Intervention

1. Modified picture based communication- we use a modified picture based communication to communicate the needs of young ASD children. Initially we started with statements requiring a “YES” or “NO” answer. After two weeks we progressed the words selection to 5 words, Mickey Mouse, lollipop, sticker, play, books. These identified the rewards for intervention. Over a 4 month period, the 4 y.o. child is now able to retrieve over 20 words.

2. Modified natural language- using a Leap Frog device (purchased at yard sale) to place letter puzzle pieces into a frame, the individual is able to work on letter recognition, sounds, colors and sequencing. We remove the letters for simple word formation (cat, tub and hat). Each letter is a different color and only fits into a predetermined area on the board. There are removable cards for word formation and sentence completion.

3. Understanding Facial Expressions- knowing this population struggles with recognition of faces and interpreting facial expressions as well as imitating skills during communication. Try using the Silly Faces by Colorform and Mr Potato Head to practice these skills. The Silly Faces can be placed on a mirror (proprioception and biofeedback techniques related to posture) and try configuring various expressions (happy, sad, surprised, etc) and the individual can improve self awareness and eye gaze tasks for social interactions. The silly faces pieces can be removed individually, and have the child practice reproducing the expression or missing piece. The Mr. Potato Head game can work on fine motor skills, top-down sequencing tasks, and also categorization.

4. Alternating Attention- ASD children often struggle with attention and alternating attention between tasks with regulating interference. One intervention tool we are beginning to use is first recognize this as a weakness in the child. We then create interference during their treatment session and see how they respond. For example, if the child is in the private treatment room, we ask a therapist that we know the child is comfortable around to simply knock on the door during our treatment and come in and sit down. We are looking to see if the child stays focused on his task, or how he acknowledges the presence of someone else. There are many ways to create interference, and it is individual specific how they react. Our goal is teach the child coping skills, or behavioral patterns to effectively filter the interference.

Speech Facilitation

The following several functional communication techniques have been used effectively to increase communication in autistic individuals as well as other language impaired individuals. A web link has been pasted as well for more information.

PROMPT: Prompts for Restructuring Oral Muscular Phonetic Targets- teaching oral motor placement to produce proper sounds. This speech production technique was created in the late 1970’s developing individual treatment programs that teach motor skills, cognitive skills and social interaction- more holistic. PROMPT uses a tactile-sensitive approach to improve language skills. The PROMPT institute is a nonprofit organization, based in Sante Fe, NM. http://www.promptinstitute.com/

NSOME: Nonspeech Oral Motor Skills- technique that uses that uses sensory stimulation and muscle actions as interventions to produce verbal sounds. This technique uses exercises such as tongue push ups, blowing kisses, tongue curling and pucker smiling to improve or strengthen tongue, lateralization, jaw stabilization and sucking abilities (Gooch 2009).

Gooch, J. L. 2009 Non-Speech Oral Motor Exercises Are They Effective? ASHA Conference. http://www.showmemsha.org/handouts/Session%20C3.pdf

PECS: Picture Exchange Communication System- developed in 1985 this alternative communication technique is directed at improving initiation of communication skills. PECS is relatively inexpensive to use and implement- involves the use or exchange picture cards to express wants/needs. The subject is able to initiate communication by identifying the card (needs/wants) and providing it to parent/caregiver. Cards can have pictures (lower functioning) or words (higher functioning) and can be used alone, or to complete a statement. Abstract reasoning is often impaired in ASD children whereas the use of cards offers more concrete cueing for initiating communication.
www.pecs.com
autism.healingthresholds.com/therapy/picture-exchange-communication-s
http://www.grocerypecs.com/

U.S.E. I.T.: Using Symbols Everyday In Teaching is computer program that uses symbols or pictures to increase communication skills. Similar to other programs which use pictures to discuss daily interactions, engage in conversations and improve general communication skills. Mayer-Johnson Picture Communication Symbols.
www.mayer-johnson.com/ProdDesc.aspx?SKU=M1MJ146

