Representational drawing ability is associated with the syntactic language comprehension phenotype in autistic individuals

Representational drawing ability is associated with the syntactic language comprehension phenotype in autistic individuals | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Representational drawing ability is associated with the syntactic language comprehension phenotype in autistic individuals Andrey Vyshedskiy, Rohan Venkatesh, Edward Khokhlovich This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4909075/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract The relationship between symbolic thinking and language abilities is a topic of intense debate. We have recently identified three distinct language comprehension phenotypes: command, modifier and syntactic (Vyshedskiy et al., 2024 ). Individuals in the command phenotype were limited to comprehension of simple commands, while those in the modifier phenotype showed additional comprehension of color, size, and number modifiers. Finally, individuals in the most-advanced syntactic phenotype added comprehension of spatial prepositions, verb tenses, flexible syntax, possessive pronouns, complex explanations, and fairytales. In this report we analyzed how these three language phenotypes differed in their symbolic thinking as evidenced by their drawing abilities. In a cohort of 39,654 autistic individuals 4- to 21-years-of-age, parents reported that ‘drawing, coloring and art’ was manifested by 36.0% of participants. Among these individuals, representational drawing was manifested by 54.1% of individuals with syntactic-phenotype, 27.7% of those with modifier-phenotype, and 10.1% of those with command-phenotype (all pairwise differences between the phenotypes were statistically significant, p < 0.0001). The ability to draw a novel image per parent’s description (e.g. a three-headed horse) was reported by 34.6% of individuals with syntactic-phenotype, 7.9% of those with modifier- phenotype, and 1.9% of individuals with command-phenotype (all pairwise differences between the phenotypes were statistically significant, p < 0.0001). These results demonstrate strong association between representational drawing ability and the syntactic-language-comprehension-phenotype, suggesting a potential benefit of drawing interventions in language therapy. representational drawing figurative drawing syntactic language patholinguistics Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Introduction Drawing has been commonly used as a window into participants’ symbolic abilities (Beyn & Knyazeva, 1962 ; Levine et al., 1985 ; Thomas & Silk, 1990 ). Representational drawing – preplanned by the child and recognizable by parents – first appears in typical children around 3 to 4 years of age (Freeman, 1993 ; Golomb, 2003 ; Krampen, 2013; Thomas & Silk, 1990 ). Children with ASD, however, often experience impairments in representational drawing. In one of the first studies to test representational drawing in ASD, Scott and Baron-Cohen (Scott & Baron-Cohen, 1996 ) compared autistic individuals 8 to 16 years of age with controls matched on verbal mental age of around 4.5 years of age, calculated using the Test of Reception of Grammar (TROG) (Bishop, 2005 ). All participants passed the pre-test by copying the geometric forms. First, participants were asked to draw a picture of a man. When they had completed the drawing, the experimenter asked participants to draw another picture of a man, but this time to “draw a man that does not exist; an impossible man.” Second, participants were asked to draw a picture of a house. When they had completed the drawing, the experimenter asked participants to draw another picture of a house, but this time to “draw a house that does not exist; an impossible house.” Children with autism were significantly worse than matched controls in their ability to introduce “unreal” changes to their representations of people and houses: only 7.7% of participants with autism successfully drew an impossible house, and 8.3% an impossible man, compared to 100% and 86.8%, respectively, for the control group. Scott and Baron-Cohen concluded that children with autism have a deficit in imagining unreal objects, the phenomenon termed mindblindness by Baron-Cohen (Baron-Cohen, 1997). Leevers and Harris (Leevers & Harris, 1998 ) and later Allen and Craig (Allen & Craig, 2016 ) challenged this interpretation, suggesting instead that children with ASD may specifically struggle with executing new and complex visuo-spatial plans. Other studies confirm differences in representational drawing between children with ASD and typical children. For example, Low et al. reported that children with ASD produced fewer representational drawings compared to a typical children (Low et al., 2009 ). Craig et al. reported deficits in children with ASD compared to typical children when asked to draw unreal objects, such as ‘a man with two heads’ (Craig et al., 2001 ). These important studies, however, were limited by a small number of participants. In 2015 we published a language training app for children (Dunn, Elgart, Lokshina, Faisman, Khokhlovich, et al., 2017b, 2017a; Dunn, Elgart, Lokshina, Faisman, Waslick, et al., 2017; Vyshedskiy et al., 2020 ; Vyshedskiy & Dunn, 2015 ), which invites parents to complete their child’s evaluations. As a result, we accumulated over 200,000 longitudinal evaluations, mostly from children diagnosed with ASD. This gives us an opportunity to study representational drawing in a large number of ASD children. Parents were surveyed on the following three questions concerning children’s drawing proclivities. One question polled caregivers on the child’s general non-representational art proclivity: “[My child] does drawing, coloring, art.” Two other questions surveyed caregivers on their child’s representational drawing: “[My child] draws a VARIETY of RECOGNIZABLE images (objects, people, animals, etc.)” and “[My child] can draw a NOVEL image following YOUR description (e.g. a three-headed horse).” The answer choices were: “very true,” “somewhat true,” and “not true.” The goal of this article was to investigate the relationships between representational drawing and the three language comprehension phenotypes. Discovered recently, these three robustly distinct language comprehension phenotypes were defined as command, modifier and syntactic. Specifically, individuals in the command phenotype were limited to comprehension of simple commands, those in the modifier phenotype showed additional comprehension of color, size, and number modifiers; and finally, individuals in the most-advanced syntactic phenotype added comprehension of spatial prepositions, verb tenses, flexible syntax, possessive pronouns, complex explanations, and fairytales (Vyshedskiy et al., 2024 ). To study the association between the representational drawing ability and language phenotypes we focus on participants reported to “do drawing, coloring, art.” These participants clearly demonstrated both an interest in and the physical ability to engage in “drawing, coloring, art.” If the representational drawing ability is unrelated to language phenotypes, then equal proportion of these participants in each language phenotype should be expected to exhibit the representational drawing ability. Conversely, if one language phenotype shows a significant association with the representational drawing ability, this will suggest the possibility that some of neurological mechanisms underlying this phenotype are shared with those involved in representational drawing. Table 1 Language comprehension items as they were posed to parents. Answer choices were as follows: very true (0 points), somewhat true (1 point), and not true (2 points). Items 1 to 4 were assessed as a part of the Autism Treatment Evaluation Checklist (ATEC) (Rimland & Edelson, 1999a ) ; the rest of items were a part of the Mental Synthesis Evaluation Checklist (MSEC) (Braverman et al., 2018a ). Language comprehension items (verbatim) Abbreviations used in dendrograms 1 Knows own name Knows own name 2 Responds to ‘No’ or ‘Stop’ Resp to no and stop 3 Responds to praise Responds to praise 4 Can follow some commands Can follow commands 5 Understands some simple modifiers (i.e., green apple vs. red apple or big apple vs. small apple) Underst. color and size 6 Understands several modifiers in a sentence (i.e., small green apple) Underst. two modifiers 7 Understands size (can select the largest/smallest object out of a collection of objects) Underst. size superlatives 8 Understands NUMBERS (i.e., two apples vs. three apples) Understands numbers 9 Understands spatial prepositions (i.e., put the apple ON TOP of the box vs. INSIDE the box vs. BEHIND the box) U. spatial prepositions 10 Understands verb tenses (i.e., I will eat an apple vs. I ate an apple) Understands verb tenses 11 Understands simple stories that are read aloud Underst. simple stories 12 Understands elaborate fairy tales that are read aloud (i.e., stories describing FANTASY creatures) Underst. elabor. fairytales 13 Understands possessive pronouns (i.e., your apple vs. her apple) U. possessive pronouns 14 Understands the change in meaning when the order of words is changed (i.e., understands the difference between 'a cat ate a mouse' vs. 'a mouse ate a cat') Underst. flexible syntax 15 Understands explanations about people, objects or situations beyond the immediate surroundings (e.g., “Mom is walking the dog,” “The snow has turned to water”). U. abstract explanations Methods Participants Participants were children and adolescents using a language therapy app that was made available gratis at all major app stores in September 2015 (Dunn, Elgart, Lokshina, Faisman, Khokhlovich, et al., 2017b, 2017a; Dunn, Elgart, Lokshina, Faisman, Waslick, et al., 2017; Vyshedskiy et al., 2020 ; Vyshedskiy & Dunn, 2015 ). Once the app was downloaded, caregivers were asked to register and to provide demographic details, including the child’s diagnosis and age. Caregivers completed the Autism Treatment Evaluation Checklist (ATEC) (Rimland & Edelson, 1999b ), and an evaluation of language comprehension using the Mental Synthesis Evaluation Checklist (MSEC) (Braverman et al., 2018b ). Inclusion criteria were the same as in the previous study (Vyshedskiy et al., 2024 ): parent-reported ASD diagnosis (a good reliability of such parent-reported diagnosis has been previously demonstrated (Jagadeesan et al., 2022 )), absence of seizures (that commonly result in intermittent, unstable language comprehension deficits (Forman et al., 2022 )), absence of serious and moderate sleep problems (that are also associated with intermittent, unstable language comprehension deficits (Levin et al., 2022 )), age range of 4 to 21 years (the lower age cutoff was chosen to ensure that participants were exposed to all variety of items listed in Table 1 (Arnold & Vyshedskiy, 2022 ); the upper age cutoff was chosen to avoid analysis of participants who may be linguistically declining due to aging). These enrollment criteria resulted in 39,654 participants. Then we selected participants for this study based on their general proclivity for art. This, in turn, was determined by their caregiver answering “very true” to the question “[My child] does drawing, coloring, art” (part of ATEC subscale 3; the other answer choices were “somewhat true,” and “not true”). Thus, the study included 14,279 participants (36.0% of the original cohort). When caregivers have completed several evaluations, the last evaluation was used for analysis. The average age was 6.4 ± 2.4 years (range of 4 to 21 years), 72% participants were males. All caregivers consented to anonymized data analysis and publication of the results. The study was conducted in compliance with the Declaration of Helsinki (World Medical Association, 2013a ). Using the Department of Health and Human Services regulations found at 45 CFR 46.101(b)(4), the Biomedical Research Alliance of New York LLC Institutional Review Board (IRB) determined that this research project is exempt from IRB oversight. Representational drawing assessment Two questions surveyed parents on their children’s representational drawing ability: “[My child] draws a VARIETY of RECOGNIZABLE images (objects, people, animals, etc.);” and “[My child] can draw a NOVEL image following YOUR description (e.g. a three-headed horse).” The answer choices were: “very true,” “somewhat true,” and “not true.” Clustering analysis to determine language comprehension phenotype All fifteen available language comprehension items were included in the cluster analysis to determine the language comprehension phenotype (Table 1 ). Unsupervised hierarchical clustering was performed using Ward’s agglomeration method with a Euclidean distance metric as in the previous study (Vyshedskiy et al., 2024 ). Two-dimensional heatmap was generated using the “pheatmap” package of R, freely available language for statistical computing. Results Compared to the previous investigation (Vyshedskiy