733113

research-article2017
AUT0010.1177/1362361317733113AutismPathak et al.

Original Article

Autism

Correlates of adaptive behavior 2019, Vol. 23(1) 87­–99

© The Author(s) 2017
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DOI: 10.1177/1362361317733113
https://doi.org/10.1177/1362361317733113

with autism: The autism speaks Autism journals.sagepub.com/home/aut

Treatment Network registry data

Manina Pathak1, Amanda Bennett  1 and Amy M Shui2

Abstract
Children with autism spectrum disorder have deficits in adaptive functioning. This study examines the adaptive behavior,
its association with cognitive ability, gender, age, and symptom severity in children with autism spectrum disorder. Using
data from Autism Treatment Network registry, the adaptive behavior profiles were examined in 2538 school-aged
children (between 5 and 17 years, mean: 8.8 years, standard deviation: 3.0) who had an overall intelligence quotient and
Vineland Adaptive Behavior Scale scores available. The children were grouped according to their intelligence quotient
(low intelligence quotient < 70; borderline intelligence quotient = 70–85; average intelligence quotient > 85), age (5–10
and 11–17 years), and gender for the analyses. Significantly lower Vineland Adaptive Behavior Scale scores were found
in borderline and average intelligence quotient groups when compared to mean intelligence quotient, while an opposite
pattern was seen in the low intelligence quotient group, with better adaptive behavior scores than mean intelligence
quotient. Vineland Adaptive Behavior Scale standard scores were positively correlated with intelligence quotient and
poorly associated with autism spectrum disorder severity. Younger children had significantly higher Vineland Adaptive
Behavior Scale scores. Adjusted comparisons by gender were not significant. Adaptive behavior profiles in the intelligence
quotient categories are discussed. This study confirms a positive relationship between adaptive behavior and intellectual
function in autism and indicates that children with higher intelligence quotient and older age are specifically impaired,
with lower adaptive behavior, highlighting the need for assessment and targeted intervention in these groups. Future
directions for research are discussed.

Keywords
adaptive behavior, age, autism spectrum disorder, cognitive ability, gender, intellectual functioning, sex differences

Introduction indicator of outcomes in ASD (Eaves and Ho, 2008).