Natural Aided Language: another alternative communication strategy using pictures or words on a specific language board or technology device for increasing communication skills. Individuals touch a picture or word and say it aloud for receptive learning. This board is used by everyone in the ASD individuals life- family, peers, caregivers to offer the most natural experience. Symbols for this board are from Mayer-Johnson Picture Communication Symbols (above).
http://www.positive-action.net/autism/communication.htm

Practice of Tasks To Promote Speech

Motor impairments of ASD individuals include gross motor patterns, proprioception, fine motor coordination, coordination, and initiation tasks. Mass et al. (2008) recognized the significance of neuroplasticity in the human brain and the impact that repeated behavioral intervention on ASD individuals could improve gross motor skills and also verbal motor skills. Motor learning needs to be more than an enhancement in performance- it needs to be an improved capability or skill that is retained over time (p. 278). This is called retention. When this improved behavior is retained and transferred to a new task, the process is called generalization. Motor movements and speech need to be generalized to better prepare individuals for social interactions. The authors identified two types of practice for generalization:

Random practice: different movements produced on successive trials, with unpredictable target
Blocked practice: practicing the same movement before advancing. Boundaries are identifiable beginning and end

Discrete-Trial Training (DTT) is systematic reinforcement pattern- providing multiple attempts to respond to a stimulus (Miller-Kuhaneck 2004). Using tasks analysis, behavioral skills are broken down and practiced in a predictable way. Reinforcement and prompting are more frequently offered than with random practice. While random skills do promote generalization, there is also a place for blocked trials. Blocked trials help ASD individuals enhance their performance in certain areas, however are not as successful at promoting generalization. More simply put, blocked trials will help a child learn a particular skill, but random practice will promote a learned behavior.

Surprisingly, ASD individuals are better able to generalize motor movements from random practice with continuous trials (Mass et al.) These individuals are better able to sequence their movements from retention using delayed feedback.
Two treatment activities to promote motor learning would be:
A child that is experiencing difficulty with bathroom ADL’s (brushing teeth, combing hair, washing hands). Using a behavioral approach, we would begin with pictures and categorization skills. Place two contrasting color mats on table (blue bathroom and yellow kitchen). Have child categorize pictures of 5 toothbrushes and 5 dinner plates into appropriate color mats. Blocked trials would be to place 5 toothbrush pictures onto the blue mat, then 5 dinner plate pictures onto the yellow mat. Progress to placing actual toothbrushes and plates on the mats in same sequence. Progress this to more randomized trials placing toothbrushes and plates onto the mats in no sequential order. Progress to having the child place the actual toothbrush in bathroom and plate on kitchen table. If the child is successfully able to perform this task then proceed to having try brushing his teeth (granted it is not a sensory issue). If the behavior is not learned, then try blocked trial of 5 toothbrushes in bathroom, 5 dinner plates on kitchen table. You may even have to place the color mats in designated areas.

Maas, E., Robin, D. A., Austermann Hula, S. N., Wulf, G., Ballard, K., Schmidt, R. Principles of Motor Learning in Treatment of Motor Speech Disorders. American Journal of Speech-Language Pathology. 2008. Vol. 17. 277-298

Motor Skills Effecting Verbal Language

Children with ASD struggle from many communication deficits, including language and motor impairments identified through difficulty with interpreting facial expressions and even more so with voice processing abilities. Couple this with the known fact that ASD children also struggle with imitation skills and the ability to reproduce facial expressions and sounds from early infancy which are necessary for later development of speech (Boucher et al. 2000). Speech production is more than a motor deficit and it has been suggested that “language impairments and behavioral/psychiatric problems may arise from, neurological immaturity or limited processing capability” (p. 854). Individuals struggle with auditory processing from comprehension and retaining information to actual retrieval of words (autismsociety .org).

