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DOI: 10.1177/1534650113508221
2014 13: 282 originally published online 24 October 2013Clinical
Case StudiesMark F. O'Reilly and Peter B. Marschik
Larah van der Meer, Jeff Sigafoos, Dean Sutherland, Laurie
McLay, Russell Lang, Giulio E. Lancioni,Communicative Functions in
a Child With Autism Spectrum Disorder
Preference-Enhanced Communication Intervention and Development
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Article
Preference-Enhanced Communication Intervention and Development
of Social Communicative Functions in a Child With Autism Spectrum
Disorder
Larah van der Meer1, Jeff Sigafoos1, Dean Sutherland2, Laurie
McLay2, Russell Lang3, Giulio E. Lancioni4, Mark F. OReilly5, and
Peter B. Marschik6
AbstractIndividuals with autism spectrum disorder (ASD) who
exhibit limited speech can learn to communicate using augmentative
and alternative communication (AAC) systems. We describe the case
of Ian, a 10-year-old boy with ASD who had learned to use an Apple
iPod- and iPad-based speech-generating device (SGD)Note 1, picture
exchange (PE), and manual signing (MS) for functional communication
(e.g., requesting), but had difficulty in using these AAC systems
for spontaneous and socially oriented functions of communication.
His difficulties were originally conceptualized as reflecting the
social interaction and communication deficits characteristic of
ASD. Alternatively, we suggest that the intervention did not allow
for the development of more advanced communication. A
preference-enhanced intervention was introduced with Ians chosen
AAC system only, that is the iPad-based SGD. Opportunities for
communication were created using highly motivating activities and
behavioral strategies. Results suggest that the approach
facilitated development of spontaneous and socially oriented
communication.
Keywordsaugmentative and alternative communication, autism
spectrum disorder, iPad, preference, speech-generating devices
1Victoria University of Wellington, New Zealand2University of
Canterbury, Christchurch, New Zealand3Texas State University, San
Marcos, USA4University of Bari, Italy5The University of Texas at
Austin, USA6Medical University of Graz, Austria
Corresponding Author:Jeff Sigafoos, School of Educational
Psychology, Victoria University of Wellington, P.O. Box 17-310,
Karori 6147, Wellington 6005, New Zealand. Email:
[email protected]
508221 CCS13310.1177/1534650113508221Van der Meer et al.Clinical
Case Studiesresearch-article2013
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Van der Meer et al. 283
1 Theoretical and Research Basis for Treatment
Communication impairment is necessary for a diagnosis of autism
spectrum disorder (ASD; American Psychiatric Association [APA],
2013; World Health Organization, 1992). Communication impairment in
ASD is characterized by the heterogeneity of expressive
com-munication skills; with one end of the spectrum presenting as
long-winded and talkative and the other end mute (Wilkinson, 1998).
Indeed, at least 25% of individuals with ASD fail to develop the
ability to speak (Osterling, Dawson, & McPartland, 2001).
Although they do not have any spoken language, these individuals
might be able to learn to communicate using aug-mentative and
alternative communication (AAC) systems (Beukelman & Mirenda,
2013). AAC systems include manual signs (MS), picture exchange
(PE), and electronic speech-generating devices (SGDs; Ganz et al.,
2012; Mirenda, 2003).
Because children with ASD have been taught to use each of these
AAC systems (MS, PE, and SGDs; Flippin, Reszka, & Watson, 2010;
van der Meer & Rispoli, 2010; Wendt, 2009), it can be difficult
for clinicians to select the most suitable AAC system for any given
individual. Guidelines suggest that a childs choice of, or
preference for, different AAC systems should be considered when
making such decisions (Beukelman & Mirenda, 2013). Previous
research has investigated the effects of assessing childrens
preferences for using one AAC system over another on com-munication
intervention outcomes (van der Meer et al., 2013; van der Meer,
Didden, et al., 2012; van der Meer, Kagohara, et al., 2012; van der
Meer, Sutherland, OReilly, Lancioni, & Sigafoos, 2012). Results
of this research suggest that children can learn to use each AAC
system (MS, PE, and SGD) for functional communication (e.g.,
requests for preferred items) and indicate a prefer-ence for a
specific AAC system. Furthermore, these data suggest that
acquisition and mainte-nance of communication skills is best with
the childs preferred AAC system. The majority of participants in
these studies preferred using an iPod-/iPad-based SGD and exhibited
better functional communication skills with this AAC system.