Children with autism spectrum disorder (ASD) often have
deficits in their cognitive functioning and adaptive behav-
ior (Carter et al., 1998; Klin et al., 2007), and there is wide
variability in intellectual functioning in ASD population.
Contrary to the previous notion that almost 75% of indi-
viduals with ASD have intellectual disability, recent epide-
miological studies have indicated that about half of the
individuals with ASD present with intelligence quotient
(IQ) of 70 or more (Chakrabarti and Fombonne, 2005;
Charman et al., 2011). Children with autism without
comorbid intellectual disability demonstrate relative
strengths in cognitive and formal language abilities with
an expectation to achieve positive outcomes. Intellectual
functioning has been found to be the best prognostic
However, within the normal IQ range, the outcomes
remain variable (Howlin et al., 2004).
Adaptive behavior is defined as the collection of con-
ceptual, social, and practical skills that have been learned
and are performed in everyday lives (American Psychiatric
Association (APA), 2013; Schalock et al., 2010). The
1The Children’s Hospital of Philadelphia, USA
2Massachusetts General Hospital Biostatistics Center, USA
Corresponding author:
Manina Pathak, Developmental and Behavioral Pediatrics, The
Children’s Hospital of Philadelphia, 3550 Market Street, 3rd Floor,
Philadelphia, PA 19104, USA.
Email: pathakm@email.chop.edu
88 Autism 23(1)
Vineland Adaptive Behavior Scale (VABS) is the most
commonly used scale to measure the adaptive behaviors in
individuals with ASD (Gillham et al., 2000; Sparrow et al.,
2005). Children with ASD display poorer adaptive behav-
ior when compared to typically developing children and
children with other developmental disorders (Carter et al.,
1998; Mouga et al., 2015). Adaptive behavior has been
observed to be more strongly related to optimal outcomes
in adulthood than cognitive function (Farley et al., 2009).
Hence, adaptive behavior is an important component in
comprehensive evaluation of ASD and a determinant of
prognosis (Klin et al., 2007; Sparrow et al., 2005; Tomanik
et al., 2007). Consensus is building regarding the impor-
tance of early intervention in ASD to improve long-term
outcomes, and adaptive behavior presents as an achievable
and crucial intervention target (Bal et al., 2015; Howlin,
2013).
A heterogeneous adaptive behavior profile in autism
has been explored in many studies although evidence
regarding a distinct autism-specific adaptive functioning
profile is mixed. Furthermore, this profile may be impacted
by intellectual functioning (Bölte and Poustka, 2002; Liss
et al., 2001). A typical “autism profile” on VABS has been
reported with higher scores for motor and daily living
skills, lowest scores for socialization, and intermediate
scores for communication (Carter et al., 1998; Kraijer,
2000). In a large sample of cognitively able children with
ASD (IQ > 70), greatest impairments were seen in sociali-
zation skills, with moderate delays in communication and
daily living skills (Kanne et al., 2011). In younger chil-
dren, Perry et al. found that such profile emerged when age
equivalents were used at different cognitive levels but not
when standard scores were examined (Perry et al., 2009).
A typical autism profile of adaptive behavior was not
observed in younger children with intellectual disability
(Fenton et al., 2003). In another recent study, this profile
was not supported, and a relative weakness in daily living
skills across different intellectual ability groups was found
(Matthews et al., 2015). Further evidence to support or
refute the existence of typical ASD adaptive behavior pro-
files in a large ASD sample with varied cognitive abilities
and age range will be helpful in determining intervention
needs, guiding outcome measures, and establishing the
role of adaptive behavior in diagnostic dilemmas for subtle
cases (Tomanik et al., 2007).
Previous research has identified several variables asso-
ciated with adaptive behavior in ASD. A positive correla-
tion exists between adaptive behavior and intellectual
ability (Bölte and Poustka, 2002). While adaptive behavior
profiles are commensurate with cognitive ability in typi-
cally developing children, individuals with ASD demon-
strate a wide gap between IQ and adaptive behavior,
particularly in intellectually able individuals, highlighting
specific deficits associated with ASD (Bölte and Poustka,
2002; Liss et al., 2001; Lopata et al., 2013). Age has also
been investigated in relation to adaptive behavior in ASD.
In cross-sectional studies, a strong negative correlation
between age and adaptive behavior has been reported
(Kanne et al., 2011; Klin et al., 2007; Pugliese et al., 2015).
Longitudinal analyses indicate that the adaptive skills
acquisition rate is attenuated among individuals with ASD
when compared to typically developing peers (Gabriels
et al., 2007). Some researchers have not found an associa-
tion between age and adaptive behavior in individuals with
high-functioning ASD (Kenworthy et al., 2010). Similar
varying trends exist in association between adaptive
behavior and ASD symptom severity. In older children, a
weak relationship between symptoms and adaptive behav-
ior has been reported (Kanne et al., 2011; Klin et al., 2007),
while in younger children, a moderate to strong associa-
tion between ASD severity and adaptive behavior has been
reported (Perry et al., 2009). It is important to investigate
the effects of age, IQ, and ASD severity on adaptive behav-
ior in a large sample of children with varying age range
and cognitive ability in order to establish the association
between these variables and adaptive behavior and to rec-
oncile inconsistent findings. Understanding the variables
relating to adaptive behavior in ASD is critical, given the
potential association between adaptive skills and long-
term ASD outcomes (Farley et al., 2009).
ASD has a high male-to-female ratio, with an average
of 3:1 and rising to 10:1 in high-functioning individuals as
compared to 2:1 in ASD with coexistent ID (Fombonne,
2009; Loomes et al., 2017). This identifies IQ as a poten-
tial confounding variable when examining sex differences
in ASD, hence the need to control its effects (Volkmar
et al., 1993). A study comparing boys and girls with high