Phonation is identified as vocal quality, and many ASD children produce syllables with atypical phonation (Volkman et al. 2005). A study by Sheinkopf et al (2000) also identified that ASD children did not have “difficulty with expression of well-formed syllables (canonical babbling) but did demonstrate atypical phonations. These same individuals also exhibit poor joint attention behaviors (p. 345). These behaviors include lack of eye contact, lack of eye gaze, more hand over hand direction. ASD individuals struggle with initiation tasks, imitation ability, hand-finger tasks, diadochokinesis and gross motor movements secondary to required increased processing time and decreased reaction time (Frietag et al. 2008). Respiration rates can be altered as ASD individuals experience greater anxiety in social-communication activities. The rise and fall of pitch can also be affected. Articulation is somewhat slower in ASD children, and commonly struggle with /r/, /l/ pronunciations (Volkman et al. 2005).

Collectively these behaviors effect speech prosody and can alter the meaning of conversation in an ASD individual. Pragmatics has been identified earlier in thsi blog and is also essential for communication styles. The tone or pitch may not be what was intended and can offer a command, when the intent was a question. The impaired gesture comprehension can inhibit the social reading of verbal exchange in conversations. Lack of intonation can yield a robot-like voice. Failure to maintain eye gaze and comprehend facial expressions can also alter verbal productions.

References

Frietag, C., Konrad, C., Haberlen, M., Kleser, C., von Gontard, A., Reith, W., Troje, N., & Krick, C. Perception of Biological Motion in Autism Spectrum Disorders. (2008). Article in press. neuropsychologia

Sheinkopf,S.J., Mundy,P.; Oller,D.K., Steffens,M. Vocal Atypicalities of Preverbal Autistic Children. 2000, J.Autism Dev.Disord.,30, 4, 345-354

Volkman, F., Paul, R., Klin, Cohen, D. 2005. A.,Handbook of Autism and Pervasive Developmental Disorders. 3rd ed. John Wiley and Sons

Word Finding

Common word finding problems in ASD children include:

Phonological error where only part of the word is produced- “key” for “hockey”

Hand over hand guiding you to the object they want

tantrums when the item of focus is not realized

excess response time during conversations

use of fillers “umm..uh…out of, ya’ know… in place of appropriate words

tip of the tongue phenomena

Measurements of early development of language skills as a predictor of later verbal skills and social-adaptive behavior in ASD children has been widely researched (Venter et al. 1992). McDuffie et al. (2005) completed a study to identify the predictive model of vocabulary comprehension and production in ASD children. They hypothesized 4 prelinguistic behaviors as predictors for language development; attention following, motor imitation, commenting, and requesting. Their result identified commenting was predictor of comprehension, but both commenting and motor imitation without objects as predictors of language production (p. 1090). It has been suggested that increasing the behavior patterns in ASD children to better indentify their attention will in turn be supportive of verbal learning skills. As clinicians, we need to understand the word learning process. We understand the many social interactions a child has allows them to reference or ‘test’ different sound productions and gestures. Academically this is identified as triadic interaction- the ability to coordinate attention between a social partner and object or event (joint attention). Through triadic interactions, children are able to comprehend behaviors of eye gaze, affect and gestures (Mundy & Markus, 1997 as cited in McDuffie et a. 2005). Knowing that ASD children have deficits in joint attention or triadic interactions, it can be concluded they will also struggle with language skills.
Attention Following- ability to change one’s head/eyes in response to adult focus. ASD individuals who are not able to correctly/accurately identify the object of attention will struggle with word-object association.
Commenting-(initiating behavior regulation) social approach behavior involving expression of shared positive affect or interest
Requesting- (initiating joint attention) the ability to express a need or want of a certain object or behavior
Motor Imitation-

a. cognitive mechanism for learning socially constructed behaviors *
b. index of the child’s understanding of others’ intentional action **
c. system for communicating shared understanding between social partners ***

Motor imitation of children can be best observed through play and symbolic play (without objects). Symbolic play has been identified as directly related to comprehension and language production skills in ASD children. Word finding difficulties in ASD children include increased processing/response time, semantics, phonology, poor word retrieval, and semantics errors from failure to target the correct phonological representation (Messer et al. 2006).

One treatment strategy would be to to use the “I SPY” to pick out simple items in the room. This would also increase joint attention skills.