For the most part, this research is limited to teaching
beginning requesting skills. Similarly, various reviews of the
literature pertaining to MS, PE, and SGD communication
interventions (e.g., Goldstein, 2002; Lancioni et al., 2007) have
stressed that children with ASD can be taught to use these AAC
systems for functional communication skills, such as requesting and
labeling items, but little research has investigated and
successfully taught the use of these systems for spontaneous and
more socially oriented communication skills. The majority of AAC
intervention studies reviewed (e.g., van der Meer & Rispoli,
2010) utilized behavioral intervention involving one-on-one
instruction, time delay, response prompting, prompt fading, error
correction, and dif-ferential reinforcement. While these procedures
appear to be effective in teaching initial com-munication skills,
it has been argued that more naturalistic teaching strategies might
allow for the development of spontaneous social communication, such
as initiations (Drager, Light, & Finke, 2009), although, as
Drager and colleagues noted, there is limited research
demonstrating that naturalistic approaches are effective in
promoting social interaction for children with ASD who use AAC.
Given that ASD is characterized by persistent deficits in social
interaction and social com-munication, including impairments in the
use of multiple nonverbal behaviors such as eye-to-eye gaze, facial
expression, and gestures to regulate social interaction as well as
marked impairment in the ability to initiate or sustain a
conversation with others (American Psychiatric Association, 2013;
World Health Organization, 1992), it is perhaps not surprising that
few interventions have been successful in teaching these skills.
There are several hypotheses to explain why individuals with ASD
struggle to learn spontaneous reciprocal communication. For
example, because many individuals with ASD exhibit an indifference
or aversion to other people, they may not be intrin-sically
motivated to interact with others and obtain new information and
perspectives necessary for socially interactive communication
(Drager et al., 2009; Sturmey & Fitzer, 2009). This may
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284 Clinical Case Studies 13(3)
be the result of a deficit in theory of mind, which relates to
an inability to understand other peo-ples cognitive states (Matson,
Kozlowski, & Matson, 2012; Tager-Flusberg, 1996; Wilkinson,
1998). Alternatively, it has been hypothesized that children with
ASD find the experience of sharing attention with other individuals
to be less rewarding (Stone, Ousley, Yoder, Hogan, & Hepburn,
1997), reflecting their usually limited and unusual range of
preferences and motiva-tional variables (Sturmey & Fitzer,
2009). This links to the notion that children with ASD are more
motivated to communicate wants and needs because they are
associated with tangible rein-forcement and therefore of direct
benefit to the speaker, while other forms of social communica-tion
are commonly of benefit to the listener (Skinner, 1957).
Furthermore, communicating wants and needs is typically linked to
tangible contextual cues (e.g., the preferred item), thereby
serving as a prompt for the communicative behavior, while social
communicative functions do not pro-vide these concrete visual cues
(Quill, 1997).
Further to the social deficits inherent among children with ASD,
there are difficulties associ-ated with the task of using AAC
systems to teach these skills. Social forms of communication can
involve abstract concepts that can be difficult to represent on AAC
systems and therefore may be more difficult to teach in
communication interventions. Furthermore, representation of these
language concepts (e.g., please and thank you) on each AAC system
(SGD, PE, and MS) can become even more complex and difficult for
children to learn. In an earlier study, we hypothe-sized that this
could explain the less favorable results in a communication
intervention with two participants (Ian and Hannah) targeting more
complex and socially oriented communication using each AAC system
(van der Meer et al., 2013). Results suggested that the highly
structured behavioral procedures were effective in teaching
two-step requesting for both participants, while only moderately
successful for three-step requesting and the more social
communication skills of (a) initiating greetings, (b) answering
questions, and (c) using etiquette with each AAC system for only
one of the participants (Ian).
