, and the impor-

tance of friends in promoting social and academic out-

comes (Ladd 1999), it will be important for future studies

to determine whether unilateral friendships satisfy similar

needs as reciprocal friendships for children with ASD

(Freeman and Kasari 1998). Additionally, friendships

outside of the school setting may provide a protective

function to children while in school, although studies have

not examined this possibility.

Second, there is some data suggesting that children with

ASD have poorer relationships at older ages (Orsmond et al.

2004; Rotheram-Fuller et al. in press). While we found

group effects in nearly all measures with children with ASD

doing less well compared to their typically developing

classmates, we found few grade differences and no grade by

group differences. There was only a grade effect for social

network centrality with all children (children with and

without ASD) having lower social network centrality at the

older grades. Relationships in general become more selec-

tive (and perhaps more challenging to maintain) as children

get older (Howlin et al. 2004; Orsmond et al. 2004). This

phenomenon appears the same for children with ASD as it is

for typically developing children.

Third, prior studies have not linked peer and child self

reports to systematic and independent playground observa-

tions and teacher reports. Thus, the current study extends our

previous findings by examining the links between peer, self,

and teacher reports, and observations of children in their

natural environment at school. One might expect that chil-

dren whose peers see them as more socially connected to

other children in the class would also be more engaged on

the playground. Yet, contrary to our expectations, there was

little association between playground engagement and peer

nominations of social connections. Regardless of social

status in the classroom, children with ASD were just as

likely to be unengaged on the playground if they were rated

as popular or isolated. Moreover, even with a reciprocal

friendship, children with ASD were no more engaged on the

playground than were children with ASD who did not have a

reciprocal friendship. Although a limitation of the study is

the lack of comparable playground data for the typical peers,

these data do provide insight into the potential problems

children with ASD experience on the playground, despite

having some important connections to their peers.

There are several reasons why the playground may be a

difficult environment for children with ASD. One is that in

contrast to the structure and expectations of the classroom in

which children may be able to connect with peers, the

playground is often chaotic and crowded. Even with a

reciprocal friend, children with ASD may be unable to

access the playground culture at their school. While adults

may be present on the yard, they are often more concerned

with safety than with facilitation of engagement between

peers (Anderson et al. 2004). Indeed, adults often believe

recess is a time away from adult intrusions, and that most

children understand how to play with each other (Giangreco

and Broer 2005). Yet, for children with ASD, playing and

engaging with others is likely the most difficult time of their

day. It seems likely that the playground is a good setting for

social skills interventions for children with autism. As a

result, one of the most common interventions for children

with ASD is to assign support staff, often in the form of a 1:1

aide (Anderson et al. 2004). In this study, over half of the

children were assigned an aide. Children with aides were

less likely to be engaged with peers on the playground, and

qualitative data indicated they were mostly unengaged from

their peers and also not engaged with their aides. These data

suggest that aides were unable to facilitate more peer

engagement of children on the playground. Future studies

J Autism Dev Disord (2011) 41:533–544 541

123

should carefully consider the role of the paraprofessional

assigned to children with ASD. Several studies now high-

light the critical need for aide training, so that aides learn

how to best facilitate interactions between children, and take

care not to stigmatize and otherwise isolate the child with

ASD (Anderson et al. 2004; Humphrey and Lewis 2008;

Brown et al. 2001).

Finally, the situation for children with ASD in inclusive

classrooms was not completely bleak. Children with ASD

did not differ from typical children in the number of

rejection nominations they received from their peers. This

finding, along with the relatively low levels of isolated

children nominated on the social networks measure, sug-

gests that children with ASD have more potential for fitting

into their typical school classrooms than other data-based

and anecdotal reports would suggest (Church et al. 2000;

Humphrey and Lewis 2008). Rather than active rejection,

children with ASD may fall into the class of neglected

children, often overlooked as potential playmates by other

children in the class (Asher and Wheeler 1985).

While our informant measures (peer, teacher and child with

ASD) did not link to our playground observations, observa-

tions of children on the playground yielded consistent data for

children’s level of engagement with initiations and responses

to peers. When children were engaged in games or conver-

sations, there were more initiations and responses to and from

peers. Thus, increasing engagement with children on the

playground is an important target of intervention that may

move children from the periphery of groups to more central

roles within the group. More engagement may lead to

increased opportunities to hone social skills, both in navigat-

ing positive interactions, and in negotiating conflicts. Better

engagement on the playground also appears associated with

more get-togethers of children outside of school (Frankel et al.