et al., 2024 ), this study focused on participants who demonstrated a general proclivity for art, as determined by their caregiver answering “very true” to the question “[My child] does drawing, coloring, art” (N = 14,279; 36.0% of the original cohort). Other participants may not have been exposed to “drawing, coloring, and art,” may have physical disability, or may not have been interested in this activity and therefore were excluded from analysis. Caregivers evaluated 15 language comprehension abilities (Table 1 ). To explore their co-occurrence, we used two common clustering methods: Unsupervised Hierarchical Cluster Analysis (UHCA) and Principal Component Analysis (PCA). Clustering techniques automatically organize abilities based on their co-occurrence. If two linguistic abilities are mediated by the same underlying mechanism, then, the breakdown of this mechanism should result in the absence of both abilities, causing them to be grouped into the same cluster. Importantly, the clustering analysis was devoid of any design or hypothesis, as the process is entirely driven by the data. Figure 1 A depicts the dendrogram generated by UHCA. The height of the branches indicates the distance between clusters, which is an indicator of greater dissimilarity. As in the previous study, three clusters have inter-cluster distances that are significantly larger than the distances between subgroups. The right-most cluster includes knowing the name, responding to ‘No’ or ‘Stop’, responding to praise, and following some commands (items 1 to 4 in Table 1 ). This cluster is identical to the command-language-comprehension-cluster identified in the previous study of 31,845 autistic individuals with the addition of the ‘responds to praise’ item that was not previously analyzed (Vyshedskiy et al., 2024 ). The cluster in the middle includes understanding color and size modifiers, several modifiers in a sentence, size superlatives, and numbers (items 5 to 8 in Table 1 ). This cluster is identical to the previously identified modifier-language-comprehension-cluster. The left-most cluster includes understanding of spatial prepositions, verb tenses, flexible syntax, possessive pronouns, explanations about people and situations, simple stories, and elaborate fairy tales (items 9 to 15 in Table 1 ). This cluster is identical to the previously identified syntactic-language-comprehension-cluster. The PCA (Fig. 1 B) also demonstrates a clear separation between the same three clusters. The command items (knowing the name, responding to ‘No’ or ‘Stop’, responding to praise, and following some commands) are clustered in the top left corner. The modifier items (understanding color and size modifiers, several modifiers in a sentence, size superlatives, and numbers) are clustered in the lower middle. The syntactic items (understanding of spatial prepositions, verb tenses, flexible syntax, possessive pronouns, explanations about people and situations, simple stories, and elaborate fairy tales) are clustered in the top right corner. The three-cluster solution was stable across multiple seeds as well as consistent across different age groups (4 to 6 years of age, Figure S1 ; 6 to 21 years of age, Figure S2;), and across different time points (first evaluation, Figure S3; last evaluation, Fig. 1 ). Next, we calculated UHCA and PCA of the 15 language comprehension abilities along with the draws representationally item defined as a “very true” response to the query “[My child] draws a VARIETY of RECOGNIZABLE images (objects, people, animals, etc.)” (Fig. 2 ). Both UHCA and PCA grouped the draws representationally item with the syntactic items indicating their common co-occurrence. Furthermore, we calculated UHCA and PCA of the 15 language comprehension abilities along with the draws to description item defined as a “very true” response to the query “[My child] can draw a NOVEL image following YOUR description (e.g. a three-headed horse)” (Fig. 3 ). Both UHCA and PCA grouped the draws to description item with the syntactic items indicating their common co-occurrence. As a control we calculated UHCA and PCA of the 15 language comprehension abilities along with the hyperactivity item, which is not expected to be related to any particular language ability and therefore should cluster into its own group. As expected, both UHCA and PCA clustered the hyperactivity item into its own group at a significant distance from the three language clusters, validating the effectiveness of both clustering techniques (Fig. 4 ). Having established that the representational drawing ability co-occurred with the cluster of syntactic language comprehension abilities, we aimed to assess the proportion of individuals in each language comprehension phenotype which exhibits representational drawing ability. To assign language comprehension phenotypes we utilized unsupervised hierarchical clustering analysis of all 14,279 participants (Fig. 5 , the dendrogram on top). The two-dimensional heatmap clearly shows the same three language comprehension phenotypes as were identified in the previous study of participants with language deficits (Vyshedskiy et al., 2024 ). Columns represent all the 14,279 participants and rows represent the 15 linguistic abilities. Blue indicates the presence of a linguistic ability (parent’s response = very true ); white indicates an intermittent presence of a linguistic ability (parent’s response = somewhat true ); and red indicates the lack of a linguistic ability (parent’s response = not true ). The three clusters of participants match the three language comprehension abilities clusters. The cluster of participants termed “Syntactic Language Phenotype” shows the predominant blue color that indicated good skills across all three (syntactic, modifier, and command) language comprehension items (26.0% of participants, Table 2 ). The cluster of participants marked as “Command Language Phenotype” shows the predominant blue color indicating good skills only among the command-items (18.9%). The third cluster of participants marked “Modifier Language Phenotype” shows the predominant blue color indicating good skills only across modifier- and command-items (55.2%). The three phenotypes were stable across different seeds, age groups (4 to 6 and 6 to 21 years of age, Figures S4 and S5, respectively), and time points (first and last evaluations; Figures S6 and 2, respectively). The representational drawing ability, as determined by a caregiver answering “very true” to the question “[My child] draws a VARIETY of RECOGNIZABLE images (objects, people, animals, etc.),” is indicated by short black vertical marks above the heatmap (marked Representational_drawing). Representational drawing was manifested by 54.1% of individuals with syntactic-, 27.8% of those with modifier-, and 10.1% of participants with command-phenotype (Table 3 , all pairwise differences between the phenotypes were statistically significant, t-test: p < 0.0001). Age did not significantly affect this distribution. Among participants of 4- to 6-years-of-age, representational drawing was manifested by 48.5% of individuals with syntactic-, 24.6% of those with modifier-, and 10.1% of those with command-phenotype (Table S1 , all pairwise differences between the phenotypes were statistically significant, p < 0.0001); among participants of 6- to 21-years-of-age, representational drawing was manifested by 63.7% of individuals with syntactic-, 35.1% of those with modifier-, and 16.9% of those with command-phenotype (Table S2, all pairwise differences between the phenotypes were statistically significant, p < 0.0001). Another question concerned with drawing-to-description ability was posed as follows: “[My child] can draw a NOVEL image following YOUR description (e.g. a three-headed horse).” The drawing-to-description ability was manifested by 34.6% of individuals with syntactic-, 7.9% of those with modifier-, and 1.9% of participants with command-phenotype (Table 4 ; all pairwise differences between the phenotypes were statistically significant, p < 0.0001). Age did not significantly affect this distribution. Among participants of 4- to 6-years-of-age, representational drawing was manifested by 28.4% of individuals with syntactic-, 6.6% of those with modifier-, and only 1.9% of individuals with command-phenotype (Table S3, all pairwise differences between the phenotypes were statistically significant, p < 0.0001); among participants of 6- to 21-years-of-age, representational drawing was manifested by 45.2% of individuals with syntactic-, 11.7% of those with modifier-, and 3.3% of those with command-phenotype (Table S4, all pairwise differences between the phenotypes were statistically significant, p < 0.0001). Table 2 Participant cluster statistics Syntactic Language Phenotype Modifier Language Phenotype Command Language Phenotype Total Number of participants 3711 7875 2693 14279 Percent of Total 26.0 55.2 18.9 100.0 Age, Mean (SD) 6.4 (2.4) 6.4 (2.5) 6.3 (2.5) 6.4 (2.4) Percent Male 70.5 72.6 73.1 72.2 Table 3 The representational drawing ability, determined by a caregiver answering “very true” to the question “[My child] draws a VARIETY of RECOGNIZABLE images (objects, people, animals, etc.).” Syntactic Language Phenotype Modifier Language Phenotype Command Language Phenotype Total Number of participants per cluster 3711 7875 2693 14279 Number of participants with the representational drawing ability 2007 2185 272 4464 Percent (%) 54.1 27.7 10.1 31.3 Table 4 The drawing-to-description ability, determined by a caregiver answering “very true” to the question “[My child] can draw a NOVEL image following YOUR description (e.g. a three-headed horse).” Syntactic Language Phenotype Modifier Language Phenotype Command Language Phenotype Total Number of participants per cluster 3711 7875 2693 14279 Number of participants with the drawing-to-description ability 1283 622 50 1955 Percent (%) 34.6 7.9 1.9 13.7 Discussion Representational drawing and language share a profound relationship, both serving as essential tools for symbolic communication. A deficit in one symbolic ability is commonly paralleled by a deficit in another (Beyn & Knyazeva, 1962 ; Levine et al., 1985 ; Thomas & Silk, 1990 ). Autistic savants attract significant attention by often breaking the conventional connection between representational drawing and language: their extraordinary drawing abilities stand in stark contrast to their limited language skills (Pring et al., 2012 ). Relationships between representational drawing and language were never investigated in a large study. We recently discovered three distinct language comprehension mechanisms (command, modifier, and syntactic) and the three corresponding language comprehension phenotypes: individuals with the syntactic phenotype utilized all three mechanisms, while individuals with the modifier phenotype were restricted to the modifier and command mechanisms, and individuals with the command phenotype were confined to the command mechanism) (Vyshedskiy et al., 2024 ). The goal of this study was to relate the representational drawing ability to language comprehension in an unprecedentedly large cohort of 39,654 autistic individuals. Parents reported that 36.0% of participants engaged in activities such as drawing, coloring, and art. These individuals demonstrated both an interest in and the physical ability to engage in these activities, making them the focus of this study. First, we conducted a clustering analysis of the 15 language comprehension abilities. Both unsupervised hierarchical clustering analysis (UHCA) and principal component analysis (PCA) confirmed the three distinct language comprehension mechanisms found in the previous study (Vyshedskiy et al., 2024 ) (Fig. 1 ). Next, we conducted clustering analysis of the 15 language comprehension abilities along with the draws representationally item “[My child] draws a VARIETY of RECOGNIZABLE images (objects, people, animals, etc.) (Fig. 2 ).” Both UHCA and PCA grouped the draws representationally item with the syntactic items indicating their common co-occurrence and therefore, suggesting that they may share a common neurological mechanism. Furthermore, we calculated UHCA and PCA of the 15 language comprehension abilities along with the draws to description item “[My child] can draw a NOVEL image following YOUR description (e.g. a three-headed horse)” (Fig. 3 ).” Again, both UHCA and PCA grouped the draws to description item with the syntactic items indicating their common co-occurrence and therefore, suggesting that they may share a common neurological mechanism. As a control, we conducted clustering analysis of the 15 language comprehension abilities along with the hyperactivity item, which is expected to have a mechanism completely unrelated to language comprehension. As anticipated, both UHCA and PCA clustered the hyperactivity item into its own group at a significant distance from the three language clusters, indicating no consistent co-occurrence between hyperactivity and language