Autism Spectrum Disorder: Intervention

Autism Spectrum Autism Spectrum Disorder:Disorder:

InterventionInterventionThomas Layton, Ph.D., CCC-SLPThomas Layton, Ph.D., CCC-SLP

Grace Hao, Ph.D., M.D., CCC-SLPGrace Hao, Ph.D., M.D., CCC-SLP

North Carolina Central UniversityNorth Carolina Central University

How much do you know about How much do you know about Autism?Autism?

Is everyone with autism the Is everyone with autism the samesame?? Is Autism an Is Autism an emotionalemotional disorder? disorder? Is Autism a Is Autism a rarerare disorder? disorder? Does Autism only affect Does Autism only affect childrenchildren?? Is it the case that people with autism do not Is it the case that people with autism do not likelike

other people?other people? Is it true that all children with autism have Is it true that all children with autism have

special special giftsgifts?? Is Autism a Is Autism a life-longlife-long difficulty that can not be difficulty that can not be

helped?helped?

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Autism Spectrum Disorders Autism Spectrum Disorders Basic GroundworkBasic Groundwork

Neuro-Neuro-

developmental developmental

disabilitydisability

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Autism Spectrum Disorders Autism Spectrum Disorders Basic GroundworkBasic Groundwork

PrevalencePrevalence 3-5/10,000 (70s); CDC:1/150 (2007)3-5/10,000 (70s); CDC:1/150 (2007)

Gender differences: 4-5 boys/girlGender differences: 4-5 boys/girl Spectrum disorderSpectrum disorder

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Diagnostic criteria (DSM-IV-TR)Diagnostic criteria (DSM-IV-TR)

Qualitative impairment in Qualitative impairment in socialsocial interaction interaction Qualitative impairment in Qualitative impairment in communicationcommunication Repetitive and Repetitive and restrictedrestricted behavior, behavior,

interests, and activitiesinterests, and activities

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ASD

Social InteractionImpairment

CommunicationImpairment

Repetitive & restricted behavior, interests,

& activities

Social interactionBehavioral/emotional

management

Speech, language, and hearing

Learning Difficulty Feeding Deficits

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Qualitative impairment in Qualitative impairment in social interactionsocial interaction

Impairment in social reciprocity, as seen Impairment in social reciprocity, as seen in:in:• NonverbalNonverbal behaviors behaviors• PeerPeer relationships relationships• Spontaneous Spontaneous sharingsharing• Lack of social or emotional Lack of social or emotional reciprocityreciprocity• Poor emotional Poor emotional regulationregulation

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Qualitative impairment in Qualitative impairment in communicationcommunication

Delay in, or lack of, development of Delay in, or lack of, development of spokenspoken language language

Impairment in Impairment in conversationconversation StereotypedStereotyped language language No or limited make-believe No or limited make-believe playplay

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Restricted repetitive behavior Restricted repetitive behavior interests, and activitiesinterests, and activities

Encompassing Encompassing preoccupationpreoccupation InflexibleInflexible routines routines StereotypedStereotyped motor mannerism motor mannerism PreoccupationPreoccupation with parts of objects with parts of objects

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LanguageLanguage Subgroup:Subgroup:Generalized Low PerformanceGeneralized Low Performance

Low in language Low in language comprehensioncomprehension and and productionproduction

Comprehension somewhat Comprehension somewhat betterbetter than than productionproduction

Poor oral and motor Poor oral and motor imitationimitation Mostly Mostly nonverbalnonverbal Progress in treatment is Progress in treatment is slowslow in all in all

modesmodes

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Language Subgroup: Verbal Language Subgroup: Verbal ImitatorsImitators

BetterBetter comprehension than production comprehension than production Performance in language skills good Performance in language skills good

until until 30 months30 months than drop off rapidly than drop off rapidly GoodGood oral and motor imitation oral and motor imitation Mostly Mostly verbalverbal…some words…some words Progress in treatment is Progress in treatment is goodgood

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Language Subgroup: Language Subgroup: High languageHigh language

Language Language productionproduction better than better than comprehensioncomprehension

High High echolaliaecholalia GoodGood oral and motor imitation oral and motor imitation PronounPronoun confusion confusion Progress in treatment is Progress in treatment is goodgood in all modes in all modes

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but what aboutbut what about……??

Autism vs. High Functioning Autism?Autism vs. High Functioning Autism?

HFA vs. Asperger’s syndrome?HFA vs. Asperger’s syndrome?

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Asperger’s HFAutismAsperger’s HFAutismSocial Social ResponsivenessResponsiveness

More to parents, More to parents, more w/ peersmore w/ peers

Less socially Less socially responsiveresponsive

CommunicationCommunication No deviant No deviant language, repetitive, language, repetitive, maintenance of topicmaintenance of topic

More echolalia, More echolalia, pronoun reversals, pronoun reversals, jargon, problems jargon, problems w/ pragmaticsw/ pragmatics

Imaginative PlayImaginative Play Yes symbolic, but Yes symbolic, but late. Play is late. Play is stereotypic, lacks stereotypic, lacks creativitycreativity

Rare imaginative Rare imaginative play, toys in play, toys in unusual waysunusual ways

BehaviorBehavior Some sameness, Some sameness, less stereotypies, less stereotypies, less sensitive to less sensitive to stimulistimuli

More stereotypies, More stereotypies, perseveration, perseveration, over sensitive to over sensitive to stimulistimuli

Age of onsetAge of onset 2 – 3 years2 – 3 years 1 – 2 years1 – 2 years 14

HFA vs Asperger’s syndromeHFA vs Asperger’s syndrome

Categorization questions for the next Categorization questions for the next decadedecade

Is Asperger’s a separate syndrome, or is Is Asperger’s a separate syndrome, or is it the high end of the autism spectrum?it the high end of the autism spectrum?

Are high functioning autism and Are high functioning autism and Asperger’s essentially the same?Asperger’s essentially the same?

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Assessment ScaleAssessment Scale

InterventionIntervention

Holistic ApproachHolistic Approach

What are the most important What are the most important skills we should teach?skills we should teach?

No matter how skilled and talented your child may be, No matter how skilled and talented your child may be, or how much knowledge he posses;or how much knowledge he posses;

If he is inflexible and cannot handle change;If he is inflexible and cannot handle change; If he is disorganized and requires constant prompts;If he is disorganized and requires constant prompts; If he obsesses on certain topics and cannot switch If he obsesses on certain topics and cannot switch

his attention;his attention; If he cannot follow directions or becomes resistant or If he cannot follow directions or becomes resistant or

angry when he is told what to do;angry when he is told what to do; -----he will sooner or later fail to keep a job-----he will sooner or later fail to keep a job

Division TEACCHDivision TEACCH

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Communication

learning Emotional

Social

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Challenges related to autismChallenges related to autism

Challenges in Learning/thinkingChallenges in Learning/thinking Challenges in social interactionChallenges in social interaction Challenges in communicationChallenges in communication Challenges in behavior/emotionChallenges in behavior/emotion Challenges in feedingChallenges in feeding

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Learning Challenges Learning Challenges Related to AutismRelated to Autism

Characteristics of thinkingCharacteristics of thinking

Difficulty with the concept of meaning: Difficulty with the concept of meaning: Central Coherence theoryCentral Coherence theory

Excessive focus on details (Spotlight Excessive focus on details (Spotlight focus)focus)

Difficulty distinguishing the relevant from Difficulty distinguishing the relevant from the irrelevantthe irrelevant

Difficulty combining or integrating ideasDifficulty combining or integrating ideas

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ExampleExample

My child sees the world in boxes. When he My child sees the world in boxes. When he is watching a dog, he sees one box which is watching a dog, he sees one box which is the eyes, and another box which is the is the eyes, and another box which is the tail, the boxes just are not connected”tail, the boxes just are not connected”

Mom of a 33 month old childMom of a 33 month old child

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Characteristics of thinking Characteristics of thinking and learningand learning

Difficulties with theory of mindDifficulties with theory of mind Difficulty in generalizingDifficulty in generalizing Concrete thinkingConcrete thinking Visual skills often a strength and Visual skills often a strength and

frequently better than auditory skillsfrequently better than auditory skills Difficulties with imitationDifficulties with imitation

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Characteristics of thinking Characteristics of thinking and learningand learning

Executive function difficulties:Executive function difficulties:• Difficulty with organization and Difficulty with organization and

sequencing/planningsequencing/planning• Understanding “finished”Understanding “finished”• Set shifting/flexibilitySet shifting/flexibility• Difficulty with transitionsDifficulty with transitions

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How can we help?How can we help?