2010). Therefore, a goal for future studies will be to more

closely examine the effects of increased engagement on

children’s social developmental outcomes.

The current study goes beyond earlier studies by com-

bining data from multiple sources and by using multiple

methods on a large sample of children with autism. Still,

there remain a number of limitations that should be con-

sidered in interpreting the findings, and in designing future

studies. First, this study highlights some of the difficulties

in working within school settings that involve as few as 1

or 2 classrooms per school that contain a child with autism.

Obtaining enough data on each child becomes a challenge

when sample sizes are fairly large (n = 60) and classrooms

are many, as in the present report. Beyond the relatively

small corpus of observational data per participant (two

recess periods in one week contributing less than 30 min of

observational data), other limitations include the lack of

data on the typically developing matched peers. We were

unable to collect playground observational data and other

background information on the typical classmates. This

may be avoided in future studies if the typical classmates

are consented and matched from the beginning of the

study. Our approach was to utilize all of the children in the

class to obtain the social network centrality measure and

then to randomly select one child who could match the

child with autism on meaningful variables of age, gender

and same classroom. We were not able to verify ethnicity,

or other background variables on the children, and it is

possible that these variables may have influenced the

results despite the fact that children were in the same class,

same school and same neighborhood. Future studies will

need to consider these factors in making comparisons to

children with autism in general education classrooms.

In summary, this study provides a unique look into the

school social experiences of a diverse group of high-

functioning children with ASD. Information was gathered

from multiple sources, including the child with ASD, his or

her peers, and teacher, as well as independent observations

of interactions on the child’s playground. While measures

converged from multiple informants (teachers, peers and

child with ASD) on the level of connection between the

child and his or her peers and the reciprocity of their

friendships, there was little association to observations

made independently on the playground. Thus, these data

yield a complicated picture of the social lives of children

with ASD suggesting that success with peers may be

greater if the supports are in place to engage children with

their peers on the school playground.

Acknowledgments This study was supported by NIMH grant5-U54-MH-068172 and HRSA grant UA3MC11055. We thank the

children, parents, schools and teachers who participated, and the

individuals who contributed countless hours of assessments, inter-

vention, and coding, Laudan Jahromi, Lisa Lee, Eric Ishijima, Kelly

Goods, Nancy Huynh, Mark Kretzmann, Tracy Guiou and Steve

Johnson. We especially appreciate the statistical support of Jeff Wood

and Fiona Whalen from the UCLA Semel Institute Statistical Group

and to Steven Kapp for feedback on earlier versions of the paper.

Open Access This article is distributed under the terms of theCreative Commons Attribution Noncommercial License which per-

mits any noncommercial use, distribution, and reproduction in any

medium, provided the original author(s) and source are credited.

References

Achenbach, T. M., Edelbrook, C., & Howell, C. T. (1987).

Empirically based assessment of the behavioral/emotional prob-

lems of 2- and 3-year old children. Journal of Abnormal ChildPsychology: An official publication of the International Societyfor Research in Child and Adolescent Psychopathology, 15,629–650.

Alexander, K. L., & Entwisle, D. R. (1988). Achievement in the first

2 years of school: Patterns and processes. Monographs of theSociety for Research in Child Development, 53, i-157.

542 J Autism Dev Disord (2011) 41:533–544

123

Anderson, A., Moore, D. W., Godfrey, R., & Fletcher-Flinn, C. M.

(2004). Social skills assessment of children with autism in free-

play situations. Autism, 8, 369–385.Asher, S., & Wheeler, V. A. (1985). Children’s loneliness: A

comparison of rejected and neglected peer status. Journal ofConsulting and Clinical Psychology, 53, 500–505.

Bauminger, N., & Kasari, C. (2000). Loneliness and friendship in

high-functioning children with autism. Child Development, 71,447–456.

Bauminger, N., Shulman, C., & Agam, G. (2003). Peer interaction

and loneliness in high-functioning children with autism. Journalof Autism and Developmental Disorders, 33(5), 489–507.