Messer, D., Dockrell, J., (2006). Children’s Naming and Word Finding Difficulties: Descriptions and Explanations. Journal of Speech, Hearing and Language Research Vol 49. 309-324. April 2006
McDuffie, A., Yoder, P., Stone, W., (2005). Prelinguistic Predictors of Vocabulary in Young Children With Autism Spectrum Disorders. Journal of Speech, Language, and Hearing 1080 Research Vol. 48. 1080–1097. October 2005

*Bates, E., Thal, D., Whitesell, K., Fenson, L., & Oakes, L. (1989). Integrating language and gesture in infancy.
Developmental Psychology, 25, 1004–1019.
Piaget, J. (1962). Play, dreams, and imitation in childhood. New York: Norton.

Uzgiris, I. (1999). Imitation as activity: its developmental aspects. In J. Nadel & G. Butterworth (Eds.), Imitation in infancy (pp. 186- 206). Cambridge, UK: Cambridge University Press.

**Carpenter, M., Akhtar, N., & Tomasello, M. (1998). Fourteen through 18-month-old infants differentially imitate intentional and accidental actions. Infant Behavior and Development, 21, 315–330.
Carpenter, M., Nagell, K., & Tomasello, M. (1998). Social cognition, joint attention and communicative competence from 9 to 15 months of age. Monographs of the Society for Research in Child Development, 63(4), Serial No. 255.

Meltzoff, A. (1995). Understanding the intentions of other: Re-enactment of intended acts by 18-month-old children. Developmental Psychology, 31, 839–850.

***Nadel, J. (2002). Imitation and imitation recognition: Functional use in preverbal infants and nonverbal children with autism. In A. Meltzoff & W. Prinz (Eds.), The imitative mind: Development, evolution, and brain bases. Cambridge studies in cognitive perceptual development (pp. 42–62). New York: Cambridge University Press.

Nadel, J., Guerini, C., Peze, A., & Rivet, C. (1999). The evolving nature of imitation as a format for communication. In J. Nadel & G. Butterworth (Eds.), Imitation in infancy (pp. 209–233). Cambridge, UK: Cambridge University Press.

Uzgiris, I. (1981). Two functions of imitation during infancy. International Journal of Behavioral Development, 4, 1–12.

Word Finding

Word problem difficulties in ASD individuals show roots in to executive functioning tasks including motor planning, mental planning problem solving and organizing ideas (Geffner 2007). When verbal skills are lacking, the ASD child can be observed taking a parents/caregivers hand to direct their attention to an object. Typical pragmatic issues are also relevant to the social impact of verbal communication, and make communication more challenging. ”Variability in expressive language for children with ASD is considerable and puzzling” (Watson et al. 2008). Imitation and echolalia are two learning behaviors that are often experienced when working with these individuals. It is known that ASD individuals sill struggle with verbal skills while others develop a profound vocabulary base. The reasons for this remain unknown. Watson & Flippin (2008) completed a language study of ASD individuals, identifying that early verbal and cognitive skills are indicative of future language skills. A great deal of reseach has been completed on joint attention and the deficits illustrated by ASD children. Joint attention can be explained as the ability to have another person attend to an object or item without using verbal language. For example: a child and his parent are in a social event in the community, and the audience is quiet. The parent was trying to call his son’s attention to someone in the crowd with an orange coat. The parent looked at the orange coat, then to his son, and back to the coat without verbal exchange. The 2 yr old son then looked at the orange coat and back to his father and smiled. This is joint attention, and the early development (usually 18-24 months) is essential to later language development. This attention will be one component related to performance in social conversation.

Kasari et al. (2008) completed a research project on language outcomes in autistic children with 12 month follow up. Fifty eight children between ages 3 and 4 yrs and randomized to joint attention (JA) task; symbolic play (SP) task or control group. Daily interventions were completed for 30 min sessions over a period of 5-6 weeks. It was concluded that symbolic play and joint attention activities are able to increase expressive language skills
In autistic children (p.136). Joint attention tasks demonstrated a greater outcome than symbolic play in developing sophisticated language skills.