Clearly define the environment according Clearly define the environment according to activities and events = physical to activities and events = physical structurestructure

Develop routine ways of giving information Develop routine ways of giving information about where to be and what to expect = about where to be and what to expect = schedule and work systemschedule and work system

Put visual supports in place = visual Put visual supports in place = visual structurestructure

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Five reasons for using Five reasons for using structurestructure

1.1. Understanding a receptive Understanding a receptive communication systemcommunication system

2.2. Helps autistic people remain calmHelps autistic people remain calm

3.3. Helps autistic people learn betterHelps autistic people learn better

4.4. Prosthetic device for independenceProsthetic device for independence

5.5. Behavior managementBehavior management

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A successful scheduleA successful schedule

Individualized around the child need and interestIndividualized around the child need and interest TangibleTangible Flexibility built-inFlexibility built-in Space outSpace out PortablePortable Child involvedChild involved Restructure while keeping the consistenceRestructure while keeping the consistence

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Individualizing SchedulesIndividualizing Schedules

Type of visual cue (e.g., icon words or a combination)Type of visual cue (e.g., icon words or a combination) Length of scheduleLength of schedule Ability of schedule (e.g., on clipboard, in folder, or Ability of schedule (e.g., on clipboard, in folder, or

notebook that travels with student) or static (posted on notebook that travels with student) or static (posted on wall, table or desk to which student returns.)wall, table or desk to which student returns.)

Location of scheduleLocation of schedule Transitional cue (e.g., match name, color, symbol, give Transitional cue (e.g., match name, color, symbol, give

pencil, buzzer, bell, check schedule, etc.)pencil, buzzer, bell, check schedule, etc.) Ways of manipulating schedule (“checking off”)Ways of manipulating schedule (“checking off”) ““It is OK to mix visual cues within a schedule!”It is OK to mix visual cues within a schedule!”

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How to Achieve Successful How to Achieve Successful TransitionTransition

Teaching strategiesTeaching strategies

Create visual and manipulative ways to Create visual and manipulative ways to teachteach

Break down an area of learning into Break down an area of learning into small stepssmall steps

Teach strategies for approaching Teach strategies for approaching problems that can be used for more problems that can be used for more than one assignmentthan one assignment

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What is a routine?What is a routine?

A routine is to know whenever something A routine is to know whenever something happens, go and check the schedule!happens, go and check the schedule!

The best teaching is to teach adaptationThe best teaching is to teach adaptation

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Challenges in Challenges in CommunicationCommunication

Best PracticesBest Practices

Communication goals should emphasize Communication goals should emphasize functionalfunctional use use Environmental arrangement should be primary strategy Environmental arrangement should be primary strategy

to foster to foster initiationsinitiations Environmental supports Environmental supports promotepromote active and active and independentindependent

participationparticipation Approaches to challenging behavior should be fully Approaches to challenging behavior should be fully

integratedintegrated with communication with communication PeerPeer mediated learning is essential mediated learning is essential Level of Level of emotional emotional arousalarousal and its effect on and its effect on

communication needs to be consideredcommunication needs to be considered

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Early Intervention ProgramsEarly Intervention Programs

Major GoalsMajor Goals• AttentionAttention• ImitationImitation• Social Interaction and intentional Social Interaction and intentional

communicationcommunication• Language DevelopmentLanguage Development• Emotional regulationEmotional regulation

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““I Can”I Can”

Look at someone’s face, listen to what they Look at someone’s face, listen to what they are saying, or speakare saying, or speak

BUTBUT

I can do only one of these at a timeI can do only one of these at a time

Adult with autism (28 years old male with a Adult with autism (28 years old male with a master degree)master degree)

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Communication ChallengesCommunication Challenges EcolaliaEcolalia Pronoun confusionPronoun confusion Pragmatics (lack taking others into consideration)Pragmatics (lack taking others into consideration)

• Initiation vs. respondingInitiation vs. responding• Turn-takingTurn-taking• RequestingRequesting• DescribingDescribing• DemandingDemanding• Role-playingRole-playing• dialoguedialogue

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Challenges in Social Challenges in Social InteractionInteraction

Communication

learning Emotional

Social

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Challenges in Social Challenges in Social InteractionInteraction

Pragmatic skillsPragmatic skills Perspective of others?Perspective of others? Behavioral issuesBehavioral issues

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Promoting Social Promoting Social interaction/intentionsinteraction/intentions

Reciprocity and social-affective signalingReciprocity and social-affective signaling Develop preverbal intentional Develop preverbal intentional

communication – means and functionscommunication – means and functions Opportunities for peer interactions and Opportunities for peer interactions and

relationshipsrelationships

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Challenges in Challenges in Behavioral/Emotional Behavioral/Emotional

ManagementManagement

WHY THESE BEHAVIORS?WHY THESE BEHAVIORS?

Behavior always happens for a reasonBehavior always happens for a reason Our challenge: to figure out the message underlying a Our challenge: to figure out the message underlying a

behavior problem and respond to the messagebehavior problem and respond to the message To understand the message, we need to be able to To understand the message, we need to be able to

understand autism and the child’s experienceunderstand autism and the child’s experience To intervene, we need to be able to make changes and To intervene, we need to be able to make changes and

teach skillsteach skills

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How do we help?How do we help?

Step 1Step 1:: what is the problem? what is the problem?

Define and describe the behavior Define and describe the behavior

Be specific Be specific

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Step 2Step 2:: Why is it happening? Why is it happening?

Gather cluesGather clues Collect data on the A-B-CsCollect data on the A-B-Cs

(Antecedents/Behavior/Consequences)(Antecedents/Behavior/Consequences)

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Step 3Step 3:: Generate theories. Why Is this Generate theories. Why Is this behavior occurring?behavior occurring?• Review the dataReview the data• Use your knowledge of autismUse your knowledge of autism• Create icebergs (it is important to know what Create icebergs (it is important to know what

is going on underneath)is going on underneath)

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Step 4Step 4:: Design and implement Design and implement interventionintervention

The intervention plan will be based on your theories, The intervention plan will be based on your theories, and will often include several components. Common and will often include several components. Common strategies include:strategies include:• Modify the environmentModify the environment• Improve schedulesImprove schedules• Modify tasksModify tasks• Modify method of presentationModify method of presentation• Teach skills, improve understandingTeach skills, improve understanding• Use different consequences Use different consequences

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Child Throws Banana RepeatedlyChild Throws Banana Repeatedly

Consequences

Throws Banana on the floor

family/personal/environmental factors

Too much going on in the cafeteria

Antecedents

Behavior

Go to the computer lab

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How to Manage Stress How to Manage Stress Level?Level?

Early InterventionEarly Intervention

Recognize early signs of distressRecognize early signs of distress Maintain calm, quite demeanorMaintain calm, quite demeanor Decrease use of verbal languageDecrease use of verbal language Reduce environmental stimuliReduce environmental stimuli Provide clear visual cues about what to doProvide clear visual cues about what to do Reduce time pressures, demands as neededReduce time pressures, demands as needed Cue to use coping strategyCue to use coping strategy

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Teach new strategiesTeach new strategies

Teach strategies to use in difficult Teach strategies to use in difficult situations and when stress level starts to situations and when stress level starts to riserise

Practice them when all is calmPractice them when all is calm• Use visual cues, guidelines, “talk time”, Use visual cues, guidelines, “talk time”,

scripts, social storiesscripts, social stories

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Managing a CrisisManaging a Crisis

Reduce language and sensory stimuliReduce language and sensory stimuli Redirect to a quiet safe areaRedirect to a quiet safe area Cue to use learned calming routineCue to use learned calming routine Remember to set up “finished” so that the escape time Remember to set up “finished” so that the escape time

has a clear beginning and endhas a clear beginning and end -->and afterwards, figure out -->and afterwards, figure out WHYWHY the problem the problem

happened and act Preventativelyhappened and act Preventatively

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Reduce stressReduce stress

Get away from the things/environment you do not likeGet away from the things/environment you do not like Give yourself a break from work: Frequent breaksGive yourself a break from work: Frequent breaks Change of gearsChange of gears Do something you likeDo something you like

• Calming ActivitiesCalming Activities Do not do anything hard close to lunch timeDo not do anything hard close to lunch time Regular physical activity ****Regular physical activity ****

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Different ApproachesDifferent Approaches

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Applied Behavioral Analysis Applied Behavioral Analysis (ABA)(ABA)

ABA is to teach prerequisites for a ABA is to teach prerequisites for a child to learn.child to learn.One-on-one treatment for 40 hours One-on-one treatment for 40 hours per weekper weekDiscrete trial teaching…child provided Discrete trial teaching…child provided stimulus, child acts, child then does stimulus, child acts, child then does task on own.task on own.ABA goal minimize failures and ABA goal minimize failures and maximize successesmaximize successes

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Antecendent is what you do to make the student respond. This can Antecendent is what you do to make the student respond. This can be a question, a visual stimulus, a prompt or an event.be a question, a visual stimulus, a prompt or an event.