Given these findings, it is expected that intervention might
continue more successfully with the participants preferred AAC
system only. In turn, this might allow for more advanced lan-guage
and communication skills to be targeted. Still, prompting
participants for each interaction could be viewed as contradictory
to the way in which children naturally learn language. Instead,
natural cues for interaction to indicate opportunities for
communication should be provided (Drager et al., 2009; Prizant
& Wetherby, 2005). This involves communication opportunities
that occur in natural environments, with familiar people, and
involve activities that are motivating. The purpose of the present
case study was to determine if a modified behavioral intervention
with Ians most preferred AAC system would result in more
spontaneous, complex, and socially ori-ented communication, which
may have been difficult to learn with all four AAC systems (iPod-
and iPad-based SGD, PE, and MS). Ians mother and a support worker
created natural opportunities for communication related to watching
his preferred DVDs. A time-delay (Halle, Marshall, & Spradlin,
1979) procedure was introduced before any communicative
initiations/responses with his preferred method, the iPad-based
SGD, were prompted by his communica-tion partner.
2 Case Introduction
Ian was a 10-year-old boy diagnosed by his pediatrician with
ASD, moderate intellectual dis-ability, developmental co-ordination
disorder, and epilepsy. Ian participated in an AAC interven-tion
where he was taught to use an iPod- and iPad-based SGD, PE, and MS
for functional communication, because of his extremely limited
communicative skills (van der Meer, Sutherland, et al., 2012).
Although Ian tried to sound out some words, these were
unintelligible to unfamiliar communication partners. He also used
some idiosyncratic gestures, seemingly to depict objects and
actions. However, these gestures were largely unintelligible to his
communicative partners.
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Ian would often take peoples hands to direct them to what he
wanted and frequently grabbed people in an apparent attempt to get
their attention. Ians mother indicated that he engaged in obsessive
behavior (e.g., fixation with certain toys) and had difficulty with
changes to routines. His vision and hearing were in the normal
range and he did not appear to have any major or obvi-ous
difficulties with gross or fine motor skills. Ians mother and a
support worker taught Ian to use the AAC systems (SGD, PE, and MS)
at home. A speech-language pathologist provided input on his
communication difficulties.
3 Presenting Complaints
With the introduction of the AAC intervention, Ian learned
functional communication skills, such as requesting preferred music
and toys, with the iPod-based SGD, PE, and MS with compara-ble ease
(van der Meer, Sutherland, et al., 2012). In that study, systematic
choice assessments were conducted, in which he consistently chose
and thereby seemingly demonstrated a prefer-ence for using the
iPod-based SGD compared with PE and MS. In a second study, he also
learned to use each AAC system for more complex and socially
oriented communication skills, such as multi-step requesting,
greetings, answering questions, and social etiquette (van der Meer
et al., 2013). However, throughout this second intervention, Ian
consistently performed better when requesting specific items with
each AAC system than he did when opportunities for more social
communication were created (e.g., using an AAC system to say Thank
you for the requested item or saying Hello to his communicative
partner). Furthermore, Ian engaged in such social communicative
responses only after a verbal prompt; spontaneous communication was
therefore not evident. He had some difficulties in activating the
iPod-based SGD. Therefore, follow-up sessions were implemented with
an iPad-based SGD to assess whether his ability to use the iPod
would generalize to the iPad and whether the larger sized icons and
increased sensitivity of the screen on the iPad would make it
easier for Ian to activate the SGD. With the introduction of the
iPad, correct communicative responding immediately improved and Ian
also indicated a preference for using the iPad-based SGD.
4 History
Although Ian was initially diagnosed with cerebral palsy at the
age of one, this diagnosis changed several times, until diagnoses
of ASD, moderate intellectual disability, developmental
co-ordination disorder, and epilepsy were given at the age of eight
years. Other than a few single and largely unintelligible word
approximations, Ian had not developed effective speech. He
attempted to communicate by creating his own signs to represent
certain items and activities. However, he had no apparent means of
easily being understood by his communicative partners. His mother
reported spending considerable time deciphering single sign
approximations he had created. Because Ian had previous exposure to
various AAC systems with limited success, he was selected for a
larger research project investigating the feasibility of assessing
childrens preferences for using one AAC system over another and
whether this would positively influence intervention outcomes. The
present case study started approximately one year after this larger
research project commenced and directly after the follow-up phase
of the second study (van der Meer et al., 2013), in which Ian had
demonstrated success in, and a preference for, using the iPad-based
SGD.
