The Use of Formal Language As a Sign of ASD in Undiagnosed Children Attending Typical Schools

Background: 'Diglossia' refers to the two varieties of the same language, which are used, under different conditions, by the same speakers within a community. In the 'diglossic' languages, we distinguish a common, colloquial or Low variety – L spoken in everyday situations and a more formal or High variety – H, reserved for specific contexts. The regular use of H as a medium of ordinary conversation is felt to be pedantic or artificial to the community. The Arabic language is a diglossic language with an L variety that varies significantly among the Arab countries, and an H-variety (Fushaa) common among all Arab speaking and commonly used in school books (but not in the teaching process by the teacher), in the Mosque, in most of the TV Arab cartoons and kids’ series (e.g. sesame street was presented in Fusha), and in “serious” programs in TV.

Objectives: This study explores the clinical observation that children with ASD tend to use the “fushaa” more often than their neurotypical counterparts. We hypothesised that this feature could represent a reliable red flag for the identification of verbally fluent children with ASD that go undiagnosed.

Methods: In an observational cohort study design we screened through their teachers all the children with first language Arabic, fluent speaking children attending Arabic Kinder Garden in two of the 5 governorates of the state of Kuwait. The identified subjects were assessed for the use of the “fushaa” during audio-recorded structured tasks lasting 30 minutes. The corroborated cases were then further assessed for the extend of exposure to the “fushaa”, their verbal IQ (PPVT-R), the presence of ASD (Social Communication Questionnaire and the ADOS-2), as well as for temperamental specific features (Children’s Behavioral Checklist).

Results: Up to November 2018, we were able to screen 36 KGs from a total of 61, i.e. 3045 children out of 5000 (60.9%). Teachers identified 26 children as using “fushaa” in everyday life, 22 of whom where corroborated fushaa users (0,72%), and we got parent permission to assess 15 of them (68.2%). From these 11 children (73.3%) were classified as ASD cases.

Conclusions: The use of “fushaa” by young children in their everyday activities is uncommon. The high probability of these children to be classified as ASD establishes the use of this phenomenon as a significant red flag for ASD in children that they are very able and thus they have been missed. The results should be replicated in other diglossic environments to assess if the phenomenon is not limited to Arab speakers only, shedding light to the way able children with ASD acquire language.