Behavior is the student’s response/or lack of response to the Behavior is the student’s response/or lack of response to the antecendent.antecendent.

Consequence is the teacher’s response to the student’s behavior.Consequence is the teacher’s response to the student’s behavior.

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ABAABA

Applied Behavioral Analysis Applied Behavioral Analysis (ABA)(ABA)

AttentionAttention– Sessions are often broken into tiny steps. Allows child to focus on Sessions are often broken into tiny steps. Allows child to focus on

task.task.

Imitation and InitiationImitation and Initiation– Directly addresses imitation and initiation.Directly addresses imitation and initiation.

Social Interaction and intentional communicationSocial Interaction and intentional communication– Objective is reward child for socially appropriate behaviorsObjective is reward child for socially appropriate behaviors– Parents participate with home activitiesParents participate with home activities

Language developmentLanguage development– Goal is on task development and imitation, less on spontaneous Goal is on task development and imitation, less on spontaneous

expressive languageexpressive language

Emotional regulationEmotional regulation– Does not directly promote self-regulation.Does not directly promote self-regulation.

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ABA Therapy GoalsABA Therapy GoalsAttending SkillsAttending Skills

– Usually addressed firstUsually addressed first

Readying self for table workReadying self for table work

Readying self for instructionReadying self for instruction

Attending jointly with anotherAttending jointly with another

ABA Therapy GoalsABA Therapy GoalsImitation SkillsImitation Skills– Imitating motor actionsImitating motor actions– Imitating vocalizationsImitating vocalizations– Complex imitationComplex imitation

ABA Therapy GoalsABA Therapy GoalsLanguage and Communication SkillsLanguage and Communication Skills– Imitating vocalizationsImitating vocalizations– Following directionsFollowing directions– Making requestsMaking requests– LabelingLabeling– ConversationConversation

ABA Therapy GoalsABA Therapy GoalsMotor SkillsMotor Skills– Gross motorGross motor– Fine motorFine motor– Oral motorOral motor

ABA Therapy GoalsABA Therapy GoalsAdaptive and Self-Help SkillsAdaptive and Self-Help Skills– EatingEating– DressingDressing– HygieneHygiene– ToiletingToileting– ChoresChores– SafetySafety

ABA Therapy GoalsABA Therapy GoalsPlay and Leisure SkillsPlay and Leisure Skills– Social GamesSocial Games– Pretend PlayPretend Play– Board GamesBoard Games– Sports and Physical PlaySports and Physical Play– Music and SingingMusic and Singing– Arts and CraftsArts and Crafts

ABA Therapy GoalsABA Therapy GoalsPre-Academic and Academic SkillsPre-Academic and Academic Skills– MatchingMatching– SortingSorting– SequencingSequencing– AlphabetAlphabet– NumbersNumbers– Counting and QuantityCounting and Quantity– MathematicsMathematics– ReadingReading

ABA videoABA video

TEACCHTEACCH

TEACCHTEACCH

TEACCH focuses on development and TEACCH focuses on development and areas of most concern to familiesareas of most concern to familiesHighly structured learning environment Highly structured learning environment that includes vocational, social and living that includes vocational, social and living skills.skills.TEACCH focus on attention and TEACCH focus on attention and communication.communication.

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TEACCHTEACCH

IndividualIndividual plan to reduce autism related behaviors plan to reduce autism related behaviors that interfere with independence.that interfere with independence.Classroom is arranged to Classroom is arranged to avoid avoid distractions.distractions.Materials are Materials are clearlyclearly marked and arranged. marked and arranged.SchedulesSchedules are required…help to overcome are required…help to overcome difficulties with sequential memory and organization difficulties with sequential memory and organization of time.of time.Prompts and Prompts and reinforcementreinforcement are used. are used.Directions are given Directions are given bothboth verbally and with alternate verbally and with alternate forms.forms.Focus of Focus of teachingteaching is on strengths and to remediate is on strengths and to remediate difficulties.difficulties.Prepare Prepare individuals to live and work more effectively individuals to live and work more effectively at home, at school, and in the community.at home, at school, and in the community.

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TEACCHTEACCHAttentionAttention– Focuses on attention to objects, people and communicationFocuses on attention to objects, people and communication

Imitation and InitiationImitation and Initiation– Begins with elicited imitation and toward spontaneous Begins with elicited imitation and toward spontaneous

speech.speech.

Social Interaction and intentional communicationSocial Interaction and intentional communication– Goal is help child understand what to do to communicate.Goal is help child understand what to do to communicate.– Social-effective signaling allows intentional communicationSocial-effective signaling allows intentional communication

Language developmentLanguage development– Five language dimensions: purpose, contexts, categories, Five language dimensions: purpose, contexts, categories,

specific words, and form.specific words, and form.

Emotional regulationEmotional regulation– Highly structured with little self-regulation.Highly structured with little self-regulation.

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TEACCH videoTEACCH video

SIGNINGSIGNING

Some History… Some History… (Mirenda & Erickson, 2000)(Mirenda & Erickson, 2000)

Margaret Creedon (1973) is often cited as the Margaret Creedon (1973) is often cited as the first report of the successful use of manual signs first report of the successful use of manual signs + speech (aka “simultaneous” or “total” + speech (aka “simultaneous” or “total” communication) with children with autismcommunication) with children with autism– Language development in nonverbal autistic children Language development in nonverbal autistic children

using a simultaneous system, using a simultaneous system, presented to the presented to the Society for Research in Child Development, Society for Research in Child Development, Philadelphia, PA.Philadelphia, PA.

Many published reports followed shortly Many published reports followed shortly thereafterthereafter

History…History…

In the 1970s and 1980s, manual signing In the 1970s and 1980s, manual signing + speech was the AAC technique used + speech was the AAC technique used most often with people with autism most often with people with autism and/or intellectual disabilities in and/or intellectual disabilities in countries such as: countries such as: – United States (Layton,1987, 1988; Matas, United States (Layton,1987, 1988; Matas,

Mathy-Laikko, Beukelman, & Legresley, Mathy-Laikko, Beukelman, & Legresley, 1985)1985)

– United Kingdom (Kiernan, 1983) Australia United Kingdom (Kiernan, 1983) Australia (Iacono & Parsons, 1986)(Iacono & Parsons, 1986)


During this time, research evidence During this time, research evidence related to the use of manual signs with related to the use of manual signs with children with autism accumulated in four children with autism accumulated in four main areas:main areas:– Verbal imitationVerbal imitation– Fine motor skillsFine motor skills– IconicityIconicity– IntelligibilityIntelligibility

Verbal ImitationVerbal Imitation

Carr, Layton, and colleagues described two groups of Carr, Layton, and colleagues described two groups of children with autism who did not speak: good and children with autism who did not speak: good and poor verbal imitatorspoor verbal imitators– In general, good verbal imitators were found to make In general, good verbal imitators were found to make

greater receptive and expressive language gains with greater receptive and expressive language gains with manual signing than poor imitatorsmanual signing than poor imitators

– In addition, speech development concurrent with signing is In addition, speech development concurrent with signing is much more likely to occur in good but not poor verbal much more likely to occur in good but not poor verbal imitatorsimitators