5 Assessment
Before implementation of the communication intervention for the
larger research project, an adaptive behavior assessment and a
stimulus preference assessment were completed. Using the
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286 Clinical Case Studies 13(3)
Vineland Adaptive Behavior Scales, second edition (Vineland-II;
Sparrow, Cicchetti, & Balla, 2005), Ian received an adaptive
behavior composite standard score of 56, indicating a low adap-tive
level with a mild deficit. He received an age equivalency of 1:4
(years:months) on the expressive communication subdomain of the
Vineland-II (Sparrow et al.) as well as age equiva-lencies of 2:2
for receptive communication, and 3:10 for written communication. An
age equiva-lency of 2:1 on the fine motor skills subdomain of the
Vineland-II (Sparrow et al.) suggested that Ian had sufficient
motor skills to communicate with each AAC system.
The stimulus preference assessment was implemented to identify
highly preferred activities that could be used to create
opportunities to teach Ian various communication skills. The
prefer-ence assessment followed a two-stage process (Green et al.,
2008). Stage 1 involved an indirect assessment in which Ians mother
was asked to provide a list of activities that Ian appeared to
enjoy and would be appropriate for the intervention. The six most
preferred activities were then selected for a direct stimulus
preference assessment, involving the simultaneous presentation of
multiple items, without replacement (DeLeon & Iwata, 1996). Ian
was offered items for these activities and allowed to select one. A
session consisted of repeating such offers six times. Items for
each activity were not replaced once they had been selected. Six
such sessions were under-taken before his most preferred activity
was identified by calculating a rank order of the percent-age of
times that an activity was selected. In order to do so, the
following formula was used: number of selections / number of offers
100. Watching DVDs was identified as his most pre-ferred activity
(selected 100% of the time). We then asked his mother to choose
four DVDs that Ian appeared to enjoy watching and could be used for
the intervention sessions only (i.e., he was not allowed to watch
them in any other context, so as to maintain his motivation to
watch the DVDs and participate in the communication intervention
sessions). Based on his mothers reports, Ian appeared to have
sufficient content knowledge of these DVDs in order to use the iPad
for communicative interactions surrounding the content related to
the people and activities in the DVDs as well as identifying
emotions of characters.
6 Case Conceptualization
A case conference was held during the follow-up phase of the
second study (van der Meer et al., 2013) to discuss ways in which
to promote more naturally occurring social communication. This was
based upon data suggesting that social communicative responses with
each AAC system were only produced by Ian after a specific prompt
(e.g., Its time to do some work, first we are going to play and
then we can have a snack. Say hello or We have finished for today.
Say thank you and good-bye). It was not known whether Ian would
spontaneously demonstrate these social communicative skills. Such
naturally occurring social communication may have been inhibited by
the complexity of having to learn the responses with each AAC
system. For example, to make a request for a cracker, Ian had to
learn to select the correct icons on the screen of the SGD to
activate the voice-output (I want a cracker, please), select the
correct icons from the laminated standard sized sheet of paper and
place them onto a separate sentence strip to result in the
sen-tence I WANT and A CRACKER and PLEASE for PE, and perform the
hand gestures to produce the correct signs for I WANT plus CRACKER
plus PLEASE for MS.
Furthermore, it could be argued that the only part of the
communicative interaction Ian gener-ated (and thereby changed the
meaning of the utterance) was the single icon for the desired item.
It was not known whether Ian could learn more complex communicative
skills with any of the AAC systems. The intervention team agreed
that such complex language might be more easily learned if
intervention continued with Ians preferred AAC system only. The
follow-up results indicated that Ian not only demonstrated a
preference for the newly implemented iPad-based SGD, but he was
also better able to use it. Thus, a decision was made to continue
intervention with the iPad-based SGD only. This was paired with a
modified behavioral intervention in
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which a time-delay procedure was introduced before any
communicative interactions were prompted. We hypothesized that
simplifying the task demands by teaching new communication skills
with his preferred AAC system only and utilizing time-delay might
allow for the emer-gence of more spontaneous, complex, and social
communication.