comprehension abilities (Fig. 4 ). Clustering analysis of participants confirmed the three distinct language comprehension phenotypes identified in the previous study (Vyshedskiy et al., 2024 ) and enabled us to assess the proportion of individuals in each language comprehension phenotype who exhibit the representational drawing ability. The representational drawing ability, defined by a caregiver answering “very true” to the question “[My child] draws a VARIETY of RECOGNIZABLE images (objects, people, animals, etc.),” was manifested by 54.1% of individuals with syntactic-, 27.8% of those with modifier-, and 10.1% of participants with command-phenotype. The drawing-to-description ability, determined by a caregiver answering “very true” to the question “[My child] can draw a NOVEL image following YOUR description (e.g. a three-headed horse),” was manifested by 34.6% of individuals with syntactic-, 7.9% of those with modifier-, and 1.9% of participants with command-phenotype. The strong association between the representational drawing ability and syntactic language was observed in both examined age ranges: 4 to 6 and 6 to 21 years of age. Limitations One limitation of this study is that it cannot draw conclusions on the underlying nature of differences in representational drawing ability between language phenotypes. A deeper analysis with more extended surveys is necessary for this purpose. As an example, drawing contours of some animals can be automated through repetitive training. In this case the process of drawing is similar to writing a signature. There is little pre-planning and the complete contour of an animal can appear on paper in a single move. We attempted to address the potential influence of automated drawing by emphasizing the word VARIETY in the question “My child draws a VARIETY of RECOGNIZABLE images (objects, people, animals, etc.),” but we simply do not know how many individuals in our cohort have been trained to draw automatically. Another drawing technique that we observed in autistic individuals was synthesis of elements directly on paper, rather than a mental pre-planning. Figure 6 shows a drawing by a verbal adolescent male diagnosed with ASD. This individual has a solid modifier-language-comprehension-phenotype. He understands colors, sizes, and numbers, but does not understand spatial prepositions, verb tenses, flexible syntax, possessive pronouns, complex explanations, and fairytales. His Vineland-II IQ standard score measured annually since he was 5 years of age is around 70. He is fond of drawing cats. When he was asked to draw “a cat with three heads,” he immediately began following the instruction. He started by drawing a cat with a single head, then added one head at a time until there were three heads drawn on paper, while counting aloud and using his finger to point to each head while counting. We surmise that such synthesis on paper is somewhat analogous to performing arithmetic on paper. Just as it is easier to add two- or three-digit numbers on paper than to do so mentally, synthesis on paper simplifies complex processes by providing a visual aid. Clinical implications Drawing holds significant therapeutic value in working with children with ASD, providing a non-verbal outlet for self-expression and communication (Schweizer et al., 2014 ). Through drawing, therapists can engage children in meaningful communication, allowing them to express their inner worlds, preferences, and emotions visually. Artistic activities can also aid in developing fine motor skills, sensory integration, and spatial awareness, which are areas of challenge for many children with ASD. Moreover, drawing promotes relaxation and can serve as a calming activity during therapy sessions, fostering a positive therapeutic environment. By harnessing the power of drawing, therapists can enhance communication, promote emotional regulation, and support the overall development of children with ASD (Di Renzo et al., 2017 ). The findings of this study imply an intriguing potential for drawing interventions. If representational drawing indeed shares some neurological mechanisms with syntactic language processing, it could potentially support the acquisition of syntactic language skills. Currently, controlled randomized studies exploring representational drawing interventions are lacking. However, the results from case studies consistently align with this hypothesis (Schweizer et al., 2014 ; Servi, 2024 ; Wright et al., 2020 ). Declarations Competing Interests Authors declare no competing interests. Informed Consent Caregivers have provided informed consent to anonymized data analysis and publication of the results. The study was conducted in compliance with the Declaration of Helsinki (World Medical Association, 2013b ). Compliance with Ethical Standards Using the Department of Health and Human Services regulations found at 45 CFR 46.101(b)(4), the Biomedical Research Alliance of New York LLC Institutional Review Board (IRB) determined that this research project is exempt from IRB oversight. Funding This research received no external funding. Author Contribution AV and EK designed the study. RV, EK, and AV analyzed the data. AV wrote the paper. Acknowledgement We wish to thank all participants’ caregivers who found time to complete children’s assessments. The authors are very grateful to Dr. Petr Ilyinskii for his scrupulous editing of this manuscript. The language therapy app used to collect the data presented in this manuscript was made possible by the contributions of Rita Dunn, Alexander Faisman, Jonah Elgart, Lisa Lokshina, and Yulia Dumov. Data Availability De-identified raw data from this manuscript are available from the corresponding author upon reasonable request. References Allen, M. L., & Craig, E. (2016). Brief Report: Imaginative Drawing in Children with Autism Spectrum Disorder and Learning Disabilities. Journal of Autism and Developmental Disorders, 46 (2), 704–712. https://doi.org/10.1007/s10803-015-2599-y Arnold, M., & Vyshedskiy, A. (2022). Combinatorial language parent-report score differs significantly between typically developing children and those with Autism Spectrum Disorders. Journal of Autism and Developmental Disorders. https://doi.org//10.1007/s10803-022-05769-8 Baron-Cohen, S. (1997). Mindblindness: An essay on autism and theory of mind . MIT press. https://books.google.com/books?hl=en&lr=&id=MDbcNu9zYZAC&oi=fnd&pg=PR9&dq=mindblindness+theory&ots=ZAYIvBXAbF&sig=F57BVzplBEnvKODMSMTvWNiJnIw Beyn, E. S., & Knyazeva, G. R. (1962). The problem of prosopagnosia. Journal of Neurology, Neurosurgery, and Psychiatry, 25 (2), 154. Bishop, D. V. M. (2005). Test for reception of grammar—Electronic. London : Psychological Corporation . Braverman, J., Dunn, R., & Vyshedskiy, A. (2018a). Development of the Mental Synthesis Evaluation Checklist (MSEC): A Parent-Report Tool for Mental Synthesis Ability Assessment in Children with Language Delay. Children, 5 (5), Article 5. https://doi.org/10.3390/children5050062 Braverman, J., Dunn, R., & Vyshedskiy, A. (2018b). Development of the Mental Synthesis Evaluation Checklist (MSEC): A Parent-Report Tool for Mental Synthesis Ability Assessment in Children with Language Delay. Children, 5 (5), 62. https://doi.org/10.3390/children5050062 Craig, J., Baron-Cohen, S., & Scott, F. (2001). Drawing ability in autism: A window into the imagination. Israel Journal of Psychiatry, 38 (3–4), 242–253. Di Renzo, M., Marini, C., Bianchi di Castelbianco, F., Racinaro, L., & Rea, M. (2017). Correlations between the drawing process in autistic children and developmental indexes. Journal of Psychology & Psychotherapy, 7 (2), 1–9. Dunn, R., Elgart, J., Lokshina, L., Faisman, A., Khokhlovich, E., Gankin, Y., & Vyshedskiy, A. (2017a). Children With Autism Appear To Benefit From Parent-Administered Computerized Cognitive And Language Exercises Independent Of the Child’s Age Or Autism Severity. Autism Open Access, 7 (217). https://doi.org/10.4172/2165-7890.1000217 Dunn, R., Elgart, J., Lokshina, L., Faisman, A., Khokhlovich, E., Gankin, Y., & Vyshedskiy, A. (2017b). Comparison of performance on verbal and nonverbal multiple-cue responding tasks in children with ASD. Autism Open Access, 7 , 218. https://doi.org/10.4172/2165-7890.1000218 Dunn, R., Elgart, J., Lokshina, L., Faisman, A., Waslick, M., Gankin, Y., & Vyshedskiy, A. (2017). Tablet-Based Cognitive Exercises as an Early Parent-Administered Intervention Tool for Toddlers with Autism—Evidence from a Field Study. Clinical Psychiatry, 3 (1). https://doi.org/10.21767/2471-9854.100037 Forman, P., Khokhlovich, E., & Vyshedskiy, A. (2022). Longitudinal Developmental Trajectories in Young Autistic Children Presenting with Seizures, Compared to those Presenting without Seizures, Gathered via Parent-report Using a Mobile Application. Journal of Developmental and Physical Disabilities. https://doi.org/10.1007/s10882-022-09851-y Freeman, N. H. (1993). Drawing: Public instruments of representation. https://psycnet.apa.org/record/1993-97468-006 Golomb, C. (2003). The child’s creation of a pictorial world . Psychology Press. https://www.taylorfrancis.com/books/mono/10.4324/9781410609250/child-creation-pictorial-world-claire-golomb Jagadeesan, P., Kabbani, A., & Vyshedskiy, A. (2022). Parent-reported assessment scores reflect ASD severity level in 2- to 7- year-old children. Children, 9 (5), 701. https://doi.org/doi.org/10.3390/children9050701 Krampen, M. (2013). Children’s drawings: Iconic coding of the environment . Springer Science & Business Media. https://books.google.com/books?hl=en&lr=&id=zk_7AwAAQBAJ&oi=fnd&pg=PA3&dq=Children%E2%80%99s+drawings:+Iconic+coding+of+the+environment.&ots=0hw-8cerqX&sig=DCdM9ICf5mbjFbago6r4-bLmmtg Leevers, H. J., & Harris, P. L. (1998). Drawing impossible entities: A measure of the imagination in children with autism, children with learning disabilities, and normal 4-year-olds. The Journal of Child Psychology and Psychiatry and Allied Disciplines, 39 (3), 399–410. Levin, J., Khokhlovich, E., & Vyshedskiy, A. (2022). Longitudinal developmental trajectories in young autistic children presenting with sleep problems, compared to those presenting without sleep problems, gathered via parent-report using a mobile application. Research in Autism Spectrum Disorders, 97 , 102024. Levine, D. N., Warach, J., & Farah, M. (1985). Two visual systems in mental imagery: Dissociation of “what” and “where” in imagery disorders due to bilateral posterior cerebral lesions. Neurology, 35 (7), Article 7. Low, J., Goddard, E., & Melser, J. (2009). Generativity and imagination in autism spectrum disorder: Evidence from individual differences in children’s impossible entity drawings. British Journal of Developmental Psychology, 27 (2), 425–444. https://doi.org/10.1348/026151008X334728 Pring, L., Ryder, N., Crane, L., & Hermelin, B. (2012). Creativity in savant artists with autism. Autism, 16 (1), 45–57. https://doi.org/10.1177/1362361311403783 Rimland, B., & Edelson, S. M. (1999a). Autism treatment evaluation checklist (ATEC). Autism Research Institute, San Diego, CA . http://www.autism.com Rimland, B., & Edelson, S. M. (1999b). Autism treatment evaluation checklist (ATEC). Autism Research Institute, San Diego, CA . http://www.autism.com Schweizer, C., Knorth, E. J., & Spreen, M. (2014). Art therapy with children with Autism Spectrum Disorders: A review of clinical case descriptions on ‘what works.’ The Arts in Psychotherapy, 41 (5), 577–593. Scott, F. J., & Baron-Cohen, S. (1996). Imagining real and unreal things: Evidence of a dissociation in autism. Journal of Cognitive Neuroscience, 8 (4), 371–382. Servi, C. (2024). Language and drawing development after a combined intervention: A single-subject case study. British Journal of Special Education, 51 (1), 35–49. https://doi.org/10.1111/1467-8578.12496 Thomas, G. V., & Silk, A. M. (1990). An introduction to the psychology of children’s drawings . New York University Press. https://psycnet.apa.org/record/1990-97551-000 Vyshedskiy, A., & Dunn, R. (2015). Mental Imagery Therapy for Autism (MITA)-An Early Intervention Computerized Brain Training Program for Children with ASD. Autism Open Access, 5 (1000153), 2. Vyshedskiy, A., Khokhlovich, E., Dunn, R., Faisman, A., Elgart, J., Lokshina, L., Gankin, Y., Ostrovsky, S., deTorres, L., & Edelson, S. M. (2020). Novel prefrontal synthesis intervention improves language in children with autism. Healthcare, 8 (4), 566. https://doi.org/doi.org/10.3390/healthcare8040566 Vyshedskiy, A., Venkatesh, R., & Khokhlovich, E. (2024). Are there distinct levels of language comprehension in autistic individuals – cluster analysis. Npj Mental Health Research, 3 (19). https://doi.org/10.1038/s44184-024-00062-1 World Medical Association. (2013a). World Medical Association Declaration of Helsinki: Ethical principles for medical research involving human subjects. JAMA, 310 (20), Article 20. World Medical Association. (2013b). World Medical Association Declaration of Helsinki: Ethical principles for medical research involving human subjects. JAMA, 310 (20), 2191–2194. Wright, B. M., Benigno, J. P., Boster, J. B., McCarthy, J. W., & Coologhan, B. K. (2020). “Tell Me About Your Picture”: Using Drawings to Support Expressive Language in Children With Autism Spectrum Disorder. Communication Disorders Quarterly, 42 (1), 3–11. https://doi.org/10.1177/1525740119868440 Additional Declarations No competing interests reported. Supplementary Files SupplementaryMaterial06152024.