In a study of the predictors of spoken vocabulary development In a study of the predictors of spoken vocabulary development following sign language instruction, Yoder & Layton (1988) found following sign language instruction, Yoder & Layton (1988) found that verbal imitation alone accounted for 63% of the variance and that verbal imitation alone accounted for 63% of the variance and that adding age and IQ to the mix accounted for 78%that adding age and IQ to the mix accounted for 78%

Fine Motor SkillsFine Motor Skills

Several researchers have described fine motor Several researchers have described fine motor (hand) coordination problems in children with autism (hand) coordination problems in children with autism (e.g., Jones & Prior, 1985)(e.g., Jones & Prior, 1985)– In a recent study, manual sign vocabulary size and the In a recent study, manual sign vocabulary size and the

accuracy of sign formation were both highly correlated with accuracy of sign formation were both highly correlated with measures of fine motor (hand) ability in 14 individuals with measures of fine motor (hand) ability in 14 individuals with autism (Seal & Bonvillian, 1997)autism (Seal & Bonvillian, 1997)

– In another study, motor apraxia was strongly correlated In another study, motor apraxia was strongly correlated with sign language production rates in children with autism with sign language production rates in children with autism (Soorya, 2004)(Soorya, 2004)

– In a third study, no imitation-sign language relationship was In a third study, no imitation-sign language relationship was apparent (Anderson, 2002)apparent (Anderson, 2002)

IconicityIconicity

Konstantareas, Oxman, & Webster (1978) Konstantareas, Oxman, & Webster (1978) provided evidence that, for children with autism, provided evidence that, for children with autism, symbols that visually resemble their referents symbols that visually resemble their referents (i.e., transparent symbols) are easier to learn (i.e., transparent symbols) are easier to learn and remember than symbols that do not not (i.e., and remember than symbols that do not not (i.e., translucent or opaque symbols)translucent or opaque symbols)

Many of the most common “functional” signs are Many of the most common “functional” signs are translucent or opaque (e.g., more, help, play, translucent or opaque (e.g., more, help, play, toilet, like, cookie, juice) toilet, like, cookie, juice)

IntelligibilityIntelligibility

Unfamiliar communication partners are Unfamiliar communication partners are typically unable to communicate with typically unable to communicate with individuals with autism who use manual individuals with autism who use manual signs, without an interpretersigns, without an interpreter

Rotholz et al. (1989) taught two adolescents Rotholz et al. (1989) taught two adolescents with autism to order fast food from unfamiliar with autism to order fast food from unfamiliar wait staffwait staff– 0-25% of manual sign requests were understood0-25% of manual sign requests were understood– 80-100% of PCS requests were understood80-100% of PCS requests were understood

ConclusionsConclusions

Good verbal imitation skills are related to more Good verbal imitation skills are related to more receptive and expressive language gains with manual receptive and expressive language gains with manual signingsigningSpeech development concurrent with manual sign Speech development concurrent with manual sign instruction is also related to good verbal imitation skills instruction is also related to good verbal imitation skills Optimal manual sign outcomes require good fine motor Optimal manual sign outcomes require good fine motor (hand) skills(hand) skillsTransparent manual signs are more likely to be learned Transparent manual signs are more likely to be learned and retained; many functional words are not and retained; many functional words are not transparenttransparentManual signs limit independent communication with Manual signs limit independent communication with unfamiliar partnersunfamiliar partners


Layton and Watson (1995) concluded that “even Layton and Watson (1995) concluded that “even after intensive training with signs, a significant after intensive training with signs, a significant number of nonverbal children [with autism] number of nonverbal children [with autism] continue to be mute and acquire only a few continue to be mute and acquire only a few useful signs (p. 81)”useful signs (p. 81)”

Between 1980 and the mid-1990s, manual Between 1980 and the mid-1990s, manual signing + speech for individuals with autism was signing + speech for individuals with autism was gradually supplanted by graphic symbols + gradually supplanted by graphic symbols + speech in many places as the result of both speech in many places as the result of both research conclusions and clinical concerns research conclusions and clinical concerns

Sign Language-candidatesSign Language-candidates

Has oral-motor difficultiesHas oral-motor difficulties

Over five years of ageOver five years of age

Less than 25 functional wordsLess than 25 functional words

Needs a communicative systemNeeds a communicative system

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Sign LanguageSign LanguageAuditory-vocal areas poor, visual-motor Auditory-vocal areas poor, visual-motor

area may be successfularea may be successful

Several guidelines for using sign:Several guidelines for using sign:– Functional, self reinforcing signsFunctional, self reinforcing signs– Signs can be produced before they are understoodSigns can be produced before they are understood– Sign enhances linguistic outputSign enhances linguistic output– Signing is fastSigning is fast– Signing limitations: someone must interpret, child with Signing limitations: someone must interpret, child with

motor problems may not form clear signs, iconic and motor problems may not form clear signs, iconic and abstractabstract

– Signing does facilitate spoken wordsSigning does facilitate spoken words

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Beginning – cookie signBeginning – cookie sign1.1. Show child cookie…take child’s hands and shape Show child cookie…take child’s hands and shape

the sign for cookie…reward child by giving child the sign for cookie…reward child by giving child piece of cookiepiece of cookie

2.2. Follow this procedure with other objects.Follow this procedure with other objects.3.3. After child has learned 10 signs, learn to wait.After child has learned 10 signs, learn to wait.4.4. Show child cookie, wait for child to sign…if child Show child cookie, wait for child to sign…if child

does not sign, then prompt by touching hands.does not sign, then prompt by touching hands.5.5. When child is signing independently, begin to use When child is signing independently, begin to use

two sign combinations…verb + object; for example, two sign combinations…verb + object; for example, [eat] + [cookie][eat] + [cookie]

6.6. Next step would be to use sentences…for example, Next step would be to use sentences…for example, 7.7. [I want ____] or [I see ____].[I want ____] or [I see ____].

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Sign LanguageSign Language

Useful beginning signs:Useful beginning signs:– Food and drink objects – 4/5 Food and drink objects – 4/5

items items – Toy objects – 3/4 itemsToy objects – 3/4 items– People – mom, dadPeople – mom, dad– Actions – eat, want, seeActions – eat, want, see– Demands – no, stopDemands – no, stop

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Sign LanguageSign Language

AttentionAttention– Does not focus, attentional focus per se.Does not focus, attentional focus per se.

Imitation and InitiationImitation and Initiation– Children who do and do not imitate can learn signs.Children who do and do not imitate can learn signs.

Social Interaction and intentional communicationSocial Interaction and intentional communication– Signing allows child to socially interact and to initiate Signing allows child to socially interact and to initiate

communication.communication.

Language developmentLanguage development– Acquire both receptive and expressive language.Acquire both receptive and expressive language.

Emotional regulationEmotional regulation– After signing ASD children have improved behaviors.After signing ASD children have improved behaviors.

88

Signing videoSigning video

PECSPECS

Alternative Treatment StrategiesAlternative Treatment Strategies

Picture Exchange Communication System Picture Exchange Communication System (PECS)(PECS)

Object ExchangeObject Exchange

Augmentative communication aidsAugmentative communication aids

Auditory Integration Therapy (AIT)Auditory Integration Therapy (AIT)

91

PECS is a unique Augmentative / Alternative Communication System.PECS is a unique Augmentative / Alternative Communication System.Augmentative / Alternative Communication systems are a collection of Augmentative / Alternative Communication systems are a collection of methods and/or devices that allow persons with severe methods and/or devices that allow persons with severe communication impairments to communicatecommunication impairments to communicateAugmentative and Alternative Communication is used when speech, Augmentative and Alternative Communication is used when speech, gestures, and writing will not or can not sufficiently accomplish ones gestures, and writing will not or can not sufficiently accomplish ones communication needs communication needs

PECSPECS

Initial language program for lower Initial language program for lower functioning children.functioning children.

Begins by teaching spontaneous requestsBegins by teaching spontaneous requests

Proceeds to communicative functions, Proceeds to communicative functions, responding to questions and commentsresponding to questions and comments

Child is required to pick up picture and Child is required to pick up picture and hand it to teacher, who exchanges picture hand it to teacher, who exchanges picture for real item.for real item.

93

PECSPECS

Children are taught to travel to a communicative Children are taught to travel to a communicative partner to be persistent in their request.partner to be persistent in their request.