7 Course of Treatment and Assessment of Progress
Communication sessions were implemented by Ians mother or
caregiver (the instructors) at the dining room table. Specifically,
within a DVD watching activity they taught Ian to use the
iPad-based SGD to request, comment, answer questions, and
name/label actions, emotions, and peo-ple. Throughout each baseline
session, the instructor sat next to Ian, with the iPad, loaded with
the software application Proloquo2Go Note 2 to enable synthesized
voice-output. The iPad was kept on the table opened to a screen
with a folder entitled DVD TIME. Within this folder, the iPad was
programmed with five subfolders: ACTIONS, CHOOSING, EMOTIONS,
GREETINGS AND ETIQUETTE, and PEOPLE. Within the CHOOSING folder,
there were icons to represent each of the DVDs Ian could request to
watch, as well as an icon to represent a request to watch MORE and
request to STOP watching the DVD. Within the GREETINGS AND
ETIQUETTE folder, there were icons to represent social niceties,
such as PLEASE and THANK-YOU. Within the ACTIONS, EMOTIONS, and
PEOPLE folders, there were icons to represent the various actions,
emotions, and people that occurred in each of the targeted DVDs.
Ian had to navigate through these folders for each communicative
initiation/response.
All icons comprised of either line drawings selected from the
available database in the Proloquo2Go software or photos. Each icon
had the word written below and resulted in the corresponding
voice-output when the icon was selected. For example, within the
CHOOSING folder, selecting the icon with a photo of a DVD and the
words BIG RED CAR would result in the voice-output I would like to
watch the Big Red Car DVD.
During baseline sessions, to initiate a communicative
interaction, the instructor asked What do you want to do? and
waited approximately 10 s for Ian to make a request to watch one of
the four DVDs identified in the preference assessment. If a request
for a specific DVD was made, that DVD was played. If a request was
not made, the instructor randomly selected a DVD for view-ing.
After a few minutes the DVD was paused and the instructor waited
for approximately 10 s to see if Ian initiated any communication
using the iPad. Regardless of any communicative attempts, the movie
was then resumed for a few minutes. This process of playing the DVD
and then pausing to wait for any communicative interactions was
repeated three times per baseline session. To signal the end of the
session, the instructor asked Ian: Want to stop?. Regardless of
Ians communicative response, the instructor stopped the DVD after
10 s. Because this was a new communicative skill, reinforcing this
response was thought to act as an instructional procedure thereby
compromising the experimental integrity of the intervention. During
these sessions, the instructor recorded whether any communicative
acts were independent (i.e., self-initiated), after a verbal cue
(prompted), incorrect, or that there was no response. Figure 1
shows the course of treatment. As indicated in this figure,
throughout baseline there were no communicative responses for any
of the communicative categories programmed to the iPad. In other
words, without any instruction on how to use the iPad, Ian did not
use it to initiate any communicative interactions surrounding the
DVD watching activity.
During intervention sessions, 10 s after the instructor
initiated a communicative interaction by asking What do you want to
do?, the instructor also provided a verbal cue by saying You can
ask to watch a DVD and, if necessary, used the least amount of
guidance necessary (point, model, physical prompt) to teach Ian how
to make a request on the iPad for watching one of the DVDs. After
Ian had watched the requested DVD for a few minutes, the instructor
paused the DVD for approximately 10 s to assess if Ian used the
iPad to initiate any communicative interactions. If
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288 Clinical Case Studies 13(3)
no communicative initiations were made, the instructor initiated
a commenting sequence by ask-ing Who is that? while pointing to one
of the characters on the screen of the DVD (PEOPLE category), then
What is he/she doing? (ACTION category), and finally How is he/she
feeling? (EMOTIONS category). If a response was not made within
approximately 10 s, the instructor prompted Ian, using the least
amount of guidance necessary, to navigate to the folder on the iPad
corresponding to the communicative category for the question asked.