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4909075","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":349585553,"identity":"01d03209-7b77-4cfb-9cbb-af36eef30782","order_by":0,"name":"Andrey Vyshedskiy","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAnklEQVRIiWNgGAWjYHACNgaGigMghgEpWs6QrIWxjRQtBjfSnz34Oe9OYgN78zYJIrXkmBv2bnuW2MBzrIw4LZIzctgkeLcdTmyQyDEjVkv6M8m/c4Ba5N8QqYVfIsFMmrcBZAsPsVp43phJyxx7ZtzGk1ZsQZQWNnagw97U3JHtZz+88QZRWhgEEqB6iVMOdtkB4tWOglEwCkbBCAUA4zAuYtMp++AAAAAASUVORK5CYII=","orcid":"","institution":"Boston University","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Andrey","middleName":"","lastName":"Vyshedskiy","suffix":""},{"id":349585554,"identity":"b342a8ff-e963-4ff6-b6b5-1dc15f59a1f2","order_by":1,"name":"Rohan Venkatesh","email":"","orcid":"","institution":"Independent researcher","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Rohan","middleName":"","lastName":"Venkatesh","suffix":""},{"id":349585555,"identity":"95850387-17a6-44c4-a452-fa3caf4c1638","order_by":2,"name":"Edward Khokhlovich","email":"","orcid":"","institution":"Independent researcher","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Edward","middleName":"","lastName":"Khokhlovich","suffix":""}],"badges":[],"createdAt":"2024-08-13 19:07:20","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4909075/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4909075/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":66650429,"identity":"7e116e82-971b-46d9-abca-aa4d6a527625","added_by":"auto","created_at":"2024-10-15 07:36:01","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":392339,"visible":true,"origin":"","legend":"\u003cp\u003eClustering analysis of language comprehension items. (A) The dendrogram representing the hierarchical clustering of language comprehension abilities. (B) Principal component analysis of the 15 language comprehension abilities shows a clear separation between command, modifier, and syntactic items.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-4909075/v1/7b1592ecf5a2dc0366691c6e.png"},{"id":66651919,"identity":"ded421bb-1aaf-4603-8f91-d244bfb63217","added_by":"auto","created_at":"2024-10-15 07:44:01","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":428611,"visible":true,"origin":"","legend":"\u003cp\u003eClustering analysis of 15 language comprehension items along with the \u003cem\u003edraws representationally\u003c/em\u003e item “My child draws a VARIETY of RECOGNIZABLE images (objects, people, animals, etc.)” (14,279 participants, 4 to 21 years of age, last evaluation). (A) The dendrogram representing the hierarchical clustering. The \u003cem\u003edraws representationally\u003c/em\u003e item was clustered with \u003cem\u003esyntactic items\u003c/em\u003e. (B) Principal component analysis clustered \u003cem\u003edraws representationally\u003c/em\u003e item was clustered with \u003cem\u003esyntactic items\u003c/em\u003e.\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-4909075/v1/eeb3da42211f82f9e17a9a1d.png"},{"id":66650432,"identity":"3eb8d82b-29f4-4490-b4c7-fc42bd11c58b","added_by":"auto","created_at":"2024-10-15 07:36:01","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":414826,"visible":true,"origin":"","legend":"\u003cp\u003eClustering analysis of 15 language comprehension items along with the \u003cem\u003edraws to description \u003c/em\u003eitem “My child can draw a NOVEL image following YOUR description (e.g. a three-headed horse)” (14,279 participants, 4 to 21 years of age, last evaluation). (A) The dendrogram representing the hierarchical clustering. The \u003cem\u003edraws to description\u003c/em\u003e item was clustered with \u003cem\u003esyntactic\u003c/em\u003e items. (B) Principal component analysis clustered \u003cem\u003edraws to description\u003c/em\u003e item was clustered with \u003cem\u003esyntactic \u003c/em\u003eitems.\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-4909075/v1/24c5457d5ccd0af25bfb697d.png"},{"id":66650431,"identity":"c729b1a0-98e8-48b7-bfc3-823c57bb071d","added_by":"auto","created_at":"2024-10-15 07:36:01","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":406396,"visible":true,"origin":"","legend":"\u003cp\u003eClustering analysis of language comprehension items along with the \u003cem\u003ehyperactive\u003c/em\u003e item (14,279 participants, 4 to 21 years of age, last evaluation). (A) The dendrogram representing the hierarchical clustering. The \u003cem\u003ehyperactive\u003c/em\u003eitem was clustered into its own group. (B) Principal component analysis shows a clear separation between language clusters (command, modifier, and syntactic) and the \u003cem\u003ehyperactive\u003c/em\u003e item.\u003c/p\u003e","description":"","filename":"floatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-4909075/v1/bcd45d6dc1ccbcefe007af44.png"},{"id":66650433,"identity":"bd255041-43a4-4303-ad3f-57d26d1b700b","added_by":"auto","created_at":"2024-10-15 07:36:01","extension":"jpeg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":972901,"visible":true,"origin":"","legend":"\u003cp\u003eTwo-dimensional heatmap relating participants to their language comprehension abilities. The 15 language comprehension abilities are shown as rows. The dendrogram representing language comprehension abilities is shown on the left. Participants are shown as 14,279 columns. The dendrogram representing participants is shown on the top. Blue color indicates the presence of a linguistic ability (the “very true” answer), red indicates the lack of a linguistic ability (the “not true” answer), and white indicates the “somewhat true” answer. The representational drawing ability is indicated by short black vertical marks above the heatmap (marked Representational_drawing).\u003c/p\u003e","description":"","filename":"floatimage5.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4909075/v1/6317775232dc3409151262f1.jpeg"},{"id":66651920,"identity":"e1343123-ea4f-4f72-ad21-ba8911316c5e","added_by":"auto","created_at":"2024-10-15 07:44:01","extension":"jpeg","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":321383,"visible":true,"origin":"","legend":"\u003cp\u003eA drawing of “a cat with three heads” by a verbal adolescent male with a modifier-language-comprehension-phenotype.\u003c/p\u003e","description":"","filename":"floatimage6.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4909075/v1/90a11b8502ecbb104cf0e9d9.jpeg"},{"id":69503790,"identity":"f38019d3-2170-4c2a-b1a7-05cea34fcd22","added_by":"auto","created_at":"2024-11-21 06:03:53","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3162049,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4909075/v1/6f58ea4c-861d-4367-863b-e0cddd291b58.pdf"},{"id":66650434,"identity":"098e9c75-8261-4309-bda0-d04940ce6195","added_by":"auto","created_at":"2024-10-15 07:36:01","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":2829318,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryMaterial06152024.docx","url":"https://assets-eu.researchsquare.com/files/rs-4909075/v1/abd43e3a0409fd959d365d69.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Representational drawing ability is associated with the syntactic language comprehension phenotype in autistic individuals","fulltext":[{"header":"Introduction","content":"\u003cp\u003eDrawing has been commonly used as a window into participants\u0026rsquo; symbolic abilities (Beyn \u0026amp; Knyazeva, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e1962\u003c/span\u003e; Levine et al., \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e1985\u003c/span\u003e; Thomas \u0026amp; Silk, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e1990\u003c/span\u003e). Representational drawing \u0026ndash; preplanned by the child and recognizable by parents \u0026ndash; first appears in typical children around 3 to 4 years of age (Freeman, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e1993\u003c/span\u003e; Golomb, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2003\u003c/span\u003e; Krampen, 2013; Thomas \u0026amp; Silk, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e1990\u003c/span\u003e). Children with ASD, however, often experience impairments in representational drawing. In one of the first studies to test representational drawing in ASD, Scott and Baron-Cohen (Scott \u0026amp; Baron-Cohen, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e1996\u003c/span\u003e) compared autistic individuals 8 to 16 years of age with controls matched on verbal mental age of around 4.5 years of age, calculated using the Test of Reception of Grammar (TROG) (Bishop, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2005\u003c/span\u003e). All participants passed the pre-test by copying the geometric forms. First, participants were asked to draw a picture of a man. When they had completed the drawing, the experimenter asked participants to draw another picture of a man, but this time to \u0026ldquo;draw a man that does not exist; an impossible man.\u0026rdquo; Second, participants were asked to draw a picture of a house. When they had completed the drawing, the experimenter asked participants to draw another picture of a house, but this time to \u0026ldquo;draw a house that does not exist; an impossible house.\u0026rdquo; Children with autism were significantly worse than matched controls in their ability to introduce \u0026ldquo;unreal\u0026rdquo; changes to their representations of people and houses: only 7.7% of participants with autism successfully drew an impossible house, and 8.3% an impossible man, compared to 100% and 86.8%, respectively, for the control group. Scott and Baron-Cohen concluded that children with autism have a deficit in imagining unreal objects, the phenomenon termed \u003cem\u003emindblindness\u003c/em\u003e by Baron-Cohen (Baron-Cohen, 1997). Leevers and Harris (Leevers \u0026amp; Harris, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e1998\u003c/span\u003e) and later Allen and Craig (Allen \u0026amp; Craig, \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2016\u003c/span\u003e) challenged this interpretation, suggesting instead that children with ASD may specifically struggle with executing new and complex visuo-spatial plans. Other studies confirm differences in representational drawing between children with ASD and typical children. For example, Low et al. reported that children with ASD produced fewer representational drawings compared to a typical children (Low et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2009\u003c/span\u003e). Craig et al. reported deficits in children with ASD compared to typical children when asked to draw unreal objects, such as \u0026lsquo;a man with two heads\u0026rsquo; (Craig et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2001\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThese important studies, however, were limited by a small number of participants. In 2015 we published a language training app for children (Dunn, Elgart, Lokshina, Faisman, Khokhlovich, et al., 2017b, 2017a; Dunn, Elgart, Lokshina, Faisman, Waslick, et al., 2017; Vyshedskiy et al., \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Vyshedskiy \u0026amp; Dunn, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2015\u003c/span\u003e), which invites parents to complete their child\u0026rsquo;s evaluations. As a result, we accumulated over 200,000 longitudinal evaluations, mostly from children diagnosed with ASD. This gives us an opportunity to study representational drawing in a large number of ASD children. Parents were surveyed on the following three questions concerning children\u0026rsquo;s drawing proclivities. One question polled caregivers on the child\u0026rsquo;s general non-representational art proclivity: \u0026ldquo;[My child] does drawing, coloring, art.\u0026rdquo; Two other questions surveyed caregivers on their child\u0026rsquo;s representational drawing: \u0026ldquo;[My child] draws a VARIETY of RECOGNIZABLE images (objects, people, animals, etc.)\u0026rdquo; and \u0026ldquo;[My child] can draw a NOVEL image following YOUR description (e.g. a three-headed horse).\u0026rdquo; The answer choices were: \u0026ldquo;very true,\u0026rdquo; \u0026ldquo;somewhat true,\u0026rdquo; and \u0026ldquo;not true.