levels of autistic traits, who did or did not meet diagnostic
criteria for ASD, suggested that girls are more likely to get
a diagnosis when they exhibit behavioral problems or low
cognitive ability (Dworzynski et al., 2012). Concomitantly,
girls are reported to “camouflage” ASD symptoms, and
high-functioning girls with ASD are often underdiagnosed
(Dean et al., 2016; Shattuck et al., 2009). Very few studies
have looked into sex differences in adaptive behavior in
ASD. A study on a large sample of children with ASD sug-
gested weaker adaptive skills and lower cognitive ability
in females. This sample consisted of a lower proportion of
females with average intelligence. IQ reductions mediated
reduced adaptive behavior in females when compared to
males (Frazier et al., 2014). It is unknown if sex differ-
ences in adaptive behavior profiles persist when control-
ling for IQ. Such information may help build evidence to
standardize symptom ascertainment based on gender, a
practice that is recommended but not often utilized in cur-
rent clinical practice (Constantino and Charman, 2016).
This study aims to build upon existing knowledge
regarding adaptive behavior in children with ASD by
examining data from a large well-defined cohort of
children—­the Autism Speaks Autism Treatment Network
Pathak et al. 89
(ATN) registry. The study aims to investigate (1) the asso-
ciation between adaptive behavior function and overall IQ
in children with varied cognitive functioning. Based on
previous studies, we hypothesize that there is a positive
relation between adaptive behavior and cognitive function;
(2) the discrepancies between adaptive and cognitive func-
tion across the range of cognitive abilities. We hypothesize
that the discrepancy is more apparent in higher functioning
children and adolescents; (3) the differences in adaptive
behavior in relation to age and severity. Based on previous
studies, we hypothesize that older children have more defi-
cits in adaptive behavior, and ASD severity is poorly asso-
ciated with adaptive behavior function; (4) sex differences
in the adaptive behavior of IQ-matched children. We
hypothesize that girls have poorer adaptive skills than
boys; (5) if a typical “autism profile” for adaptive behavior
exists in our large study cohort. Characterizing the adap-
tive behavior profiles in ASD is essential to the develop-
ment of customized intervention strategies to optimize
self-sufficiency for autistic individuals at all levels of
functioning.
Methods
Participants
The ATN registry includes children and adolescents with
ASD enrolled across 14 sites in the United States and
Canada. The study sample included 2538 children, enrolled
between 2008 and 2016, ages 5–17 years (mean: 8.8,
standard deviation (SD) = 3.0), who had IQ and any VABS
subscale or total standard scores available. For age-spe-
cific analysis, they were divided into two groups: young
(5–10 years, n = 1939) and old (11–17 years, n = 599).
Other variables considered for analysis were race (White
vs non-White), ethnicity (Hispanic vs non-Hispanic), and
primary caregiver education level (at least some college vs
at most high school). One of the ATN registry inclusion
requirements was parent or guardian’s fluency in English
or Spanish. Exclusion criteria included medical conditions
precluding valid testing. The study sample consisted of
85% boys (boys vs girls’ ratio 5.6:1), Caucasian (83%),
Asian (4%), Black or African (7%), multiracial (6%), and
a majority of non-Hispanic (91%) children. Autism was
diagnosed in 62% (n = 1533), Asperger’s in 15% (n =
374), and pervasive developmental disorder not otherwise
specified (PDD-NOS) in 23% (n = 555). Most of the pri-
mary caregivers (82%) received higher education (at least
some college or more).
Measures
Adaptive functioning.  The VABS second edition (VABS-II)
is a standardized, structured parent/caregiver survey inter-
view of adaptive behaviors and has been shown to have
strong reliability and validity (Sparrow et al., 2005). The
ATN uses the Vineland-II, Survey Interview Form. This
measure produces an overall composite standard score and
age-equivalent standard scores in four domains: communi-
cation, daily living skills, socialization, and motor skills.
In this study, standard scores for communication, daily liv-
ing skills, and socialization domains along with the com-
posite standard scores were used. The motor skills domain
was not included in the analyses, as it is only administered
to individuals under the age of 6 years.
Cognitive ability.  A number of standardized tests with estab-
lished psychometric properties were used to obtain full
scale or abbreviated IQ scores, a common scenario in
autism practice and research. These included Stanford–
Binet (Roid, 2003), Mullen Scales of Early Learning (Mul-
len, 1995), Wechsler Abbreviated Scale of Intelligence
(WASI) (Wechsler, 1999), Differential Abilities Scale-sec-
ond edition (DAS-II) (Elliott et al., 1990), Wechsler Intel-
ligence Scale for Children-fourth edition (WISC-IV)
(Wechsler, 2003), or Wechsler Preschool and Primary
Scale of Intelligence-third edition (WPPSI-III) (Wechsler,
2002), depending on the ATN site’s preference, scale avail-
ability, and child’s age and language ability. Most partici-
pants were administered the Stanford–Binet (n = 2024)
followed by WISC-IV (n = 158), DAS-II (n = 157), Mul-
len (n = 99), WPPSI (n = 56), and the WASI (n = 44). For
all participants, norm-referenced overall deviation scores
were used as a measure of IQ. Children were divided into
three IQ categories based on SD below the population
mean: low (IQ < 70, n = 838), borderline (IQ between 70
and 85, n = 506), and average (IQ > 85, n = 1194) intel-
lectual functioning.
Autism diagnosis. Assessment of ASD was based on the
Diagnostic and Statistical Manual of Mental disorders
(4th ed., text rev.; DSM-IV-TR) criteria using the checklist
that allowed the clinician to indicate the diagnosis of
autism, Asperger’s, or PDD-NOS. The majority (88%) of
the children were assessed using Autism Diagnostic Obser-
vation Schedule (ADOS) or its second edition (ADOS-2)
(Lord et al., 2012). Severity of symptoms was assessed
using ADOS/ADOS-2 calibrated severity scores.
Participants were eligible to be included in the database
after meeting ASD diagnostic criteria, as determined by