As in baseline, this process of playing the DVD and then pausing to
wait for any communicative interactions was repeated three times
per session. To signal the end of the session, the instructor asked
Ian Want to stop or keep going?. Within the CHOOSING folder, Ian
could request to watch MORE or STOP. If he requested to watch more,
he was able to continue watching the DVD, but the communica-tion
intervention session did not continue.
For each intervention session, the number of communicative acts
for each category of com-munication (i.e., ACTIONS, CHOOSING,
EMOTIONS, GREETINGS and ETTIQUETTE, PEOPLE) was tallied according
to whether the communication was: independent (i.e.,
self-initiated), after a verbal cue, incorrect, or if no response
was made.
As shown in Figure 1, with the introduction of systematic
instruction (the least amount of guidance necessary) to teach Ian
to navigate through the iPad for communicative interactions, he did
learn to request the DVDs and comment on what was happening in the
DVD, who was in the DVD, and how particular people in the DVD were
feeling. Requesting was self-initiated 53% of the time, while
commenting on the DVDs primarily only occurred after the instructor
provided a verbal cue (e.g., What is he/she doing?). Naming of the
characters in the DVD was initiated by Ian 10% of the time, while
labeling actions and feelings independently only occurred 3% and 2%
of the time, respectively. Requests to continue or stop the DVD
only occurred after a verbal cue. Across all communicative
categories, Ian only made incorrect responses 3% to 7% of the
time.
Figure 1. Percentage of response types across communicative
categories and each phase of the study for Ian.
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Van der Meer et al. 289
Throughout the intervention he did not communicate any social
niceties. However, a verbal cue for this category of communication
(GREETINGS AND ETIQUETTE) was not provided.
To assess reliability of the instructors data collection, an
independent observer simultane-ously and independently collected
the same data (i.e., whether communicative interactions were
independent, after a verbal cue, incorrect, or if there was no
response). A percentage of agreement between the instructor and the
independent observer was calculated using the formula: [Agreement /
(Agreements + Disagreements)] 100. The data can be seen as highly
reliable in that inter-observer agreement on Ians performance was
checked on 24% of all baseline, intervention, and follow-up
sessions with agreement ranging from 80% to 100% (M = 95%). To
assess procedural integrity, the independent observer had a
checklist of the procedural steps (e.g., 1. Child sits at table
with iPad in reach and DVD player in view; 2. Instructor asks What
do you want to do?; 3. Wait 10 s, then prompt request to watch DVD
as necessary, etc.) and recorded whether or not the instructor had
correctly implemented each procedural step in its proper sequence.
Procedural integrity checks collected on 24% of all baseline,
intervention, and follow-up sessions showed that correct
implementation of procedural steps ranged from 83% to 100% (M =
94%). Inter-observer agreement on the procedural checks was
collected on 5% of sessions (1 session) with 100% agreement.
Unfortunately, the video-camera malfunctioned during the long-term
follow-up meaning inter-observer agreement and procedural integrity
data could not be collected.
8 Complicating Factors
While an appropriate AAC system was selected for Ian (his
preferred iPad-based SGD) and intervention strategies were modified
in an attempt to elicit spontaneous social communication, these
skills may also have been inhibited because he only had access to
the iPad-based SGD in the specified intervention sessions, thereby
limiting opportunities for naturalistic communicative exchanges.
Future research could examine ways in which the use of such
structured procedures might allow for more spontaneous and complex
communication in AAC interventions or whether a more qualitative
and naturalistic approach is better suited to achieving this aim.
This follows a recent finding that suggests discrete trial
(structured behavioral) intervention is better suited to children
with lower receptive language levels, while milieu (naturalistic)
models appear to be more effective for children with higher levels
of receptive language (Paul, Campbell, Gilbert, & Tsiouri,
2013).
More generally, there may be several complicating factors to AAC
intervention that might need to be considered with future cases.