\u0026rdquo;\u003c/p\u003e \u003cp\u003eThe goal of this article was to investigate the relationships between representational drawing and the three language comprehension phenotypes. Discovered recently, these three robustly distinct language comprehension phenotypes were defined as command, modifier and syntactic. Specifically, individuals in the \u003cem\u003ecommand\u003c/em\u003e phenotype were limited to comprehension of simple commands, those in the \u003cem\u003emodifier\u003c/em\u003e phenotype showed additional comprehension of color, size, and number modifiers; and finally, individuals in the most-advanced \u003cem\u003esyntactic\u003c/em\u003e phenotype added comprehension of spatial prepositions, verb tenses, flexible syntax, possessive pronouns, complex explanations, and fairytales (Vyshedskiy et al., \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). To study the association between the representational drawing ability and language phenotypes we focus on participants reported to \u0026ldquo;do drawing, coloring, art.\u0026rdquo; These participants clearly demonstrated both an interest in and the physical ability to engage in \u0026ldquo;drawing, coloring, art.\u0026rdquo; If the representational drawing ability is unrelated to language phenotypes, then equal proportion of these participants in each language phenotype should be expected to exhibit the representational drawing ability. Conversely, if one language phenotype shows a significant association with the representational drawing ability, this will suggest the possibility that some of neurological mechanisms underlying this phenotype are shared with those involved in representational drawing.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eLanguage comprehension items as they were posed to parents. Answer choices were as follows: very true (0 points), somewhat true (1 point), and not true (2 points). Items 1 to 4 were assessed as a part of the Autism Treatment Evaluation Checklist (ATEC) (Rimland \u0026amp; Edelson, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e1999a\u003c/span\u003e) ; the rest of items were a part of the Mental Synthesis Evaluation Checklist (MSEC) (Braverman et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2018a\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLanguage comprehension items (verbatim)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAbbreviations used in dendrograms\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eKnows own name\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eKnows own name\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eResponds to \u0026lsquo;No\u0026rsquo; or \u0026lsquo;Stop\u0026rsquo;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eResp to no and stop\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eResponds to praise\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eResponds to praise\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCan follow some commands\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCan follow commands\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnderstands some simple modifiers (i.e., green apple vs. red apple or big apple vs. small apple)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUnderst. color and size\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnderstands several modifiers in a sentence (i.e., small green apple)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUnderst. two modifiers\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnderstands size (can select the largest/smallest object out of a collection of objects)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUnderst. size superlatives\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnderstands NUMBERS (i.e., two apples vs. three apples)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUnderstands numbers\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnderstands spatial prepositions (i.e., put the apple ON TOP of the box vs. INSIDE the box vs. BEHIND the box)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eU. spatial prepositions\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnderstands verb tenses (i.e., I will eat an apple vs. I ate an apple)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUnderstands verb tenses\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnderstands simple stories that are read aloud\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUnderst. simple stories\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnderstands elaborate fairy tales that are read aloud (i.e., stories describing FANTASY creatures)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUnderst. elabor. fairytales\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnderstands possessive pronouns (i.e., your apple vs. her apple)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eU. possessive pronouns\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnderstands the change in meaning when the order of words is changed (i.e., understands the difference between 'a cat ate a mouse' vs. 'a mouse ate a cat')\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUnderst. flexible syntax\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnderstands explanations about people, objects or situations beyond the immediate surroundings (e.g., \u0026ldquo;Mom is walking the dog,\u0026rdquo; \u0026ldquo;The snow has turned to water\u0026rdquo;).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eU. abstract explanations\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eParticipants\u003c/h2\u003e \u003cp\u003eParticipants were children and adolescents using a language therapy app that was made available gratis at all major app stores in September 2015 (Dunn, Elgart, Lokshina, Faisman, Khokhlovich, et al., 2017b, 2017a; Dunn, Elgart, Lokshina, Faisman, Waslick, et al., 2017; Vyshedskiy et al., \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Vyshedskiy \u0026amp; Dunn, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). Once the app was downloaded, caregivers were asked to register and to provide demographic details, including the child\u0026rsquo;s diagnosis and age. Caregivers completed the Autism Treatment Evaluation Checklist (ATEC) (Rimland \u0026amp; Edelson, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e1999b\u003c/span\u003e), and an evaluation of language comprehension using the Mental Synthesis Evaluation Checklist (MSEC) (Braverman et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2018b\u003c/span\u003e). Inclusion criteria were the same as in the previous study (Vyshedskiy et al., \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2024\u003c/span\u003e): parent-reported ASD diagnosis (a good reliability of such parent-reported diagnosis has been previously demonstrated (Jagadeesan et al., \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2022\u003c/span\u003e)), absence of seizures (that commonly result in intermittent, unstable language comprehension deficits (Forman et al., \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2022\u003c/span\u003e)), absence of serious and moderate sleep problems (that are also associated with intermittent, unstable language comprehension deficits (Levin et al., \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2022\u003c/span\u003e)), age range of 4 to 21 years (the lower age cutoff was chosen to ensure that participants were exposed to all variety of items listed in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e (Arnold \u0026amp; Vyshedskiy, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2022\u003c/span\u003e); the upper age cutoff was chosen to avoid analysis of participants who may be linguistically declining due to aging). These enrollment criteria resulted in 39,654 participants. Then we selected participants for this study based on their general proclivity for art. This, in turn, was determined by their caregiver answering \u0026ldquo;very true\u0026rdquo; to the question \u0026ldquo;[My child] does drawing, coloring, art\u0026rdquo; (part of ATEC subscale 3; the other answer choices were \u0026ldquo;somewhat true,\u0026rdquo; and \u0026ldquo;not true\u0026rdquo;). Thus, the study included 14,279 participants (36.0% of the original cohort). When caregivers have completed several evaluations, the last evaluation was used for analysis. The average age was 6.4\u0026thinsp;\u0026plusmn;\u0026thinsp;2.4 years (range of 4 to 21 years), 72% participants were males. All caregivers consented to anonymized data analysis and publication of the results. The study was conducted in compliance with the Declaration of Helsinki (World Medical Association, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2013a\u003c/span\u003e). Using the Department of Health and Human Services regulations found at 45 CFR 46.101(b)(4), the Biomedical Research Alliance of New York LLC Institutional Review Board (IRB) determined that this research project is exempt from IRB oversight.\u003c/p\u003e \u003cdiv id=\"Sec4\" class=\"Section3\"\u003e \u003ch2\u003eRepresentational drawing assessment\u003c/h2\u003e \u003cp\u003eTwo questions surveyed parents on their children\u0026rsquo;s representational drawing ability: \u0026ldquo;[My child] draws a VARIETY of RECOGNIZABLE images (objects, people, animals, etc.);\u0026rdquo; and \u0026ldquo;[My child] can draw a NOVEL image following YOUR description (e.g. a three-headed horse).\u0026rdquo; The answer choices were: \u0026ldquo;very true,\u0026rdquo; \u0026ldquo;somewhat true,\u0026rdquo; and \u0026ldquo;not true.\u0026rdquo;\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eClustering analysis to determine language comprehension phenotype\u003c/h2\u003e \u003cp\u003eAll fifteen available \u003cem\u003elanguage comprehension\u003c/em\u003e items were included in the cluster analysis to determine the language comprehension phenotype (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Unsupervised hierarchical clustering was performed using Ward\u0026rsquo;s agglomeration method with a Euclidean distance metric as in the previous study (Vyshedskiy et al., \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Two-dimensional heatmap was generated using the \u0026ldquo;pheatmap\u0026rdquo; package of R, freely available language for statistical computing.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eCompared to the previous investigation (Vyshedskiy et al., \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2024\u003c/span\u003e), this study focused on participants who demonstrated a general proclivity for art, as determined by their caregiver answering \u0026ldquo;very true\u0026rdquo; to the question \u0026ldquo;[My child] does drawing, coloring, art\u0026rdquo; (N\u0026thinsp;=\u0026thinsp;14,279; 36.0% of the original cohort). Other participants may not have been exposed to \u0026ldquo;drawing, coloring, and art,\u0026rdquo; may have physical disability, or may not have been interested in this activity and therefore were excluded from analysis.\u003c/p\u003e \u003cp\u003eCaregivers evaluated 15 language comprehension abilities (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). To explore their co-occurrence, we used two common clustering methods: Unsupervised Hierarchical Cluster Analysis (UHCA) and Principal Component Analysis (PCA). Clustering techniques automatically organize abilities based on their co-occurrence. If two linguistic abilities are mediated by the same underlying mechanism, then, the breakdown of this mechanism should result in the absence of both abilities, causing them to be grouped into the same cluster. Importantly, the clustering analysis was devoid of any design or hypothesis, as the process is entirely driven by the data.\u003c/p\u003e \u003cp\u003eFigure \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eA depicts the dendrogram generated by UHCA. The height of the branches indicates the distance between clusters, which is an indicator of greater dissimilarity. As in the previous study, three clusters have inter-cluster distances that are significantly larger than the distances between subgroups. The right-most cluster includes knowing the name, responding to \u0026lsquo;No\u0026rsquo; or \u0026lsquo;Stop\u0026rsquo;, responding to praise, and following some commands (items 1 to 4 in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). This cluster is identical to the command-language-comprehension-cluster identified in the previous study of 31,845 autistic individuals with the addition of the \u0026lsquo;responds to praise\u0026rsquo; item that was not previously analyzed (Vyshedskiy et al., \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). The cluster in the middle includes understanding color and size modifiers, several modifiers in a sentence, size superlatives, and numbers (items 5 to 8 in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). This cluster is identical to the previously identified modifier-language-comprehension-cluster. The left-most cluster includes understanding of spatial prepositions, verb tenses, flexible syntax, possessive pronouns, explanations about people and situations, simple stories, and elaborate fairy tales (items 9 to 15 in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). This cluster is identical to the previously identified syntactic-language-comprehension-cluster.