Bauminger, N., Shulman, C., & Agam, G. (2004). The link between

perceptions of self and of social relationships in high-functioning

children with autism. Journal of Developmental and PhysicalDisabilities, 16(2), 193–214.

Brown, W. H., Odom, S. L. & Conroy, M. A. (2001). An intervention

hierarchy for prompting young children’s peer interactions in

natural environments. Topics in Early Special Education, 21(3),162–175.

Bukowski, W. M., Hoza, B., & Boivin, M. (1994). Measuring

friendship quality during pre- and early adolescence: The

development and psychometric properties of the Friendship

Qualities Scale. Journal of Social and Personal Relationships.Special Issue: Children’s Friendships, 11(3), 471–484.

Burack, J. A., Root, R., & Zigler, E. (1997). Inclusive education for

students with autism: Reviewing ideological, empirical and

community considerations. In D. J. Cohen, F. R. Volkmar, D.

J. Cohen, & F. R. Volkmar (Eds.), Handbook of autism andpervasive developmental disorders (pp. 799–807). New York:Wiley.

Cairns, R., & Cairns, B. (1994). Lifelines and risks: Pathways ofyouth in our time. New York: Cambridge University Press.

Cairns, R. B., Gariépy, J.-L., & Kindermann, T. A. (1990). Identifyingsocial clusters in natural settings. Unpublished manuscript.Chapel Hill, NC: University of North Carolina and Chapel Hill.

Carr, E. G., & Darcy, M. (1990). Setting generality of peer modeling

in children with autism. Journal of Autism and DevelopmentalDisorders, 20(1), 45–59.

Chamberlain, B., Kasari, C., & Rotheram-Fuller, E. (2007). Involve-

ment or isolation? The social networks of children with autism in

regular classrooms. Journal of Autism and DevelopmentalDisorders, 37(2), 230–242.

Church, C., Alisanski, S., & Amanullah, S. (2000). The social,

behavioral, and academic experiences of children with Asperger

syndrome. Focus on Autism and Other Developmental Disabil-ities, 15(1), 12–20.

Cook, B. G., & Semmel, M. I. (1999). Peer acceptance of included

students with disabilities as a function of severity of disability

and classroom composition. The Journal of Special Education,33, 50–61.

Farmer, T. W., & Farmer, E. M. Z. (1996). Social relationships of

students with exceptionalities in mainstream classrooms: Social

networks and homophily. Exceptional Children, 62(5), 431–450.Fein, G. G. (1981). Pretend play in childhood: An integrative review.

Child Development, 52(4), 1095–1118.Frankel, F., Gorospe, C. M., Chang, Y., & Sugar, C. A. (2010).

Mothers reports of play dates and observation of school

playground behavior of children having high-functioning autism

spectrum disorders (submitted).

Freeman, S., & Kasari, C. (1998). Friendships in children with

developmental disabilities. Early Education and Development, 9,341–355.

Giangreco, M., & Broer, S. (2005). Questionable utilization of

paraprofessionals in inclusive schools: Are we addressing

symptoms or causes? Focus on Autism and other DevelopmentalDisabilities, 20, 10–25.

Guralnick, M. J. (1990). Social competence and early intervention.

Journal of Early Intervention, 14, 3–14.Howlin, P., Goode, S., Hutton, J., & Rutter, M. (2004). Adult outcome

for children with autism. Journal of Child Psychology andPsychiatry, 45(2), 212–229.

Humphrey, N., & Lewis, S. (2008). Make me normal: The views and

experiences of pupils on the autistic spectrum in mainstream

secondary schools. Autism, 12, 1362–3613.Ingram, D. H., Mayes, S. D., Troxell, L. B., & Calhoun, S. L. (2007).

Assessing children with autism, mental retardation, and typical

development using the Playground Observation Checklist.

Autism, 11, 311–319.Kasari, C., Freeman, S. F. N., Bauminger, N., & Alkin, M. C. (1999).

Parental perspectives on inclusion: Effects of autism and down

syndrome. Journal of Autism and Developmental Disorders,29(4), 297–305.

Kasari, C., Rotheram-Fuller, & Locke. J., (2005). The development ofthe playground observation of peer engagement (POPE) Mea-sure. Unpublished manuscript. Los Angeles, CA: University ofCalifornia Los Angeles.