clinical consensus using ADOS, ADOS-2, and/or DSM-
IV-TR (APA, 2000).
Statistical methods
IQ, demographics, DSM-IV-TR diagnosis, calibrated
ADOS severity score, and VABS total and subscale stand-
ard scores were tabulated for categorical variables and
described with means and SDs for continuous variables.
Continuous age and IQ variables were converted into
90 Autism 23(1)
categories based on clinically meaningful groups, and the
use of categorical variables facilitated interpretation of
interactive effects. Bivariate tests of baseline characteris-
tics with each VABS score were performed using t-tests or
analysis of variance (ANOVA) for categorical variables
and Spearman correlation for continuous variables. Cohen’s
d and omega-square effect sizes were reported for t-tests
and ANOVA, respectively. Covariates for multiple linear
regression models were selected based on a 0.05 signifi-
cance threshold from the bivariate tests. Tukey’s post hoc
pairwise comparison tests were used to assess differences
in scores by domain category within each IQ category.
The associations between VABS standard scores and IQ
(continuous) were assessed using Pearson correlation and
scatterplots, and differences in the VABS scores and IQ
(VABS score–IQ) were described in each IQ category
using means, SDs, and boxplots and were tested using
paired t-tests. To determine the association between adap-
tive behavior and cognitive intelligence, each regression
model used VABS score as the dependent variable and IQ
category, with reference group >85, as the main independ-
ent variable of interest, while controlling for covariates.
Adjusted least square means, differences in the adjusted
means (unstandardized and standardized beta coefficients),
standard errors, and p values are reported. Listwise dele-
tion was used in the multivariable models, and multiple
imputation sensitivity analyses were also performed. A
Bonferroni-corrected significance threshold of 0.0125
(=0.05/4) was used to account for the four model out-
comes. To determine if the effect of IQ on adaptive behav-
ior differs by gender, we assessed the IQ category ×
gender interaction in each multivariable model. Likewise,
to determine if the effect of IQ on adaptive behavior is
modified by age (5–10 vs 11–17 years), we assessed the IQ
category × age group interaction in each model. The asso-
ciations between adaptive behavior and age or gender were
assessed using adjusted regression models overall and
within each IQ group, and the association between adap-
tive behavior and IQ was assessed within each age group.
Results
Less than 10% of data were missing for each covariate,
except for ADOS severity score, which was missing for
12%. Table 1 indicates that the VABS scores for adaptive
behavior composite and the four subscales differ signifi-
cantly by IQ category, age group, DSM-IV diagnosis, race,
primary caregiver education, and calibrated ADOS severity
score (negative correlation) on bivariate analyses. Of these
variables, IQ, age, and DSM-IV diagnosis were signifi-
cantly correlated with VABS scores (except for small effect
size for socialization scores and DSM-IV diagnosis). The
pattern of VABS profile differed in the IQ categories. In the
borderline and average IQ groups, both daily living skills
and communication scores differed significantly from
socialization score, while in the low IQ group none of the
pairwise comparisons were significant. There was no sig-
nificant difference between the daily living skills and com-
munication scores in any of the IQ categories.
Table 2 summarizes the results from the multivariable
regression analyses of the VABS scores, adjusting for the
covariates mentioned above. IQ and age of the children
were strongly correlated with the VABS scores. Comparing
multiple imputation to listwise deletion, none of the results
differed in terms of significance, and all estimates from
both methods of handling missing data were similar.
Results are reported from the models that used listwise
deletion.
Figure 1 shows the positive correlation of IQ with
VABS composite (r = 0.58, p < 0.0001), communication
(r = 0.64, p < 0.0001), daily living skills (r = 0.52, p <
0.0001), and socialization (r = 0.42, p < 0.0001). Children
with low and borderline IQ had lower scores for VABS
composite (low: mean, 62.04, p < 0.0001; borderline:
mean, 70.51, p < 0.0001; average: mean, 74.66) and four
subscales (p < 0.0001, ω2 = 0.22) when compared with
children with average IQ. Figure 2 illustrates the gap
between IQ and adaptive behavior in each IQ category.
The VABS composite, communication, socialization, and
daily living skills scores exceeded mean IQ in low IQ
group (p < 0.0001 for each difference, Cohen’s d range:
0.86–1.07), whereas the VABS composite, communica-
tion, and socialization scores were below mean IQ in both
the borderline and average IQ groups (p < 0.0001 for each
difference, Cohen’s d range borderline: 0.47–0.49; aver-
age: 1.35–1.85; except communication in borderline
group, p = 0.0155,Cohen’s d: 0.11); and daily living skills
score was lower than IQ in the IQ > 85 category (p <
0.0001, Cohen’s d: 1.27) (Table 3). Although adaptive
behavior improved with increasing IQ, the discrepancy
between the adaptive behavior and IQ widened in children
with average intellectual functioning (IQ > 85).
Age and adaptive behavior were negatively correlated
on all subscales. Adjusted comparisons of VABS scores by
age group were significant (p < 0.0001 for each subscale
score; ω2 range: 0.04–0.12), with younger children having
better composite, communication, daily living skills, and
socialization skills. In the adjusted linear regression model,
controlling for IQ and other variables, the mean VABS
composite score among younger children was 8.7 units
higher than among older children (p < 0.0001, ω2 = 0.11).
Similar results were found on subgroup adjusted analysis
for younger versus older children within each IQ category
(p < 0.0001 for each difference; low IQ: ω2 range, 0.05–
0.10; borderline IQ: ω2 range, 0.02–0.10; average IQ: ω2
range, 0.05–0.17), except for daily living skills in border-
line group (p = 0.0032, ω2 = 0.02). In older children,
VABS scores were significantly different when comparing
the low and average IQ groups (p < 0.0001; ω2 = 0.07–
0.21) but not when comparing borderline and average IQ
Pathak et al. 91