Next step is for child to acquire phrases…through Next step is for child to acquire phrases…through use of sentence strips…”I want ____” is written.use of sentence strips…”I want ____” is written.

Teacher then faces the strip toward child and Teacher then faces the strip toward child and reads it back to them, while delivering the item.reads it back to them, while delivering the item.

Next, child is taught to answer questions, such as Next, child is taught to answer questions, such as “What do you see?”“What do you see?”

94

Behavioral AnalysisBehavioral Analysis

ABA utilizes the same M-S-R-SR principle from ABA utilizes the same M-S-R-SR principle from Skinner’s theory, in conjunction with:Skinner’s theory, in conjunction with:

An individualized plan for each childAn individualized plan for each child

Small attainable goalsSmall attainable goals

Fading StimulusFading Stimulus

Highly structured environmentHighly structured environment

PECS uses concepts from Skinner’s Verbal PECS uses concepts from Skinner’s Verbal Behaviors and ABA therapy to facilitate new Behaviors and ABA therapy to facilitate new communication behaviors with autistic childrencommunication behaviors with autistic children

PECS Phase1PECS Phase1

The most important factor in beginning The most important factor in beginning PECS training is identifying an object that PECS training is identifying an object that will motivate the child. will motivate the child.

Next a card/picture is created to represent Next a card/picture is created to represent the motivating object.the motivating object.

The object is then shown to the child. The The object is then shown to the child. The child may reach for the object or exhibit child may reach for the object or exhibit other behaviors that indicate they want the other behaviors that indicate they want the object.object.

PECS Phase 1PECS Phase 1

Phase one of PECS training Phase one of PECS training requires two persons in requires two persons in addition to the child.addition to the child.

One person to serve as the One person to serve as the initial communicative partner, initial communicative partner, and the other the to assist the and the other the to assist the child with communicative acts.child with communicative acts.

Once the child indicates his Once the child indicates his interest in the object, the interest in the object, the communicative assistant communicative assistant physically directs and assists physically directs and assists the child in picking up the the child in picking up the picture card representing the picture card representing the desired object desired object


Once the communicative partner receives the Once the communicative partner receives the picture from the child, he or she immediately picture from the child, he or she immediately gives the desired object to the child along with gives the desired object to the child along with verbal praise.verbal praise.The process is repeated several times while The process is repeated several times while slowly fading the child’s need for communicative slowly fading the child’s need for communicative assistance.assistance.The child will eventually begin exchanging The child will eventually begin exchanging pictures independently.pictures independently.To promote generalization and carry over of this To promote generalization and carry over of this new behavior, the communicative partner and new behavior, the communicative partner and communicative assistant often switch placescommunicative assistant often switch places


Phase 2 encourages greater spontaneity, Phase 2 encourages greater spontaneity, persistence, and generalization of the skills persistence, and generalization of the skills acquired in phase 1.acquired in phase 1.

The child continues to request the motivating The child continues to request the motivating object, however the communicative partner is object, however the communicative partner is positioned further away from the child.positioned further away from the child.

This process is gradual, starting with a few feet This process is gradual, starting with a few feet and progressing to the CP being in different and progressing to the CP being in different rooms. rooms.


The communicative act is carried out in a variety The communicative act is carried out in a variety of settings to encourage generalization .of settings to encourage generalization .

Recommended settings include the classroom, Recommended settings include the classroom, the home, the store, and the park.the home, the store, and the park.

The communicative partner is changed The communicative partner is changed frequently, and will often include teachers, frequently, and will often include teachers, schoolmates, parents, grandparents, and schoolmates, parents, grandparents, and siblings. siblings.


It is at this point that the child also begins It is at this point that the child also begins to expand his/her vocabulary.to expand his/her vocabulary.

The fist few objects introduced should The fist few objects introduced should continue to be objects that will motivate continue to be objects that will motivate and/or please the child.and/or please the child.

It is important not to over stimulate the It is important not to over stimulate the child too quickly. Only one picture should child too quickly. Only one picture should be available to the child at a time.be available to the child at a time.

PECS Phase 3PECS Phase 3Phase three requires the child to discriminate among multiple pictures Phase three requires the child to discriminate among multiple pictures when requesting an itemwhen requesting an itemThe child must first locate the correct picture for the item or activity they The child must first locate the correct picture for the item or activity they wantwantFor some learners this is easy, for others it is much tougher.For some learners this is easy, for others it is much tougher.Some learners learn best with photos of objects, while others do better Some learners learn best with photos of objects, while others do better with graphic images that approximate the appearance of an object.with graphic images that approximate the appearance of an object.

PECS Phase 3PECS Phase 3Phase three also encourages the child to make choices about Phase three also encourages the child to make choices about what he or she wants and/or would like to do.what he or she wants and/or would like to do.

The child begins by answering questions such as “what do you The child begins by answering questions such as “what do you want” or “what would you like to play with”want” or “what would you like to play with”

The child must locate the picture among several pictures, initially The child must locate the picture among several pictures, initially two or three progressing to multiple pictures on multiple pages.two or three progressing to multiple pictures on multiple pages.

PECS Phase 4PECS Phase 4Once a child is comfortable discriminating Once a child is comfortable discriminating between and making requests for a variety of between and making requests for a variety of items, to a variety of people, and in a variety of items, to a variety of people, and in a variety of settings and environments, the program begins to settings and environments, the program begins to focus on sentence structure.focus on sentence structure.

PECS Phase 4PECS Phase 4Phase four starts learners Phase four starts learners in the process of building in the process of building sentences through the use sentences through the use of sentence strips.of sentence strips.The child will start The child will start combining a picture for “I combining a picture for “I want: with a picture of the want: with a picture of the requested item or activity.requested item or activity.The two pictures would be The two pictures would be attached to a sentence attached to a sentence strip, and the entire strip strip, and the entire strip would be exchanged with would be exchanged with the communicative partner the communicative partner for the pictured item or for the pictured item or activity.activity.


Phase five challenges the child to build Phase five challenges the child to build more complex sentences and questions.more complex sentences and questions.

Adjectives and other words can be added Adjectives and other words can be added to the child’s repertoire to help the child to the child’s repertoire to help the child further refine requests.further refine requests.

Examples include moving from sentences Examples include moving from sentences such as “I want candy” to “I want three such as “I want candy” to “I want three green candies”green candies”

PECS Phase 6PECS Phase 6In phase six, the child is taught to comment on the world around In phase six, the child is taught to comment on the world around them.them.

Communicative behaviors move from requesting behaviors to Communicative behaviors move from requesting behaviors to commenting or questioning behaviorscommenting or questioning behaviors

The child is prompted with questions such as “what do you see” The child is prompted with questions such as “what do you see” or “what do you hear”or “what do you hear”


The child’s initial responses maybe similar The child’s initial responses maybe similar to “the big red ball” or “The birds singing”to “the big red ball” or “The birds singing”

However new picture cards are introduced However new picture cards are introduced to facilitate the child’s use of more to facilitate the child’s use of more complete sentences.complete sentences.

These new cards will include phrases such These new cards will include phrases such as “I hear”, “I see”, “I feel”, and “I smell”as “I hear”, “I see”, “I feel”, and “I smell”


Phase six is a fundamental Phase six is a fundamental shift in the child’s shift in the child’s communication communication By this phase the child’s By this phase the child’s communication should be communication should be spontaneousspontaneousThe child should be able to The child should be able to communicate with multiple communicate with multiple partners in multiple settingspartners in multiple settingsThe child is now able to The child is now able to communicate on various levels communicate on various levels by making requests, by making requests, commenting on their commenting on their environment, and expressing environment, and expressing their feelings. their feelings.