Ladd, G. W. (1999). Peer relationships and social competence during

early and middle childhood. Annual Review of Psychology, 50,333–359.

Locke, J., Ishijima, E., Kasari, C., & London, N. (2010). Loneliness,

friendship quality, and the social networks of adolescents with

high-functioning autism in an inclusive school setting. Journal ofResearch in Special Educational Needs.

Lord, C., Risi, S., Lambrecht, L., Cook, E. H., Jr., Leventhal, B. L.,

DiLavore, P. C., et al. (2000). The autism diagnostic observation

schedule–generic: A standard measure of social and communi-

cation deficits associated with the spectrum of autism. Journal ofAutism and Developmental Disorders, 30(3), 205–223.

Lord, C., Rutter, M., & Le Couteur, A. (1994). Autism diagnostic

interview-revised: A revised version of a diagnostic interview for

caregivers of individuals with possible pervasive developmental

disorders. Journal of Autism and Developmental Disorders,24(5), 659–685.

MacMillan, D. L., Gresham, F. M., & Forness, S. R. (1996). Full

inclusion: An empirical perspective. Behavioral Disorders,21(2), 145–159.

Mesibov, G. B., & Shea, V. (1996). Full inclusion and students with

autism. Journal of Autism and Developmental Disorders, 26(3),337–346.

Ochs, E., Kremer-Sadlik, T., Solomon, O., & Sirota, K. G. (2001).

Inclusion as social practice: Views of children with autism.

Social Development, 10(3), 399–419.Orsmond, G. I., Krauss, M. W., & Seltzer, M. M. (2004). Peer

relationships and social and recreational activities among

adolescents and adults with autism. Journal of Autism andDevelopmental Disorders, 34, 245–256.

Pellegrini, A. D., Long, J. D., Roseth, C. J., Bohn, C. M., & Van

Ryzin, M. (2007). A short-term longitudinal study of preschool-

ers’ (Homo sapiens) sex segregation: The role of physicalactivity, sex, and time. Journal of Comparative Psychology, 121,282–289.

Roeyers, H. (1996). The influence of nonhandicapped peers on the

social interactions of children with a pervasive developmental

disorder. Journal of Autism and Developmental Disorders, 26(3),303–320.

Rotheram-Fuller, E., Kasari, C., Chamberlain, B., & Locke, J.

(in press). Grade related changes in the social inclusion of

children with autism in general education classrooms. Journal ofChild Psychology & Psychiatry.

J Autism Dev Disord (2011) 41:533–544 543

123

Ryndak, D. L., Downing, J. E., Jacqueline, L. R., & Morrison, A. P.

(1995). Parents’ perceptions after inclusion of their children with

moderate or severe disabilities. Journal of the Association forPersons with Severe Handicaps, 20(2), 147–157.

Sale, P., & Carey, D. M. (1995). The sociometric status of students

with disabilities in a full-inclusion school. Exceptional Children,62(1), 6–19.

Shearer, D., Kohler, F., Buchan, K., & McCullough, K. (1996).

Promoting independent interactions between preschoolers with

autism and their nondisabled peers: An analysis of self-

monitoring. Early Education and Development, 7, 205–220.Sigman, M., & Ruskin, E. (1999). Continuity and change in the social

competence of children with autism, down syndrome, and

developmental delays. Monographs of the Society for Researchin Child Development, 64(1), v-114.

Staub, D., Schwartz, I. S., Gallucci, C., & Peck, C. A. (1994). Four

portraits of friendship at an inclusive school. Journal of theAssociation for Persons with Severe Handicaps, 19(4), 314–325.

Villa, R., Thousand, J., & Rosenberg, R. (1995). Creating heteroge-

neous schools: A systems change perspective. In M. Falvey (Ed.),

Inclusive and heterogeneous schooling: Assessment, curriculum,and instruction (pp. 1–50). Baltimore: Paul H. Brookes.

Weschler, D. (1991). Manual for the Weschler intelligence scale forchildren (3rd edn ed.). New York: Psychological Corporation.

Zill, N. (1990). The behavior problems index [descriptive material].Washington, DC: Child Trends.

544 J Autism Dev Disord (2011) 41:533–544

123