Specifically, successful adoption of AAC systems involves using a
particular system/s (SGD, PE, MS) not only for expressing basic
wants and needs when prompted to do so but also for spontaneous use
of the system and for more complex and socially oriented
communicative purposes. While intervention studies have
demonstrated children with ASD can learn to use SGD, PE, and MS
(Flippin et al., 2010; van der Meer & Rispoli, 2010; Wendt,
2009) for functional communication in structured environments, less
empirical research has been undertaken to guide clinicians in
facilitating self-initiated social communication (Drager et al.,
2009). Drager and colleagues explained that there are two
essen-tial components in AAC interventions to promote social
communication for children with ASD: the AAC system itself and the
AAC intervention/instructional techniques. AAC technologies alone
will not allow for the development of social communication, they
must be paired with appropriate intervention strategies to
encourage spontaneous social communicative interactions.
One reason for the dearth of empirical research in this field is
that highly structured proce-dures are needed for data collection
and to ensure experimental control, limiting the type, com-plexity,
and spontaneity of communication skills targeted (van der Meer et
al., 2013).
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290 Clinical Case Studies 13(3)
9 Access and Barriers to Care
This clinical case study was carried out in New Zealand. By law,
all children in New Zealand, regardless of their disability, are
allowed access to public education. Children identified as high
needs are provided with extra education funding to support their
development and are required to have an individual education plan
(IEP). The IEP commonly includes a number of related ser-vices,
such as speech-language therapy. However, the speech-pathologist
typically works within a consultancy model of practice by providing
advice and guidance to the childs teachers, teach-ing assistants,
and parents on how to implement the plan. Similarly, little direct
intervention was being provided by a speech-language pathologist,
which led to Ians identification as a suitable participant for a
research project involving AAC intervention.
Ethical approval from the relevant university committee and
informed consent from Ians parents were gained before the
intervention program was undertaken. Ians assent to participate was
implied by his willingness to cooperate in the intervention. Ian
always readily took part in the intervention sessions. The initial
objective was to teach Ian to use three common forms of AAC (SGD,
PE, and MS) and assess his preference for using one system over the
others. Ian demonstrated a preference for using the iPad-based SGD
and the intervention team decided that he would be motivated to
continue communication intervention targeting more complex language
with this AAC system only. His parents were consulted in the
process and agreed that continued intervention with the iPad was
the best option for Ian. This treatment, while home-based, was
consistent with objectives in his IEP, where the school was
starting to use iPads for academic activities.
While students with severe communication impairment are usually
provided with a SGD on the recommendation of speech-language
pathologists, this can often be a lengthy and difficult process.
Fortunately, an iPad Mini-based SGD was donated to Ian upon
completion of the first follow-up of this case study. Ians parents,
speech-language pathologist, teacher, and teaching assistants
consulted with the intervention team to develop a communication
plan using the iPad Mini to meet Ians on-going and increasing
communication needs.
10 Follow-Up
Four follow-up sessions were conducted 10 weeks after the final
session of the intervention phase. During the 10-week break, Ian
did not have access to the iPad. The follow-up proce-dures were the
same as those described for intervention, except that prompting
(using the least amount of guidance necessary) was not given. As
shown in Figure 1, Ians self-initiated requests for watching a DVD
increased to 75%. He did not independently comment on aspects of
the DVD (people, actions, emotions), but did respond correctly 75%
to 88% of the time for these communicative categories. Incorrect
responses did increase slightly (12% to 25%) from interven-tion for
these communicative categories. Again, Ian did not communicate any
greetings or other social etiquette using the iPad. Never the less,
these follow-up data suggest good maintenance of the treatment
effect for increasing the number of communicative interactions.
Two long-term follow-up sessions were implemented one year after
the first follow-up phase. During this year, Ian had been using the
iPad Mini as his primary mode of communication. Procedures were
identical to those outlined for the first follow-up. As indicated
in Figure 1, Ians self-initiated requests for watching the DVD were
100% and self-initiated commenting about the people in the DVD,
what they were doing, and how they were feeling increased to
between 38% and 70%. He even independently initiated use of the
GREETINGS AND ETIQUETTE category, although needed a verbal cue to
then use the iPad for the greeting resulting in the voice-output:
hello.
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Van der Meer et al. 291
Anecdotally, Ians mother reported that since Ian received his
own iPad Mini-based SGD, he began using it to initiate interactions
for a range of communicative functions. For example, he will
persist in using the iPad Mini to request to visit his caregiver by
selecting an icon with the voice-output: Can I go to . . . house?