PECSPECS

The PECS program may take several The PECS program may take several months or several years to completemonths or several years to completeThe amount of time depends on the child, The amount of time depends on the child, and how well they adapt to this style of and how well they adapt to this style of communicationcommunicationTime may also be extended with those Time may also be extended with those children who have other cognitive, children who have other cognitive, developmental, and/or physical developmental, and/or physical impairments and/or disorders impairments and/or disorders

PECSPECSSelection of picture type and size is dependent on individual needsSelection of picture type and size is dependent on individual needsThe pictures used with the PECS program may be photographs in color The pictures used with the PECS program may be photographs in color or black and white, white lines drawings, or even tangible items or or black and white, white lines drawings, or even tangible items or objectsobjectsThere are many companies that produce pictures and objects that may There are many companies that produce pictures and objects that may be used with the PECS program, or the user can opt to create their ownbe used with the PECS program, or the user can opt to create their own

PECSPECSSome children begin to Some children begin to spontaneously use speech spontaneously use speech while involved in the PECS while involved in the PECS programprogram

Although PECS is primarily Although PECS is primarily used with children who are used with children who are non verbal, it could be used non verbal, it could be used with those who are ecolalic, with those who are ecolalic, unintelligible, and/or those unintelligible, and/or those with expressive language with expressive language delays delays

Success With PECSSuccess With PECS

The PECS system has been successful The PECS system has been successful with person with a variety of with person with a variety of communicative, cognitive, and physical communicative, cognitive, and physical difficultiesdifficulties

PECS is thought to be ideal for those with PECS is thought to be ideal for those with autism because typically they are visual autism because typically they are visual learners, and PECS is a visual orientated learners, and PECS is a visual orientated programprogram


To be successful in teaching PECS there To be successful in teaching PECS there are three basic rules to follow.are three basic rules to follow.

1.1. Start slow with high use symbols such as Start slow with high use symbols such as toys, drink, food ect…toys, drink, food ect…

2.2. Be consistent and maintain reasonable Be consistent and maintain reasonable expectationsexpectations

3.3. Be patient, don’t give up, and stick with Be patient, don’t give up, and stick with it!it!


PECS has been successful with a variety PECS has been successful with a variety of ages including preschool, adolescents, of ages including preschool, adolescents, and adultsand adultsA PECS candidate should be an A PECS candidate should be an intentional communicator, meaning the intentional communicator, meaning the child/adult is aware of his/her need to child/adult is aware of his/her need to communicate messages to others.communicate messages to others.The individual should have some personal The individual should have some personal preferences.preferences.


Personal Preferences are key in PECS Personal Preferences are key in PECS training. training.

Personal preferences provide the initial Personal preferences provide the initial motivation needed to implement the PECS motivation needed to implement the PECS program.program.

Picture discrimination is helpful, but is not Picture discrimination is helpful, but is not a pre-requisite for candidacy a pre-requisite for candidacy

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Object ExchangeObject Exchange

Use of miniature objects.Use of miniature objects.

Similar to PECS except rather than using Similar to PECS except rather than using pictures objects are made available.pictures objects are made available.

Child retrieves object from display and gives it Child retrieves object from display and gives it to teacher, who exchanges it for real item.to teacher, who exchanges it for real item.

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Signs vs PECSSigns vs PECS

(Adapted from Pat Mirenda)(Adapted from Pat Mirenda)

Gail, Ramon, and BenGail, Ramon, and Ben(Ganz & Simpson, 2004)(Ganz & Simpson, 2004)

All three children spoke few words (15-30), little All three children spoke few words (15-30), little functional use of speech, echolalia functional use of speech, echolalia Gail, age 5;8, severe autism, ESL family; half-Gail, age 5;8, severe autism, ESL family; half-day kindergartenday kindergartenRamon, age 7;2, developmental delay, mild-Ramon, age 7;2, developmental delay, mild-moderate autism, speech/language impairment; moderate autism, speech/language impairment; grade 1 classroomgrade 1 classroomBen, age 3;9, developmental delay, severe Ben, age 3;9, developmental delay, severe autism, speech/language impairment; half-day autism, speech/language impairment; half-day ECSE preschoolECSE preschool


Taught to make requests with coloured Taught to make requests with coloured line drawings and photos using line drawings and photos using standard PECS procedures for Phases standard PECS procedures for Phases 1-4 (“I want…”)1-4 (“I want…”)Measures taken of Measures taken of – trails to independent mastery for each trails to independent mastery for each

phasephase– number of words spoken per trial andnumber of words spoken per trial and– presence/absence of non-word presence/absence of non-word

vocalizations per trialvocalizations per trial

Results: Results: GailGail

(447 trials total)(447 trials total)

Results: Results: RamonRamon


20 pictures

Results: Results: BenBen


Signs vs. Graphic SymbolsSigns vs. Graphic Symbols

Two studies with adults with mild to profound Two studies with adults with mild to profound intellectual disability (Sundberg & Sundberg, intellectual disability (Sundberg & Sundberg, 1990; Wraikat, Sundberg, & Michael, 1991)1990; Wraikat, Sundberg, & Michael, 1991)Taught manual signs and graphic symbols for Taught manual signs and graphic symbols for nonsense words (e.g., “doof”) in response to nonsense words (e.g., “doof”) in response to “What’s this?” and “What’s doof?” (i.e., “What’s this?” and “What’s doof?” (i.e., tacts/labels not mands/requests)tacts/labels not mands/requests)For most (but not all) participants, manual signs For most (but not all) participants, manual signs required fewer teaching trials than pictures, with required fewer teaching trials than pictures, with varying degrees of differencevarying degrees of difference

Signs vs. Graphic Symbols: Signs vs. Graphic Symbols: Requesting Requesting (Adkins & Axelrod, 2001)(Adkins & Axelrod, 2001)

One boy with PDD and ADHDOne boy with PDD and ADHDDesirable objects identified and matched with regard to Desirable objects identified and matched with regard to preference and iconicitypreference and iconicityPicture use was taught using standard PECS Picture use was taught using standard PECS instruction, Phases 1-3instruction, Phases 1-3Manual signs were taught using modeling and physical Manual signs were taught using modeling and physical prompts, approximating the three phases of PECSprompts, approximating the three phases of PECSRequired an average of 7.1 trials per picture and 15.7 Required an average of 7.1 trials per picture and 15.7 trials per sign to meet criteriontrials per sign to meet criterionMore spontaneous, better generalization with pictures More spontaneous, better generalization with pictures as wellas well

Brian, Chris, Jenny, & MandiBrian, Chris, Jenny, & Mandi(Chambers & Rehfeldt , 2003)(Chambers & Rehfeldt , 2003)

Brian: 19 years old, severe intellectual Brian: 19 years old, severe intellectual disability (ID), autismdisability (ID), autism

Chris: 26 years old, severe ID, cerebral palsy, Chris: 26 years old, severe ID, cerebral palsy, seizure disorderseizure disorder

Jenny: 40 years old, profound ID, Down Jenny: 40 years old, profound ID, Down syndrome, seizure disordersyndrome, seizure disorder

Mandi: 36 years old, severe IDMandi: 36 years old, severe ID

None had functional communication, all lived None had functional communication, all lived in a developmental training centerin a developmental training center


Preferred foods, leisure items identified for each Preferred foods, leisure items identified for each personpersonAll items taught via both manual signing and All items taught via both manual signing and picture symbolspicture symbolsPicture use was taught using standard PECS Picture use was taught using standard PECS instruction, Phases 1-3instruction, Phases 1-3Manual signs were taught using modeling and Manual signs were taught using modeling and physical prompts, approximating the three physical prompts, approximating the three phases of PECSphases of PECS

ResultsResults

Signs vs. Graphic Symbols: Requesting and Signs vs. Graphic Symbols: Requesting and Speech (Anderson, 2002)Speech (Anderson, 2002)

John, age 2;11, PDD-NOS, NVMA 16 mo, 3 wordsJohn, age 2;11, PDD-NOS, NVMA 16 mo, 3 words

Cory, age 2;3, severe autism, NVMA 17 mo, no speechCory, age 2;3, severe autism, NVMA 17 mo, no speech

Alex, age 2;7, severe autism, NVMA 15 mo, no speechAlex, age 2;7, severe autism, NVMA 15 mo, no speech

Maya, age 2;10, severe autism, NVMA 16 mo, 4 wordsMaya, age 2;10, severe autism, NVMA 16 mo, 4 words

Ryan, age 4;11, severe autism, NVMA 19 mo, 4 wordsRyan, age 4;11, severe autism, NVMA 19 mo, 4 words

Sara, age 1;11, mild-moderate autism, NVMA 15 mo, no speechSara, age 1;11, mild-moderate autism, NVMA 15 mo, no speech


Preferred foods, leisure items identified for each Preferred foods, leisure items identified for each childchild– Rank ordered by preference and assigned Rank ordered by preference and assigned

sequentially to sign or PCS conditions (coin toss for sequentially to sign or PCS conditions (coin toss for each child used to assign #1)each child used to assign #1)