\u003c/p\u003e \u003cp\u003eThe PCA (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eB) also demonstrates a clear separation between the same three clusters. The command items (knowing the name, responding to \u0026lsquo;No\u0026rsquo; or \u0026lsquo;Stop\u0026rsquo;, responding to praise, and following some commands) are clustered in the top left corner. The modifier items (understanding color and size modifiers, several modifiers in a sentence, size superlatives, and numbers) are clustered in the lower middle. The syntactic items (understanding of spatial prepositions, verb tenses, flexible syntax, possessive pronouns, explanations about people and situations, simple stories, and elaborate fairy tales) are clustered in the top right corner.\u003c/p\u003e \u003cp\u003eThe three-cluster solution was stable across multiple seeds as well as consistent across different age groups (4 to 6 years of age, Figure \u003cspan refid=\"MOESM1\" class=\"InternalRef\"\u003eS1\u003c/span\u003e; 6 to 21 years of age, Figure S2;), and across different time points (first evaluation, Figure S3; last evaluation, Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eNext, we calculated UHCA and PCA of the 15 language comprehension abilities along with the \u003cem\u003edraws representationally\u003c/em\u003e item defined as a \u0026ldquo;very true\u0026rdquo; response to the query \u0026ldquo;[My child] draws a VARIETY of RECOGNIZABLE images (objects, people, animals, etc.)\u0026rdquo; (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Both UHCA and PCA grouped the \u003cem\u003edraws representationally\u003c/em\u003e item with the syntactic items indicating their common co-occurrence.\u003c/p\u003e \u003cp\u003eFurthermore, we calculated UHCA and PCA of the 15 language comprehension abilities along with the \u003cem\u003edraws to description\u003c/em\u003e item defined as a \u0026ldquo;very true\u0026rdquo; response to the query \u0026ldquo;[My child] can draw a NOVEL image following YOUR description (e.g. a three-headed horse)\u0026rdquo; (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Both UHCA and PCA grouped the \u003cem\u003edraws to description\u003c/em\u003e item with the syntactic items indicating their common co-occurrence.\u003c/p\u003e \u003cp\u003eAs a control we calculated UHCA and PCA of the 15 language comprehension abilities along with the \u003cem\u003ehyperactivity\u003c/em\u003e item, which is not expected to be related to any particular language ability and therefore should cluster into its own group. As expected, both UHCA and PCA clustered the hyperactivity item into its own group at a significant distance from the three language clusters, validating the effectiveness of both clustering techniques (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eHaving established that the representational drawing ability co-occurred with the cluster of syntactic language comprehension abilities, we aimed to assess the proportion of individuals in each language comprehension phenotype which exhibits representational drawing ability. To assign language comprehension phenotypes we utilized unsupervised hierarchical clustering analysis of all 14,279 participants (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e, the dendrogram on top). The two-dimensional heatmap clearly shows the same three language comprehension phenotypes as were identified in the previous study of participants with language deficits (Vyshedskiy et al., \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Columns represent all the 14,279 participants and rows represent the 15 linguistic abilities. \u003cem\u003eBlue\u003c/em\u003e indicates the presence of a linguistic ability (parent\u0026rsquo;s response\u0026thinsp;=\u0026thinsp;\u003cem\u003every true\u003c/em\u003e); \u003cem\u003ewhite\u003c/em\u003e indicates an intermittent presence of a linguistic ability (parent\u0026rsquo;s response\u0026thinsp;=\u0026thinsp;\u003cem\u003esomewhat true\u003c/em\u003e); and \u003cem\u003ered\u003c/em\u003e indicates the lack of a linguistic ability (parent\u0026rsquo;s response\u0026thinsp;=\u0026thinsp;\u003cem\u003enot true\u003c/em\u003e). The three clusters of participants match the three language comprehension abilities clusters. The cluster of participants termed \u0026ldquo;Syntactic Language Phenotype\u0026rdquo; shows the predominant blue color that indicated good skills across all three (syntactic, modifier, and command) language comprehension items (26.0% of participants, Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The cluster of participants marked as \u0026ldquo;Command Language Phenotype\u0026rdquo; shows the predominant blue color indicating good skills only among the command-items (18.9%). The third cluster of participants marked \u0026ldquo;Modifier Language Phenotype\u0026rdquo; shows the predominant blue color indicating good skills only across modifier- and command-items (55.2%). The three phenotypes were stable across different seeds, age groups (4 to 6 and 6 to 21 years of age, Figures S4 and S5, respectively), and time points (first and last evaluations; Figures S6 and 2, respectively).\u003c/p\u003e \u003cp\u003eThe representational drawing ability, as determined by a caregiver answering \u0026ldquo;very true\u0026rdquo; to the question \u0026ldquo;[My child] draws a VARIETY of RECOGNIZABLE images (objects, people, animals, etc.),\u0026rdquo; is indicated by short black vertical marks above the heatmap (marked Representational_drawing). Representational drawing was manifested by 54.1% of individuals with syntactic-, 27.8% of those with modifier-, and 10.1% of participants with command-phenotype (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, all pairwise differences between the phenotypes were statistically significant, t-test: \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.0001). Age did not significantly affect this distribution. Among participants of 4- to 6-years-of-age, representational drawing was manifested by 48.5% of individuals with syntactic-, 24.6% of those with modifier-, and 10.1% of those with command-phenotype (Table \u003cspan refid=\"MOESM1\" class=\"InternalRef\"\u003eS1\u003c/span\u003e, all pairwise differences between the phenotypes were statistically significant, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.0001); among participants of 6- to 21-years-of-age, representational drawing was manifested by 63.7% of individuals with syntactic-, 35.1% of those with modifier-, and 16.9% of those with command-phenotype (Table S2, all pairwise differences between the phenotypes were statistically significant, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.0001).\u003c/p\u003e \u003cp\u003eAnother question concerned with drawing-to-description ability was posed as follows: \u0026ldquo;[My child] can draw a NOVEL image following YOUR description (e.g. a three-headed horse).\u0026rdquo; The drawing-to-description ability was manifested by 34.6% of individuals with syntactic-, 7.9% of those with modifier-, and 1.9% of participants with command-phenotype (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e; all pairwise differences between the phenotypes were statistically significant, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.0001). Age did not significantly affect this distribution. Among participants of 4- to 6-years-of-age, representational drawing was manifested by 28.4% of individuals with syntactic-, 6.6% of those with modifier-, and only 1.9% of individuals with command-phenotype (Table S3, all pairwise differences between the phenotypes were statistically significant, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.0001); among participants of 6- to 21-years-of-age, representational drawing was manifested by 45.2% of individuals with syntactic-, 11.7% of those with modifier-, and 3.3% of those with command-phenotype (Table S4, all pairwise differences between the phenotypes were statistically significant, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.0001).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eParticipant cluster statistics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSyntactic Language Phenotype\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eModifier Language Phenotype\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCommand Language Phenotype\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of participants\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3711\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7875\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2693\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e14279\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePercent of Total\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e55.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e100.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge, Mean (SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.4 (2.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.4 (2.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6.3 (2.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6.4 (2.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePercent Male\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e70.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e72.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e73.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e72.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe representational drawing ability, determined by a caregiver answering \u0026ldquo;very true\u0026rdquo; to the question \u0026ldquo;[My child] draws a VARIETY of RECOGNIZABLE images (objects, people, animals, etc.).\u0026rdquo;\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSyntactic Language Phenotype\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eModifier Language Phenotype\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCommand Language Phenotype\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of participants per cluster\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3711\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7875\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2693\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e14279\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of participants with the representational drawing ability\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2007\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2185\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e272\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4464\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePercent (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e54.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e31.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe drawing-to-description ability, determined by a caregiver answering \u0026ldquo;very true\u0026rdquo; to the question \u0026ldquo;[My child] can draw a NOVEL image following YOUR description (e.g. a three-headed horse).\u0026rdquo;\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSyntactic Language Phenotype\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eModifier Language Phenotype\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCommand Language Phenotype\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of participants per cluster\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3711\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7875\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2693\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e14279\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of participants with the drawing-to-description ability\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1283\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e622\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1955\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePercent (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e34.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e13.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eRepresentational drawing and language share a profound relationship, both serving as essential tools for symbolic communication. A deficit in one symbolic ability is commonly paralleled by a deficit in another (Beyn \u0026amp; Knyazeva, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e1962\u003c/span\u003e; Levine et al., \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e1985\u003c/span\u003e; Thomas \u0026amp; Silk, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e1990\u003c/span\u003e). Autistic savants attract significant attention by often breaking the conventional connection between representational drawing and language: their extraordinary drawing abilities stand in stark contrast to their limited language skills (Pring et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2012\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eRelationships between representational drawing and language were never investigated in a large study. We recently discovered three distinct language comprehension mechanisms (command, modifier, and syntactic) and the three corresponding language comprehension phenotypes: individuals with the syntactic phenotype utilized all three mechanisms, while individuals with the modifier phenotype were restricted to the modifier and command mechanisms, and individuals with the command phenotype were confined to the command mechanism) (Vyshedskiy et al., \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). The goal of this study was to relate the representational drawing ability to language comprehension in an unprecedentedly large cohort of 39,654 autistic individuals.