Table 1.  VABS standard scores overall and by IQ and baseline covariates.

Variablea Overall % (n) or Adaptive behavior Communication DLS Socialization

mean ± SD composite

Overall sample (n = 2538) 72.1 ± 12.1 75.7 ± 14.6 76.0 ± 14.8 69.7 ± 12.6
(n = 2455) (n = 2535) (n = 2534) (n = 2532)
IQ *** *** *** ***
  <70 33.0% (838) 63.1 ± 10.6 64.3 ± 11.9 65.9 ± 13.0 62.5 ± 11.3
 70–85 19.9% (506) 72.9 ± 8.9 76.4 ± 9.8 77.2 ± 11.9 71.6 ± 11.3
  >85 47.0% (1194) 78.0 ± 10.4 83.5 ± 12.8 82.6 ± 13.1 73.8 ± 11.7
Omega-square 0.29 0.33 0.25 0.16
Age *** *** *** ***
  5–10 years 76.4% (1939) 74.0 ± 11.6 77.9 ± 14.5 77.5 ± 14.3 71.7 ± 11.9
  11–17 years 23.6% (599) 65.9 ± 11.7 68.8 ± 12.9 70.9 ± 15.1 62.9 ± 12.3
Cohen’s d 0.69 0.64 0.46 0.74
Gender NS NS NS NS
 Female 15.2% (386) 71.7 ± 12.3 75.4 ± 14.9 75.1 ± 14.7 69.7 ± 12.5
 Male 84.8% (2150) 72.1 ± 12.1 75.8 ± 14.6 76.1 ± 14.8 69.6 ± 12.6
Cohen’s d 0.03 0.02 0.07 0.00
DSM-IV diagnosis *** *** *** ***
 Autism 62.3% (1533) 68.8 ± 11.7 72.0 ± 14.1 72.4 ± 14.2 66.8 ± 12.3
 PDD-NOS 22.5% (555) 75.8 ± 10.9 79.4 ± 12.8 79.7 ± 13.2 74.5 ± 11.2
 Asperger’s 15.2% (374) 79.7 ± 10.9 85.3 ± 13.4 85.5 ± 13.6 74.3 ± 12.0
Omega-square 0.12 0.11 0.09 0.01
Race *** *** *** ***
 White 82.8% (2008) 72.6 ± 12.1 76.3 ± 14.6 76.5 ± 14.9 70.1 ± 12.5
 Non-White 17.2% (416) 69.8 ± 12.3 73.2 ± 14.8 73.9 ± 14.2 67.7 ± 12.6
Cohen’s d 0.23 0.21 0.18 0.19
Primary caregiver education *** *** *** ***
  At most HS 18.3% (433) 68.6 ± 11.7 70.6 ± 13.3 73.1 ± 14.3 67.0 ± 12.1
  Some college or more 81.7% (1937) 73.0 ± 12.1 77.0 ± 14.7 76.8 ± 14.8 70.3 ± 12.6
Cohen’s d 0.36 0.44 0.25 0.26
ADOS severity scoreb (n = 2222) 7.2 ± 2.0 r = −0.18*** r = −0.15*** r = −0.18*** r = −0.18***

VABS: Vineland Adaptive Behavior Scale; IQ: intelligence quotient; DLS: daily living skills; SD: standard deviation; ANOVA: analysis of variance; DSM:
Diagnostic and Statistical Manual of Mental Disorders; PDD-NOS: pervasive developmental disorder not otherwise specified; HS: high school; ADOS:
Autism Diagnostic Observation Schedule; NS: not significant.
aVABS standard scores reported with mean ± SD for each category and tested using ANOVA.
bSpearman correlation coefficient r reported for calibrated ADOS severity score.

Cohen’s d and omega-square: bold values indicate more than medium effect size (Cohen’s d ⩾ 0.5; omega-square ⩾ 0.06).
***p < 0.001.

groups (p > 0.0125 for each score difference; ω2 = 0.00–
0.01), indicating that IQ was not significantly associated
with VABS scores among older children with IQ > 70.
Figure 3(a) shows that the effect of IQ on adaptive behav-
ior composite and communication scores differed by age;
however, the effect size was small. Age did not modify the
effect of IQ on daily living or socialization scores.
There was no association between gender and VABS
scores on the bivariate or multivariable analyses. However,
in the subgroup adjusted analyses within each IQ category
with significance threshold 0.05, females with IQ > 85
had higher adaptive scores than IQ-matched males for
composite (adjusted mean: female 76.4 vs male 74.2, p =
0.0233, 95% confidence interval (CI) for difference (0.31,
4.07)) and communication (adjusted mean: female 81.3 vs
male 78.6, p = 0.0199, 95% CI for difference (0.42, 4.84)).
When applying the Bonferroni-corrected significance
threshold of 0.0125, none of these mean differences were
significant. Figure 3(b) shows that the effect of IQ on
VABS composite, communication and daily living scores
differed by gender; however, the effect size was small.
Gender did not modify the effect of IQ on socialization
score.
While ADOS severity scores and VABS scores were
negatively correlated (Table 1), the multivariable models
did not show a significant association between ADOS
severity and VABS scores. In Table 2 models, higher pri-
mary caregiver education was associated with higher com-
posite (β = 2.03, SE = 0.57, p = 0.0004) and
communication (β = 3.30, SE = 0.65, p < 0.0001) scores
92 Autism 23(1)

Table 2.  VABS standard score results from multivariable regression models.