PCS use was taught using standard PECS PCS use was taught using standard PECS protocol, Phases 1-3protocol, Phases 1-3Manual signs were taught using modeling and Manual signs were taught using modeling and physical prompts, approximating the three physical prompts, approximating the three phases of PECSphases of PECS

ResultsResults

ParticipantParticipant PCSPCS SignsSigns PCSPCS SignsSigns

JohnJohn 6*6* 4*4* XX

CoryCory 77 22 XX

AlexAlex 88 22 XX

MayaMaya 77 33 XX

RyanRyan 88 5*5* XX

SaraSara 99 22 XX

Mastered Preferred

* Some items were mastered by speech alone

Results: Speech Results: Speech

Vocal Imitation 10% 0% 0% 15% 100% 0%

Carl and JenniferCarl and Jennifer(Tincani, 2004)(Tincani, 2004)

Carl, age 5;10, autism and intellectual Carl, age 5;10, autism and intellectual disabilitydisability

Jennifer, age 6;8, PDD-NOS and intellectual Jennifer, age 6;8, PDD-NOS and intellectual disabilitydisability

Both could imitate some words but never Both could imitate some words but never used them to communicate without promptsused them to communicate without prompts

Preference assessment done to identify 10-Preference assessment done to identify 10-12 motivating foods, drinks, toys for each 12 motivating foods, drinks, toys for each childchild


Manual signs taught for half the items; PECS Manual signs taught for half the items; PECS taught for the other halftaught for the other half– Protocol from Sundberg & Partington (1998) used to Protocol from Sundberg & Partington (1998) used to

teach signsteach signsModified slightly for Carl after 5 training sessionsModified slightly for Carl after 5 training sessions

– Protocol from Frost & Bondy (2002) used to teach Protocol from Frost & Bondy (2002) used to teach PECS, through Phase 3PECS, through Phase 3

““Best” treatment then used to teach mands (i.e., Best” treatment then used to teach mands (i.e., requests) for all itemsrequests) for all items

Results: CarlResults: Carl

Mands

Speech: Words

Results: JenniferResults: Jennifer

Mands

Speech: Words

ConclusionsConclusions

In the short-term, both manual signs and PECS In the short-term, both manual signs and PECS can result in can result in – Functional requestingFunctional requesting– Natural speech productionNatural speech production

Vocal imitation skills appear to be related to Vocal imitation skills appear to be related to speech production, regardless of symbol speech production, regardless of symbol modalitymodalityNo studies have examined functions beyond No studies have examined functions beyond requestingrequestingNo long-term comparative studies existNo long-term comparative studies exist

The DebateThe Debate

In 1993, applied behavior analysts who ascribe to In 1993, applied behavior analysts who ascribe to Skinner’s theory of verbal behavior published two Skinner’s theory of verbal behavior published two papers comparing the utility of “topography-based” papers comparing the utility of “topography-based” AAC systems such as manual signs and “selection-AAC systems such as manual signs and “selection-based” systems such as graphic symbols (Shafer, based” systems such as graphic symbols (Shafer, 1993; Sundberg, 1993)1993; Sundberg, 1993)They (and others) claim that there is considerable They (and others) claim that there is considerable research evidence to support the research evidence to support the superioritysuperiority of of manual signs for individuals with autism with regard manual signs for individuals with autism with regard toto– Functional communication in generalFunctional communication in general– Natural speech development in particularNatural speech development in particular

The Evidence The Evidence (Mirenda, 2003)(Mirenda, 2003)

Research studies in both AAC and verbal Research studies in both AAC and verbal behavior/ABA were reviewed using a behavior/ABA were reviewed using a narrative approachnarrative approach– Studies were not evaluated using stringent criteria Studies were not evaluated using stringent criteria

to assess reliability, validity, etc.to assess reliability, validity, etc.– A “face value” approach was used to summarize A “face value” approach was used to summarize

existing researchexisting research

Several additional studies have been Several additional studies have been published since 2003, but the results do not published since 2003, but the results do not change the conclusionschange the conclusions

Augmentative CommunicationAugmentative Communication

(Adapted from Pat Mirenda)(Adapted from Pat Mirenda)

Speech-Generating Devices (SGDs)Speech-Generating Devices (SGDs)

Only a few studies have documented the utility of SGDs Only a few studies have documented the utility of SGDs with individuals with autism (see Schlosser & Blischak, with individuals with autism (see Schlosser & Blischak, 2001 and Schlosser, 2003 for reviews)2001 and Schlosser, 2003 for reviews)Generally, there is Generally, there is suggestive evidencesuggestive evidence that SGDs can that SGDs can be useful with individuals with autism to teachbe useful with individuals with autism to teach– Literacy skills (e.g., Schlosser, Blischak, Belfiore, Bartley, & Literacy skills (e.g., Schlosser, Blischak, Belfiore, Bartley, &

Barnett, 1998) Barnett, 1998) – Communicative requests (e.g., Sigafoos, Didden, & O’Reilly, Communicative requests (e.g., Sigafoos, Didden, & O’Reilly,

2003)2003)– Communicative repairs (Sigafoos et al., 2004)Communicative repairs (Sigafoos et al., 2004)– Social comments (e.g., Schepis, Reid, Behrmann, & Sutton, Social comments (e.g., Schepis, Reid, Behrmann, & Sutton,

1998)1998)– Receptive labels (e.g., Brady, 2000)Receptive labels (e.g., Brady, 2000)

SGDsSGDsThere is also some evidence that SGDs can have There is also some evidence that SGDs can have positive effects on positive effects on – Reducing the frequency of problem behavior (e.g., Reducing the frequency of problem behavior (e.g.,

Durand, 1999) Durand, 1999) – Generative (i.e., non-echolalic) speech production (e.g., Generative (i.e., non-echolalic) speech production (e.g.,

Hetzroni & Tannous, 2004; Sigafoos et al., 2003)Hetzroni & Tannous, 2004; Sigafoos et al., 2003)

Finally, there are several case study and other Finally, there are several case study and other reports documenting SGDs has positive affects on reports documenting SGDs has positive affects on day-to-day communication abilities of individuals day-to-day communication abilities of individuals with autism (e.g., Bornman & Alant, 1999; Light, with autism (e.g., Bornman & Alant, 1999; Light, Roberts, Dimarco, & Greiner, 1998)Roberts, Dimarco, & Greiner, 1998)

Retrospective StudyRetrospective Study(Mirenda, Wilk, & Carson, 2000)(Mirenda, Wilk, & Carson, 2000)

Retrospective study of 63 students with Retrospective study of 63 students with autism in British Columbia, Canada (age autism in British Columbia, Canada (age 5-17) who used static display SGDs in 5-17) who used static display SGDs in school over a 5-year period school over a 5-year period Success scores were assigned to annual Success scores were assigned to annual follow-up reports:follow-up reports:

0-1: no or little success0-1: no or little success2-3: some or limited success2-3: some or limited success4-5: successful or very successful 4-5: successful or very successful

SGD Success Scores SGD Success Scores

19

31.7

49.2

0102030405060708090

100

Little/no success Some/moderate

success

Successful/very

successful

SGD Users by Success Scores SGD Users by Success Scores and Ageand Age

10.4

34.4

56.3

7.7

30.8

61.5

20

40 4037.5

25

37.5

0102030405060708090

100

Little/no success Some/moderatesuccess

Successful/verysuccessful

5-8

9-11

12-14

15-17

SGD Users by Success Scores and SGD Users by Success Scores and Cognitive AbilitiesCognitive Abilities

6.7

40

53.3

27.3 27.3

45.5

19

28.6

52.4

0

36.4

63.6

0102030405060708090

100

Little/no success Some/moderate

success

Successful/very

successful

Average

Mild ID

Moderate ID

Severe ID

SGDs and SpeechSGDs and Speech

Seven SGD users (11%) developed sufficient Seven SGD users (11%) developed sufficient speech that they no longer needed SGDs and speech that they no longer needed SGDs and “traded them in” for computers + software“traded them in” for computers + software– Five 5-8 year-olds, one 9-11, one 13Five 5-8 year-olds, one 9-11, one 13– All had limited functional speech prior to service; all All had limited functional speech prior to service; all

but one used prior low-tech AACbut one used prior low-tech AAC– Cognitive abilities: 3 average, 2 mild ID, 1 moderate Cognitive abilities: 3 average, 2 mild ID, 1 moderate

ID, 1 severe IDID, 1 severe ID– Variety of static display SGDs (IntroTalker, Macaw, Variety of static display SGDs (IntroTalker, Macaw,

etc.)etc.)