Early intervention should be directed at joint attention and imitation tasks to better develop language skills. Children learn through play, particularly in motivating tasks that drives them to succeed. When choosing a task, the therapist should select objects that are of interest to the child, using a family centered approach.


Geffner, D. Managing Executive Function Disorders. ASHS Conference. St. John’s University. PPT 2007. ASHA.org
Kasari, C.; Paparella, T.; Freeman, S.; Jahromi, L. B.; Language Outcome in Autism: Randomized Comparison of Joint Attention and Play Interventions, 2008, 76, 1, 125-137, Journal of Consulting and Clinical Psychology
Watson, L R. & Flippin, M. (2008, May 27). Language outcomes for young children with autism spectrum disorders. The ASHA Leader, 13(7), 8-12.

Profiles of Language and Communication Skills in Autism

Wilkinson (1998) identifies a form/function dissociation of individuals with relation to communication in which deficits are realized in ability to apply language form to functional communication. She further identifies four interrelated systems of linguistic communication that ASD children struggle with (p.73):

Pragmatics- the social aspect of language such as body language and eye gaze in conjunction with appropriate verbal use.

Semantics- rules that govern word meanings and concepts

Phonology- rules that govern production of speech sounds (pronunciation/articulation)
Prosody- intonation, rhythm, stress

Syntax- rules that govern how words are put together to form sentences

Each system above is thought to develop in an interrelated way and in congruent fashion. However it ASD individuals are often assessed with difficulty in one or multiple of the 4 areas. Some autistic individuals develop with mutism (Lord & Paul, 1997 as cited in Shriberg, et al 2001) while some others develop more advanced verbal skills with functional communicating skills as seen with Asperger’s Syndrome (Miller-Kuhaneck, 2004; Mirenda, 2006).

Pragmatics: pragmatics is the social aspect of language that includes “eye gaze, gesture and social smiling along with skills of turn taking, choice of topic and relevance of contributions to conversation” (Wilkinson p.74). The concept of joint attention can be observed where there is an impaired ability of attention and intentional behaviors such as pointing and gestures used in social interactions. Pragmatic challenges are also witnessed in speech based conversations through turn taking, echolalia and relevant topics in a discussion (Miller-Kuhaneck, 2004; Wilkinson 1998).

Semantics: defined as unusual word use pattern with increased frequency of neologisms, echolalia and use of made up words. Semantics can often be delayed language skills seen in ASD children, however it can also be due in part to impaired pragmatics and joint attention (Wilkinson, p. 75). The delayed learned vocabulary skills can further challenge the conceptual and symbolic language and the relating it to functional communication.

Phonology: can be observed when looking at the prosody aspect of communication, or the intonation, stress and pitch. Some individuals struggle modulating rhythm or volume, while others with ASD have no deficits. More commonly, this can be observed with monotone or robot speech, or range from baby soft tone to very loud speech. The patterns vary to each individual, but are one avenue for further research. This research article also suggested that as language skills increase with alter development, prosody remains a continuous challenge.

Syntax: syntax itself is not impaired in ASD individuals, but rather features of communication such as pronoun reversal, echolalia, and pragmatics. Pronoun reversal (saying ‘you’ for ‘me’ and vice versa) is more evident in social conversation with the shifting of referents (p. 76) as compared to individual talk-applying formal skill to functional communication (Shriberg, et al 2001).

An impairment of language skills is evident from the form and function perspective. ASD individuals have intact functions of form (eye gaze, gesture), but struggle with the transition to functional communication in social situations. Individuals struggling with the most basic forms of communication may demonstrate the typical behavior often associated with ASD as coping strategies (outbursts, tantrums, hand flapping, withdrawal, etc).

The intensive early intervention approach strategy, with child initiated social goals would be most productive for the child. The child is able to identify the motivational factors that will drive his performance and offer him the best chance for success (Lynch, PPD 2009). The intervention could use a profiling approach to identify the weakness in the 4 systems described above to guide interventions.

Wilkinson, K. M. Profiles of Language and Communication Skills in Autism Mental Retardation and Developmental Disabilities 4: 73-79 (1998)