Dependent variable Independent variable Category Adj.a LS mean Difference Std. beta SE p value
Adaptive behavior IQ <70 62.04 −12.62 −0.49 0.56 <0.0001*
composite 70–85 70.51 −4.15 −0.14 0.61 <0.0001*
>85 (Ref) 74.66  
Age 5–10 years 73.41 8.67 0.28 0.56 <0.0001*
11–17 years (Ref) 64.74  
Gender Female 69.54 0. 58 0.02 0.62 0.3509
Male (Ref) 68.96  
Communication IQ <70 62.17 −17.03 −0.55 0.63 <0.0001*
70–85 72.97 −6.22 −0.17 0.69 <0.0001*
>85 (Ref) 79.20  
Age 5–10 years 76.48 10.07 0.28 0.64 <0.0001*
11–17 years (Ref) 66.41  
Gender Female 71.84 0.49 0.01 0.70 0.4877
Male (Ref) 71.36  
DLS IQ <70 66.56 −13.91 −0.45 0.70 <0.0001*
70–85 76.66 −3.81 −0.10 0.77 <0.0001*
>85 (Ref) 80.47  
Age 5–10 years 77.85 6.57 0.18 0.71 <0.0001*
11–17 years (Ref) 71.28  
Gender Female 74.31 −0.31 −0.01 0.78 0.6867
Male (Ref) 74.62  
Socialization IQ <70 61.02 −8.99 −0.33 0.63 <0.0001*
70–85 68.59 −1.43 −0.04 0.69 0.0375
>85 (Ref) 70.01  
Age 5–10 years 71.26 9.43 0.30 0.63 <0.0001*
11–17 years (Ref) 61.82  
Gender Female 67.15 0.76 0.02 0.69 0.2739
Male (Ref) 66.40  

VABS: Vineland Adaptive Behavior Scale; IQ: intelligence quotient; Adj.: adjusted; LS mean: least squares mean; Std.: standardized; SE: standard error;
DLS: daily living skills; Ref: reference group.
aMultivariable model includes IQ category, age group, DSM-IV diagnosis, race, ethnicity, primary caregiver education, and ADOS severity score;

gender was not included as a covariate for the adjusted IQ and age estimates.
*Significant at the Bonferroni-corrected 0.0125 level.

but not with socialization (β = 1.46, SE = 0.64, p =
0.0226) or daily living skills scores (β = 1.16, SE = 0.72,
p = 0.1069). On multivariable analysis, race (White vs
non-White) was not independently associated with VABS
scores (β = 0.01, SE = 0.59, p > 0.0125 for composite),
while non-Hispanic children had better scores in the com-
munication (β = 0.05, SE = 0.93, p < 0.0125) and sociali-
zation (β = 0.06, SE = 0.92, p < 0.0125) domains but not
for composite (β = 0.04, SE = 0.82, p = 0.0194), and
daily living (β = 0.03, SE = 1.04, p = 0.0837).
Discussion
The study describes adaptive behavior profiles using the
ATN registry, one of the largest ASD datasets that include
school-aged children with varying cognitive abilities. We
found a strong positive correlation between adaptive
behavior and cognitive function. Children with higher IQ
had more discrepancies between adaptive behavior and
cognitive function compared to the children with intellec-
tual disability. Age was negatively correlated with adap-
tive behavior and ADOS severity was poorly associated
with adaptive behavior. Additionally, there was no associa-
tion between gender and overall adaptive behavior. A typi-
cal autism profile was not observed as significantly lower
socialization scores were seen only in groups with IQ >
70, with no significant difference between daily living and
communication scores.
Our study found a positive correlation between cogni-
tive and adaptive function across different cognitive level
groups. This confirms previous findings that overall IQ is
strongly associated with adaptive behavior function in
children with ASD, even when controlling for ADOS
severity (Kanne et al., 2011; Liss et al., 2001; Perry et al.,
2009). We found that IQ had the strongest correlation with
communication (r = 0.64) and the weakest with socializa-
tion (r = 0.42) scores (Kanne et al., 2011). Strong correla-
tion between the communication scores and IQ is not
Pathak et al. 93
Figure 1.  Scatterplots of VABS standard scores and IQ.
VABS: Vineland Adaptive Behavior Scale; IQ: intelligence quotient; DLS: daily living skills; SD: standard deviation.
surprising as the IQ tests have verbal subscales, and good
language skill is helpful in engagement during the assess-
ment. Additionally, the study also found that the children
with higher IQ had more discrepancies between adaptive
behavior and cognitive ability compared to the children
with intellectual disability, for whom adaptive skills are
relative strengths in relation to their cognitive functioning
(Bölte and Poustka, 2002; Liss et al., 2001; Perry et al.,
2009). To quantify the deficit, we found that the mean
adaptive composite and subscale scores in those with aver-
age intelligence (IQ > 85) fall between one to two SD
below the population mean IQ. This implies that the chil-
dren without comorbid intellectual disability experience
substantial challenges in everyday life and are not consist-
ently able to apply their intellectual abilities into func-
tional skills.
We observed a negative correlation between age and
adaptive behavior and a poor association between adaptive
behavior and ASD symptoms (Kanne et al., 2011; Klin
et al., 2007; Pugliese et al., 2015). We used the age groups
5–10 years and 11–17 years to corroborate our results with
the developmental level and functional requirement
(primary school vs middle-high school age). The negative
correlation between age and adaptive behavior prevailed
in children with or without intellectual disability. We
observed significant differences in adaptive behavior and
cognitive function in older children with IQ > 70 that is,
children who were cognitively higher functioning. This
attenuation in adaptive behavior was most marked for
socialization skills (Figure 3(a)). As children reach the
adolescent years, environmental expectations increase,
and the level of intellectual ability required to successfully
learn adaptive skills in order to cope with environmental
demands is much higher; and this may not be attained in
cognitively able (having IQ > 70) adolescents with ASD.
Moreover, children with ASD without comorbid intellec-
tual disability are often diagnosed later than the cogni-
tively impaired children (Shattuck et al., 2009). Hence, our
findings identify intellectually able adolescents at rela-
tively high risk for adaptive behavior impairments and
emphasize the need for careful assessment in children with
late ASD diagnosis and to focus on outcome research in
this subgroup.
Our fourth hypothesis that the girls with ASD have
poorer adaptive skills than boys was only accepted in the
low IQ group; however, the effect size was extremely
94 Autism 23(1)