\u003c/p\u003e \u003cp\u003eParents reported that 36.0% of participants engaged in activities such as drawing, coloring, and art. These individuals demonstrated both an interest in and the physical ability to engage in these activities, making them the focus of this study. First, we conducted a clustering analysis of the 15 language comprehension abilities. Both unsupervised hierarchical clustering analysis (UHCA) and principal component analysis (PCA) confirmed the three distinct language comprehension mechanisms found in the previous study (Vyshedskiy et al., \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2024\u003c/span\u003e) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eNext, we conducted clustering analysis of the 15 language comprehension abilities along with the \u003cem\u003edraws representationally\u003c/em\u003e item \u0026ldquo;[My child] draws a VARIETY of RECOGNIZABLE images (objects, people, animals, etc.) (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u0026rdquo; Both UHCA and PCA grouped the \u003cem\u003edraws representationally\u003c/em\u003e item with the syntactic items indicating their common co-occurrence and therefore, suggesting that they may share a common neurological mechanism. Furthermore, we calculated UHCA and PCA of the 15 language comprehension abilities along with the \u003cem\u003edraws to description\u003c/em\u003e item \u0026ldquo;[My child] can draw a NOVEL image following YOUR description (e.g. a three-headed horse)\u0026rdquo; (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u0026rdquo; Again, both UHCA and PCA grouped the \u003cem\u003edraws to description\u003c/em\u003e item with the syntactic items indicating their common co-occurrence and therefore, suggesting that they may share a common neurological mechanism. As a control, we conducted clustering analysis of the 15 language comprehension abilities along with the \u003cem\u003ehyperactivity\u003c/em\u003e item, which is expected to have a mechanism completely unrelated to language comprehension. As anticipated, both UHCA and PCA clustered the hyperactivity item into its own group at a significant distance from the three language clusters, indicating no consistent co-occurrence between hyperactivity and language comprehension abilities (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eClustering analysis of participants confirmed the three distinct language comprehension phenotypes identified in the previous study (Vyshedskiy et al., \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2024\u003c/span\u003e) and enabled us to assess the proportion of individuals in each language comprehension phenotype who exhibit the representational drawing ability. The representational drawing ability, defined by a caregiver answering \u0026ldquo;very true\u0026rdquo; to the question \u0026ldquo;[My child] draws a VARIETY of RECOGNIZABLE images (objects, people, animals, etc.),\u0026rdquo; was manifested by 54.1% of individuals with syntactic-, 27.8% of those with modifier-, and 10.1% of participants with command-phenotype. The drawing-to-description ability, determined by a caregiver answering \u0026ldquo;very true\u0026rdquo; to the question \u0026ldquo;[My child] can draw a NOVEL image following YOUR description (e.g. a three-headed horse),\u0026rdquo; was manifested by 34.6% of individuals with syntactic-, 7.9% of those with modifier-, and 1.9% of participants with command-phenotype. The strong association between the representational drawing ability and syntactic language was observed in both examined age ranges: 4 to 6 and 6 to 21 years of age.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eOne limitation of this study is that it cannot draw conclusions on the underlying nature of differences in representational drawing ability between language phenotypes. A deeper analysis with more extended surveys is necessary for this purpose. As an example, drawing contours of some animals can be automated through repetitive training. In this case the process of drawing is similar to writing a signature. There is little pre-planning and the complete contour of an animal can appear on paper in a single move. We attempted to address the potential influence of automated drawing by emphasizing the word VARIETY in the question \u0026ldquo;My child draws a VARIETY of RECOGNIZABLE images (objects, people, animals, etc.),\u0026rdquo; but we simply do not know how many individuals in our cohort have been trained to draw automatically.\u003c/p\u003e \u003cp\u003eAnother drawing technique that we observed in autistic individuals was synthesis of elements directly on paper, rather than a mental pre-planning. Figure\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003e shows a drawing by a verbal adolescent male diagnosed with ASD. This individual has a solid modifier-language-comprehension-phenotype. He understands colors, sizes, and numbers, but does not understand spatial prepositions, verb tenses, flexible syntax, possessive pronouns, complex explanations, and fairytales. His Vineland-II IQ standard score measured annually since he was 5 years of age is around 70. He is fond of drawing cats. When he was asked to draw \u0026ldquo;a cat with three heads,\u0026rdquo; he immediately began following the instruction. He started by drawing a cat with a single head, then added one head at a time until there were three heads drawn on paper, while counting aloud and using his finger to point to each head while counting. We surmise that such synthesis on paper is somewhat analogous to performing arithmetic on paper. Just as it is easier to add two- or three-digit numbers on paper than to do so mentally, synthesis on paper simplifies complex processes by providing a visual aid.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eClinical implications\u003c/h2\u003e \u003cp\u003eDrawing holds significant therapeutic value in working with children with ASD, providing a non-verbal outlet for self-expression and communication (Schweizer et al., \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2014\u003c/span\u003e). Through drawing, therapists can engage children in meaningful communication, allowing them to express their inner worlds, preferences, and emotions visually. Artistic activities can also aid in developing fine motor skills, sensory integration, and spatial awareness, which are areas of challenge for many children with ASD. Moreover, drawing promotes relaxation and can serve as a calming activity during therapy sessions, fostering a positive therapeutic environment. By harnessing the power of drawing, therapists can enhance communication, promote emotional regulation, and support the overall development of children with ASD (Di Renzo et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). The findings of this study imply an intriguing potential for drawing interventions. If representational drawing indeed shares some neurological mechanisms with syntactic language processing, it could potentially support the acquisition of syntactic language skills. Currently, controlled randomized studies exploring representational drawing interventions are lacking. However, the results from case studies consistently align with this hypothesis (Schweizer et al., \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Servi, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Wright et al., \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2020\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eCompeting Interests\u003c/h2\u003e \u003cp\u003eAuthors declare no competing interests.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eInformed Consent\u003c/strong\u003e \u003cp\u003eCaregivers have provided informed consent to anonymized data analysis and publication of the results. The study was conducted in compliance with the Declaration of Helsinki (World Medical Association, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2013b\u003c/span\u003e).\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eCompliance with Ethical Standards\u003c/strong\u003e \u003cp\u003eUsing the Department of Health and Human Services regulations found at 45 CFR 46.101(b)(4), the Biomedical Research Alliance of New York LLC Institutional Review Board (IRB) determined that this research project is exempt from IRB oversight.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThis research received no external funding.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAV and EK designed the study. RV, EK, and AV analyzed the data. AV wrote the paper.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eWe wish to thank all participants\u0026rsquo; caregivers who found time to complete children\u0026rsquo;s assessments. The authors are very grateful to Dr. Petr Ilyinskii for his scrupulous editing of this manuscript. The language therapy app used to collect the data presented in this manuscript was made possible by the contributions of Rita Dunn, Alexander Faisman, Jonah Elgart, Lisa Lokshina, and Yulia Dumov.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eDe-identified raw data from this manuscript are available from the corresponding author upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAllen, M. L., \u0026amp; Craig, E. (2016). Brief Report: Imaginative Drawing in Children with Autism Spectrum Disorder and Learning Disabilities. Journal of Autism and Developmental Disorders, \u003cem\u003e46\u003c/em\u003e(2), 704\u0026ndash;712. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s10803-015-2599-y\u003c/span\u003e\u003cspan address=\"10.1007/s10803-015-2599-y\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eArnold, M., \u0026amp; Vyshedskiy, A. (2022). Combinatorial language parent-report score differs significantly between typically developing children and those with Autism Spectrum Disorders. Journal of Autism and Developmental Disorders. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org//10.1007/s10803-022-05769-8\u003c/span\u003e\u003cspan address=\"/10.1007/s10803-022-05769-8\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBaron-Cohen, S. (1997). \u003cem\u003eMindblindness: An essay on autism and theory of mind\u003c/em\u003e. MIT press. https://books.google.com/books?hl=en\u0026amp;lr=\u0026amp;id=MDbcNu9zYZAC\u0026amp;oi=fnd\u0026amp;pg=PR9\u0026amp;dq=mindblindness+theory\u0026amp;ots=ZAYIvBXAbF\u0026amp;sig=F57BVzplBEnvKODMSMTvWNiJnIw\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBeyn, E. S., \u0026amp; Knyazeva, G. R. (1962). The problem of prosopagnosia. Journal of Neurology, Neurosurgery, and Psychiatry, \u003cem\u003e25\u003c/em\u003e(2), 154.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBishop, D. V. M. (2005). Test for reception of grammar\u0026mdash;Electronic. \u003cem\u003eLondon\u003c/em\u003e: \u003cem\u003ePsychological Corporation\u003c/em\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBraverman, J., Dunn, R., \u0026amp; Vyshedskiy, A. (2018a). Development of the Mental Synthesis Evaluation Checklist (MSEC): A Parent-Report Tool for Mental Synthesis Ability Assessment in Children with Language Delay. Children, \u003cem\u003e5\u003c/em\u003e(5), Article 5. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3390/children5050062\u003c/span\u003e\u003cspan address=\"10.3390/children5050062\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBraverman, J., Dunn, R., \u0026amp; Vyshedskiy, A. (2018b). Development of the Mental Synthesis Evaluation Checklist (MSEC): A Parent-Report Tool for Mental Synthesis Ability Assessment in Children with Language Delay. Children, \u003cem\u003e5\u003c/em\u003e(5), 62. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3390/children5050062\u003c/span\u003e\u003cspan address=\"10.3390/children5050062\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCraig, J., Baron-Cohen, S., \u0026amp; Scott, F. (2001). Drawing ability in autism: A window into the imagination. Israel Journal of Psychiatry, \u003cem\u003e38\u003c/em\u003e(3\u0026ndash;4), 242\u0026ndash;253.