No data on lesser degrees of speech No data on lesser degrees of speech development development

SCD vacuum videoSCD vacuum video

Relationship Development InterventionRelationship Development Intervention

Relationship Development Intervention Relationship Development Intervention (RDI)(RDI)

Elements of social competence (Gutstein Elements of social competence (Gutstein & Whitney, 2002)& Whitney, 2002)– Secure attachment (tie of infants to parents)Secure attachment (tie of infants to parents)

Baby falls and reaches to be comfortedBaby falls and reaches to be comforted

Stranger cause infant to run to momStranger cause infant to run to mom


Elements of social competence (Gutstein Elements of social competence (Gutstein & Whitney, 2002)& Whitney, 2002)– Instrumental social learning (social actions to Instrumental social learning (social actions to

achieve a specific social end)achieve a specific social end)Pointing to obtain a toyPointing to obtain a toy

Following classroom rules to get a rewardFollowing classroom rules to get a reward

Inviting child to play checkers so you can winInviting child to play checkers so you can win


Elements of social competence (Gutstein & Elements of social competence (Gutstein & Whitney, 2002)Whitney, 2002)– Experience sharing relationships (reciprocal Experience sharing relationships (reciprocal

playmate, value others’ view point, emotion-based playmate, value others’ view point, emotion-based transactions)transactions)

FriendshipFriendship

Consoling a friend after losing a gameConsoling a friend after losing a game

Telling silly jokes that make you laugh togetherTelling silly jokes that make you laugh together

Celebrating finishing a job with friends after feeling closeness Celebrating finishing a job with friends after feeling closeness and camaraderieand camaraderie


Social skills much be taught within the context of Social skills much be taught within the context of meaningmeaning– Research shown over and over again that isolated Research shown over and over again that isolated

social skills training does not help without connection social skills training does not help without connection to contextto context

Experienced based relationship interventionExperienced based relationship intervention– Shift from survival oriented behaviorsShift from survival oriented behaviors– Guided experiences to socially adapt, co-regulate, Guided experiences to socially adapt, co-regulate,

and coordinate actions, perceptions and feelings with and coordinate actions, perceptions and feelings with social partnerssocial partners

SummarySummary

None of the approaches should harm the None of the approaches should harm the child.child.

Some may be valueless for an individual.Some may be valueless for an individual.

It is hoped that the reviews are helpful and It is hoped that the reviews are helpful and will provide parents and professionals will provide parents and professionals clearer choices.clearer choices.

155

Case studyCase study

Jill, 5 year old, picky eater, dislike meat, vegetables:Jill, 5 year old, picky eater, dislike meat, vegetables: History of pneumoniaHistory of pneumonia Losing weightLosing weight

GaggingGagging Coughing after eatingCoughing after eating Wet soundsWet sounds DroolingDrooling PocketingPocketing Food stuck in palateFood stuck in palate Multiple swallowsMultiple swallows

156


Jill, 5 year old:Jill, 5 year old: Tx: Oral motor exercisesTx: Oral motor exercises

Improve strength and/or mobility of tougue, lips, Improve strength and/or mobility of tougue, lips, cheeks, and jawcheeks, and jaw

Passive, assistive, active movementPassive, assistive, active movement

157


Samuel: 4 years oldSamuel: 4 years old Uncomfortable with touch-brushing, kissing, washing face, Uncomfortable with touch-brushing, kissing, washing face,

getting food on lipsgetting food on lips Limited food texture: yogurt or smoothy onlyLimited food texture: yogurt or smoothy only Gagging oftenGagging often Does like like any strong smell foodDoes like like any strong smell food

158


Samuel: 4 years oldSamuel: 4 years old Tx: desensitize; feeding hierachyTx: desensitize; feeding hierachy

ToleratesTolerates Interacts with foodInteracts with food SmellSmell TouchTouch TastesTastes EatsEats swallowsswallows

159

Case Study--AlbertCase Study--Albert

Albert (age 5 years) – good comprehension Albert (age 5 years) – good comprehension – highly echolalic. – highly echolalic. Cannot initiateCannot initiate Cannot generate novel utterancesCannot generate novel utterances Cannot describeCannot describe Can listCan list Repeats easilyRepeats easily

160

Case Study--AlbertCase Study--Albert

Treatment: Treatment: Work on social routine utterances, like “I want xxx”Work on social routine utterances, like “I want xxx” Modify routine utterances, like “I want xx and xx”, or Modify routine utterances, like “I want xx and xx”, or

“May I have xxx.”“May I have xxx.” Impose alternatives in routine, like “I want ball (show Impose alternatives in routine, like “I want ball (show

pencil)” Model “No this is not a ball, this is a ball pencil)” Model “No this is not a ball, this is a ball (show ball.) Follow routine until Allen makes (show ball.) Follow routine until Allen makes adjustments. adjustments.

Rotate routines between alternates and routines.Rotate routines between alternates and routines. Model – alternate- expand-reviseModel – alternate- expand-revise

161

Case Study--ChipCase Study--Chip

Chip (age 5 years)– verbal, high Chip (age 5 years)– verbal, high pitch/monotone, rigid/lacks transitions, pitch/monotone, rigid/lacks transitions, some delayed echolalia, retells events like some delayed echolalia, retells events like he was quoting from a story line.he was quoting from a story line.

162

Case Study--ChipCase Study--Chip TreatmentTreatment

Flexibility in conversation. Model different ways of requesting, Flexibility in conversation. Model different ways of requesting, describing, demanding. Set up routines where each is describing, demanding. Set up routines where each is practiced. Adjust so that spontaneous use of conversation practiced. Adjust so that spontaneous use of conversation occurs.occurs.

Role Playing. Use others (parent) or stuffed animals as models Role Playing. Use others (parent) or stuffed animals as models for requesting, describing, and demanding. Have stuffed for requesting, describing, and demanding. Have stuffed animal make mistakes. Help Charlie to explain by example animal make mistakes. Help Charlie to explain by example how to correct the mistake.how to correct the mistake.

Use story books with different intonation patterns, like “Three Use story books with different intonation patterns, like “Three Little Pigs” or “Goldilocks,” to teach stress, rising pitch, and Little Pigs” or “Goldilocks,” to teach stress, rising pitch, and loudness.loudness.

Use people pictures with different expressions, like happy, sad, Use people pictures with different expressions, like happy, sad, surprise, confused, angry/mad, tired. Have Charlie describe surprise, confused, angry/mad, tired. Have Charlie describe each and model the expression using a mirror. Follow through each and model the expression using a mirror. Follow through by having parent/teacher demonstrate the by having parent/teacher demonstrate the

163

Case Study-MarkCase Study-Mark

Mark (age 5 years) – Adopted from Mark (age 5 years) – Adopted from Eastern Europe, verbal, quiet/inhibited, Eastern Europe, verbal, quiet/inhibited, inflexible, concrete.inflexible, concrete.

164

Case Study-MarkCase Study-Mark TreatmentTreatment

Executive function skills – organization, flexibility, Executive function skills – organization, flexibility, retrieval, retelling events, generating novel events, retrieval, retelling events, generating novel events, defining.defining.

Use picture adapted story books, with sentences Use picture adapted story books, with sentences adapted and pictures scanned. Read story book, adapted and pictures scanned. Read story book, unscramble picture to follow the story event (from unscramble picture to follow the story event (from memory), match scrambled sentences to the pictures. memory), match scrambled sentences to the pictures. Retell the story from the pictures. Retell the story from the pictures.

Use story events to acquire new vocabulary and Use story events to acquire new vocabulary and concepts, like learning the concept of first, second, concepts, like learning the concept of first, second, and third.and third.

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Autism Spectrum Disorder: Intervention

Documents

high functioning autism

language subgroup

language comprehension

language skills good

emotional disorder

social responsivenessmore

social reciprocity

social interactionimpairment