Figure 2.  VABS standard scores and IQ by IQ category.

VABS: Vineland Adaptive Behavior Scale; IQ: intelligence quotient; DLS: daily living skills.

Table 3.  Differences in VABS standard scores and IQ by IQ category.

Variablea IQ Adaptive behavior Communication-IQ DLS-IQ Socialization-IQ

composite-IQ
IQ (n = 2538) 81.3 ± 24.1  
  <70 (n = 838) 52.8 ± 8.0 10.0 ± 10.3*** 11.4 ± 10.7*** 13.1 ± 12.3*** 9.7 ± 11.2***
  70–85 (n = 506) 77.5 ± 4.7 −4.6 ± 9.9*** −1.1 ± 10.5* −0.35 ± 12.8 −6.0 ± 12.2***
  >85 (n = 1194) 102.9 ± 11.8 −25.0 ± 13.7*** −19.5 ± 14.4*** −20.4 ± 16.0*** −29.1 ± 15.7***

VABS: Vineland Adaptive Behavior Scale; IQ: intelligence quotient; DLS: daily living skills; SD: standard deviation.
aVABS standard scores-IQ differences reported with mean ± SD for each category and tested using paired t-test.

***p < 0.001, *p < 0.05.

small. While girls with borderline IQ had similar adaptive
scores to the IQ-matched males, females with average IQ
were observed to have slightly better mean adaptive scores
than their male counterparts, but a statistical significance
was not achieved when the Bonferroni-corrected signifi-
cance threshold of 0.0125 was applied. Additionally, we
did not observe a significant difference in adaptive behav-
ior standard scores with IQ reduction in girls when com-
pared to boys. To our knowledge, this is the first study
describing the sex differences in adaptive behavior profiles
in children with ASD in relation to their cognitive abilities.
A poorer cognitive and adaptive skills in females have
been shown previously (Frazier et al., 2014). Our results
are limited for interpretation, as we did not find marked
differences in adaptive function between IQ-matched
males and females with an ASD diagnosis. Our cohort had
higher proportion of males (boys vs girls’ ratio 5.6:1),
which may have implication on generalizability of the
results. However, it is discernible that impairment in adap-
tive function in ASD is consistent, irrespective of gender,
and it is an important outcome measure for consideration
in all children with ASD.
Finally, we found the socialization scores to be signifi-
cantly lower than the communication and daily living
scores, yet the communication and daily living skills did
not differ significantly in borderline and average IQ groups
(IQ > 70). In the low IQ group, no significant differences
were seen between the domains. Hence, existence of a
Pathak et al. 95

(Continued)
96 Autism 23(1)