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDi Renzo, M., Marini, C., Bianchi di Castelbianco, F., Racinaro, L., \u0026amp; Rea, M. (2017). Correlations between the drawing process in autistic children and developmental indexes. Journal of Psychology \u0026amp; Psychotherapy, \u003cem\u003e7\u003c/em\u003e(2), 1\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDunn, R., Elgart, J., Lokshina, L., Faisman, A., Khokhlovich, E., Gankin, Y., \u0026amp; Vyshedskiy, A. (2017a). Children With Autism Appear To Benefit From Parent-Administered Computerized Cognitive And Language Exercises Independent Of the Child\u0026rsquo;s Age Or Autism Severity. Autism Open Access, \u003cem\u003e7\u003c/em\u003e(217). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.4172/2165-7890.1000217\u003c/span\u003e\u003cspan address=\"10.4172/2165-7890.1000217\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDunn, R., Elgart, J., Lokshina, L., Faisman, A., Khokhlovich, E., Gankin, Y., \u0026amp; Vyshedskiy, A. (2017b). Comparison of performance on verbal and nonverbal multiple-cue responding tasks in children with ASD. Autism Open Access, \u003cem\u003e7\u003c/em\u003e, 218. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.4172/2165-7890.1000218\u003c/span\u003e\u003cspan address=\"10.4172/2165-7890.1000218\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDunn, R., Elgart, J., Lokshina, L., Faisman, A., Waslick, M., Gankin, Y., \u0026amp; Vyshedskiy, A. (2017). Tablet-Based Cognitive Exercises as an Early Parent-Administered Intervention Tool for Toddlers with Autism\u0026mdash;Evidence from a Field Study. Clinical Psychiatry, \u003cem\u003e3\u003c/em\u003e(1). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.21767/2471-9854.100037\u003c/span\u003e\u003cspan address=\"10.21767/2471-9854.100037\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eForman, P., Khokhlovich, E., \u0026amp; Vyshedskiy, A. (2022). Longitudinal Developmental Trajectories in Young Autistic Children Presenting with Seizures, Compared to those Presenting without Seizures, Gathered via Parent-report Using a Mobile Application. Journal of Developmental and Physical Disabilities. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s10882-022-09851-y\u003c/span\u003e\u003cspan address=\"10.1007/s10882-022-09851-y\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFreeman, N. H. (1993). \u003cem\u003eDrawing: Public instruments of representation.\u003c/em\u003e \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://psycnet.apa.org/record/1993-97468-006\u003c/span\u003e\u003cspan address=\"https://psycnet.apa.org/record/1993-97468-006\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGolomb, C. (2003). \u003cem\u003eThe child\u0026rsquo;s creation of a pictorial world\u003c/em\u003e. Psychology Press. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.taylorfrancis.com/books/mono/10.4324/9781410609250/child-creation-pictorial-world-claire-golomb\u003c/span\u003e\u003cspan address=\"https://www.taylorfrancis.com/books/mono/10.4324/9781410609250/child-creation-pictorial-world-claire-golomb\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJagadeesan, P., Kabbani, A., \u0026amp; Vyshedskiy, A. (2022). Parent-reported assessment scores reflect ASD severity level in 2- to 7- year-old children. Children, \u003cem\u003e9\u003c/em\u003e(5), 701. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/doi.org/10.3390/children9050701\u003c/span\u003e\u003cspan address=\"10.3390/children9050701\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKrampen, M. (2013). \u003cem\u003eChildren\u0026rsquo;s drawings: Iconic coding of the environment\u003c/em\u003e. Springer Science \u0026amp; Business Media. https://books.google.com/books?hl=en\u0026amp;lr=\u0026amp;id=zk_7AwAAQBAJ\u0026amp;oi=fnd\u0026amp;pg=PA3\u0026amp;dq=Children%E2%80%99s+drawings:+Iconic+coding+of+the+environment.\u0026amp;ots=0hw-8cerqX\u0026amp;sig=DCdM9ICf5mbjFbago6r4-bLmmtg\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLeevers, H. J., \u0026amp; Harris, P. L. (1998). Drawing impossible entities: A measure of the imagination in children with autism, children with learning disabilities, and normal 4-year-olds. The Journal of Child Psychology and Psychiatry and Allied Disciplines, \u003cem\u003e39\u003c/em\u003e(3), 399\u0026ndash;410.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLevin, J., Khokhlovich, E., \u0026amp; Vyshedskiy, A. (2022). Longitudinal developmental trajectories in young autistic children presenting with sleep problems, compared to those presenting without sleep problems, gathered via parent-report using a mobile application. Research in Autism Spectrum Disorders, \u003cem\u003e97\u003c/em\u003e, 102024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLevine, D. N., Warach, J., \u0026amp; Farah, M. (1985). Two visual systems in mental imagery: Dissociation of \u0026ldquo;what\u0026rdquo; and \u0026ldquo;where\u0026rdquo; in imagery disorders due to bilateral posterior cerebral lesions. Neurology, \u003cem\u003e35\u003c/em\u003e(7), Article 7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLow, J., Goddard, E., \u0026amp; Melser, J. (2009). Generativity and imagination in autism spectrum disorder: Evidence from individual differences in children\u0026rsquo;s impossible entity drawings. British Journal of Developmental Psychology, \u003cem\u003e27\u003c/em\u003e(2), 425\u0026ndash;444. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1348/026151008X334728\u003c/span\u003e\u003cspan address=\"10.1348/026151008X334728\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePring, L., Ryder, N., Crane, L., \u0026amp; Hermelin, B. (2012). Creativity in savant artists with autism. Autism, \u003cem\u003e16\u003c/em\u003e(1), 45\u0026ndash;57. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/1362361311403783\u003c/span\u003e\u003cspan address=\"10.1177/1362361311403783\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRimland, B., \u0026amp; Edelson, S. M. (1999a). Autism treatment evaluation checklist (ATEC). \u003cem\u003eAutism Research Institute, San Diego, CA\u003c/em\u003e. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://www.autism.com\u003c/span\u003e\u003cspan address=\"http://www.autism.com\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRimland, B., \u0026amp; Edelson, S. M. (1999b). Autism treatment evaluation checklist (ATEC). \u003cem\u003eAutism Research Institute, San Diego, CA\u003c/em\u003e. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://www.autism.com\u003c/span\u003e\u003cspan address=\"http://www.autism.com\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchweizer, C., Knorth, E. J., \u0026amp; Spreen, M. (2014). Art therapy with children with Autism Spectrum Disorders: A review of clinical case descriptions on \u0026lsquo;what works.\u0026rsquo; The Arts in Psychotherapy, \u003cem\u003e41\u003c/em\u003e(5), 577\u0026ndash;593.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eScott, F. J., \u0026amp; Baron-Cohen, S. (1996). Imagining real and unreal things: Evidence of a dissociation in autism. Journal of Cognitive Neuroscience, \u003cem\u003e8\u003c/em\u003e(4), 371\u0026ndash;382.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eServi, C. (2024). Language and drawing development after a combined intervention: A single-subject case study. British Journal of Special Education, \u003cem\u003e51\u003c/em\u003e(1), 35\u0026ndash;49. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/1467-8578.12496\u003c/span\u003e\u003cspan address=\"10.1111/1467-8578.12496\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eThomas, G. V., \u0026amp; Silk, A. M. (1990). \u003cem\u003eAn introduction to the psychology of children\u0026rsquo;s drawings\u003c/em\u003e. New York University Press. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://psycnet.apa.org/record/1990-97551-000\u003c/span\u003e\u003cspan address=\"https://psycnet.apa.org/record/1990-97551-000\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVyshedskiy, A., \u0026amp; Dunn, R. (2015). Mental Imagery Therapy for Autism (MITA)-An Early Intervention Computerized Brain Training Program for Children with ASD. Autism Open Access, \u003cem\u003e5\u003c/em\u003e(1000153), 2.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVyshedskiy, A., Khokhlovich, E., Dunn, R., Faisman, A., Elgart, J., Lokshina, L., Gankin, Y., Ostrovsky, S., deTorres, L., \u0026amp; Edelson, S. M. (2020). Novel prefrontal synthesis intervention improves language in children with autism. Healthcare, \u003cem\u003e8\u003c/em\u003e(4), 566. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/doi.org/10.3390/healthcare8040566\u003c/span\u003e\u003cspan address=\"10.3390/healthcare8040566\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVyshedskiy, A., Venkatesh, R., \u0026amp; Khokhlovich, E. (2024). Are there distinct levels of language comprehension in autistic individuals \u0026ndash; cluster analysis. Npj Mental Health Research, \u003cem\u003e3\u003c/em\u003e(19). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1038/s44184-024-00062-1\u003c/span\u003e\u003cspan address=\"10.1038/s44184-024-00062-1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Medical Association. (2013a). World Medical Association Declaration of Helsinki: Ethical principles for medical research involving human subjects. JAMA, \u003cem\u003e310\u003c/em\u003e(20), Article 20.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Medical Association. (2013b). World Medical Association Declaration of Helsinki: Ethical principles for medical research involving human subjects. JAMA, \u003cem\u003e310\u003c/em\u003e(20), 2191\u0026ndash;2194.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWright, B. M., Benigno, J. P., Boster, J. B., McCarthy, J. W., \u0026amp; Coologhan, B. K. (2020). \u0026ldquo;Tell Me About Your Picture\u0026rdquo;: Using Drawings to Support Expressive Language in Children With Autism Spectrum Disorder. Communication Disorders Quarterly, \u003cem\u003e42\u003c/em\u003e(1), 3\u0026ndash;11. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/1525740119868440\u003c/span\u003e\u003cspan address=\"10.1177/1525740119868440\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"representational drawing, figurative drawing, syntactic language, patholinguistics","lastPublishedDoi":"10.21203/rs.3.rs-4909075/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4909075/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eThe relationship between symbolic thinking and language abilities is a topic of intense debate. We have recently identified three distinct language comprehension phenotypes: command, modifier and syntactic (Vyshedskiy et al., \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Individuals in the \u003cem\u003ecommand\u003c/em\u003e phenotype were limited to comprehension of simple commands, while those in the \u003cem\u003emodifier\u003c/em\u003e phenotype showed additional comprehension of color, size, and number modifiers. Finally, individuals in the most-advanced \u003cem\u003esyntactic\u003c/em\u003e phenotype added comprehension of spatial prepositions, verb tenses, flexible syntax, possessive pronouns, complex explanations, and fairytales. In this report we analyzed how these three language phenotypes differed in their symbolic thinking as evidenced by their drawing abilities. In a cohort of 39,654 autistic individuals 4- to 21-years-of-age, parents reported that \u0026lsquo;drawing, coloring and art\u0026rsquo; was manifested by 36.0% of participants. Among these individuals, representational drawing was manifested by 54.1% of individuals with syntactic-phenotype, 27.7% of those with modifier-phenotype, and 10.1% of those with command-phenotype (all pairwise differences between the phenotypes were statistically significant, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.0001). The ability to draw a novel image per parent\u0026rsquo;s description (e.g. a three-headed horse) was reported by 34.6% of individuals with syntactic-phenotype, 7.9% of those with modifier- phenotype, and 1.9% of individuals with command-phenotype (all pairwise differences between the phenotypes were statistically significant, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.0001). These results demonstrate strong association between representational drawing ability and the syntactic-language-comprehension-phenotype, suggesting a potential benefit of drawing interventions in language therapy.\u003c/p\u003e","manuscriptTitle":"Representational drawing ability is associated with the syntactic language comprehension phenotype in autistic individuals","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-10-15 07:35:56","doi":"10.21203/rs.3.rs-4909075/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"3d231ea9-7263-409a-afe3-6c44ee79f666","owner":[],"postedDate":"October 15th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-11-21T05:54:42+00:00","versionOfRecord":[],"versionCreatedAt":"2024-10-15 07:35:56","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4909075","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4909075","identity":"rs-4909075","version":["v1"]},"buildId":"7rjqhiLT3MXkJMwkYKINL","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}