Figure 3.  (a) Age interactions with IQ on VABS composite and subscales standard scores and (b) gender interactions with IQ on
VABS composite and subscales standard scores.
Pathak et al. 97
typical autism profile for adaptive behavior was not estab-
lished in our large cohort although we found relatively
more significant impairment in socialization skills in chil-
dren with IQ > 70. Our results are consistent with other
studies that have shown significant impairment in sociali-
zation skills while describing adaptive behavior profiles in
individuals with ASD and high IQ (Kanne et al., 2011;
Klin et al., 2007; Liss et al., 2001; Lopata et al., 2013). For
communication and daily living skills, we did not find any
significant difference in any of the IQ categories in con-
trast to some previous studies (Carter et al., 1998; Kraijer,
2000). Nonetheless, children with ASD without comorbid
intellectual disability exhibit significant delays in all the
domains of adaptive behavior relative to their cognitive
function. In our cohort, a statistically significant difference
was not found between any adaptive behavior domain in
children with low IQ (<70). This is in contrast to the find-
ings of Matthews et al. (2015), who observed daily living
skills to be the lowest and socialization skills to be higher
than communication in children with ASD and coexistent
intellectual disability (Matthews et al., 2015). Previous
smaller studies that have compared the VABS profiles in
children with intellectual disability with or without autism
have shown that the adaptive behavior does not follow the
typical autism profile in children with autism and intellec-
tual disability (Fenton et al., 2003; Liss et al., 2001). Our
study confirms and extends this important finding to a
broader age group and to children with ASD without coex-
istent intellectual disability.
To our knowledge, this is the largest sample, compris-
ing children and adolescents with ASD analyzed for the
adaptive behavior profiles. Our findings not only add to
the growing literature on adaptive behavior in ASD, but
also have implications on current clinical practice. It is
evident that adaptive behaviors are specifically impaired
in children with ASD without intellectual disability and
should be included when characterizing impairment in
ASD. These children are often considered to have a milder
level of disability (“high functioning”), with an expecta-
tion of positive outcomes based on their higher cognitive
abilities. It is particularly concerning that these children
may not receive targeted interventions focusing on adap-
tive behaviors due to their cognitive status. This study
highlights the importance of the assessment of adaptive
behavior in children with ASD, irrespective of cognitive
ability, in order to provide interventions with explicit focus
on teaching such skills. Future outcome research in sub-
groups who have relatively higher impairment in adaptive
skills is needed. Additionally, the age-related differences
in the adaptive behavior profiles among the IQ-matched
children suggest a different trajectory of gains in adaptive
skills in children with ASD as compared to typically devel-
oping children. This study analyzed the adaptive behavior
profiles in two broad age groups. Further studies compar-
ing smaller age groups and longitudinal outcomes are
required to delineate the trajectory of adaptive behavior
development in ASD. Furthermore, the current tools used
to measure adaptive behavior rely on the standard scores
based on the age-equivalent normative references obtained
from a representative sample comprising of various clini-
cal groups including autism, and it is not known if the
adaptive behavior scores in ASD population can truly dis-
criminate between a developmental deviation or delay.
Additionally, VABS item subset scores were not included
in the analysis, which may provide a more detailed assess-
ment of specific adaptive behavior in ASD (Balboni et al.,
2016). Further evaluation of trajectories of specific adap-
tive behavior development in ASD is vital to understand
the significance of adaptive behavior scores in this
population.
Study limitations
There are some important limitations that need to be
acknowledged. First, the ATN data were collected at base-
line visits from a clinical sample, and the study has inher-
ent biases of an observational study, which may limit
generalization of the results. Our sample had a heteroge-
neous demographic profile, where Caucasian children of
highly educated parents were overrepresented. Second,
although VABS was used in all children to measure adap-
tive profile, different tools were used to obtain overall IQ,
as is common in ASD practice and research. In our cohort,
overall IQ was reported from six different tests, and
assuming comparability in IQ test scores is disputable.
The majority of children in our cohort had a Stanford–
Binet test for IQ assessment. We ran a sensitivity analysis
including only these children, and the results did not
change in significance and changed minimally in magni-
tude. Moreover, the IQ categories were defined by SD
below the population mean and not by the descriptive
labels used for the individual test. Hence, results for all
the participants with available overall IQ are reported to
make the results generalizable across various clinical set-
tings. Using overall IQ score is another limitation, as chil-
dren with autism have inherent differences between verbal
and non-verbal IQ. We categorized the cohort in three
groups; low (IQ < 70), borderline (IQ: 70–85), and aver-
age (IQ > 85), whereas most of the previous studies con-
sidered IQ of 70 as cut-off for low or high-functioning
ASD. This proved to be advantageous, as the relative
strengths and deficits of “borderline” intellectual func-
tioning group are more apparent with this method although
we recognize that IQ boundaries are no longer part of the
classification of intellectual functioning in Diagnostic
and Statistical Manual of Mental disorders (5th ed.;
DSM-V; APA, 2013). Finally, these data were collected
before DSM-5 was available and the results are based on
DSM-IV-TR diagnosis. The diagnostic criteria for ASD
have been modified, and this may have implication on
98 Autism 23(1)
receiving a diagnosis of ASD in current practice.
Nevertheless, this study highlights the level of functional
impairment that children with ASD experience and exam-
ines some interesting questions regarding the adaptive
behavior profiles in children with ASD.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) disclosed receipt of the following financial support
for the research, authorship, and/or publication of this article:
This Network activity was supported by Autism Speaks and
cooperative agreement UA3 MC11054 through the US
Department of Health and Human Services, Health Resources
and Services Administration, Maternal and Child Health
Research Program to the Massachusetts General Hospital. This
work was conducted through the Autism Speaks Autism
Treatment Network.
ORCID iD
Amanda Bennett http://orcid.org/0000-0003-3878-1925
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