He has even learned to use various social niceties, such as
repeatedly using the iPad Mini to select an icon with the
voice-output: please when his mother does not allow him to visit
his caregiver.
11 Treatment Implications of the Case
The introduction of the iPad utilizing applications such as
Proloquo2Go to serve as commu-nication systems with speech-output
has offered many potential benefits to individuals with ASD who
require AAC. Benefits include a device that is low cost, easy to
obtain and transport, readily available, and socially acceptable
(Shane et al., 2012). However, McNaughton and Light (2013) also
highlight potential challenges in the adoption of these new
technologies. Namely, the mere use of the technology itself is not
enough to enhance the communicative interactions of individu-als
with ASD. The focus must remain on appropriate assessment and
intervention to support a wide variety of communicative functions.
Furthermore, with research suggesting individuals with ASD may only
focus their attention to stimuli, which are of interest and highly
motivating to them (Casanova, 2007; Casanova, Buxhoeveden, &
Brown, 2002; Geschwind, 2009), the intervention should generate
opportunities for communication within preferred activities and
using highly reinforcing items.
Still, teaching more abstract and socially oriented
communication skills may be too difficult for some children with
ASD (as was the case with Hannah; van der Meer et al., 2013) and is
typi-cally attributed to deficits in social interaction and social
communication characteristic of ASD (Drager et al., 2009). However,
it is also well documented in the AAC field that individuals
require intensive intervention to learn a range of communicative
functions (Beukelman & Mirenda, 2013). For cases such as Ian,
structured intervention can be used to explicitly teach some social
communicative functions. We propose that a combination of factors
led to Ians com-municative competence: (a) using his preferred AAC
system (iPad-based SGD) only, (b) creat-ing opportunities for
communication within highly motivating activities (watching DVDs),
(c) one-on-one intervention with behavioral procedures (prompts) to
teach specific communicative functions, and (d) introduction of
time delay before communication was prompted to allow for
initiations. With such reductions to instructional control
(Sigafoos, OReilly, Schlosser, & Lancioni, 2007) and as Ian
became familiar with the new communicative functions, he indicated
the ability to take part in these social communicative interchanges
(e.g., commenting on who certain people in the DVDs were, what they
were doing, and how they were feeling). Furthermore, after this
initial structured behavioral intervention, long-term follow-up
data suggest that inte-grating iPad use into everyday communication
exchanges across contexts allowed for further development of
spontaneous, creative, and socially oriented communication.
12 Recommendations to Clinicians and Students
A key issue for research and practice in designing effective
communication interventions for individuals with ASD is the
selection of an appropriate AAC system (Sigafoos, Drasgow, &
Schlosser, 2003). Because there does not appear to be one single
mode of AAC that is most read-ily taught to, and learned by, these
children, we suggest that decisions regarding which AAC system to
implement can be based upon an assessment of the individuals
preferences for using one AAC system above the others. It is
recognized that with heavy caseloads, a wide range of assessment
considerations, and short timeframes for service delivery,
clinicians often find it dif-ficult to assess client preferences
(Ruggero, McCabe, Ballard, & Munro, 2012; Verdon, Wilson,
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292 Clinical Case Studies 13(3)
Smith-Tamaray, & McAllister, 2011). Results of our
preference-enhanced communication inter-vention provide an
efficient method for clinicians to assess choice and indicate that
giving stu-dents the opportunity to select their most preferred AAC
system positively influences progress in learning to communicate
and maintain these newly acquired AAC skills (van der Meer, Didden,
et al., 2012; van der Meer, Kagohara, et al., 2012; van der Meer et
al., 2013; van der Meer, Sutherland, et al., 2012). Furthermore, we
expect that by using the childs preferred AAC system there will be
less chance of device abandonment at the conclusion of initial
interventions, a com-mon issue in the field of AAC (Abbott, Brown,
Evett, Standen, & Wright, 2011; Johnson, Inglebret, Jones,
& Ray, 2006). However, if new technologies, such as the
iPad-based SGD, are indicated as preferred by students, then
parents, teachers, and clinicians need to gain confidence in
programming and maintaining the hardware and software to meet each
individuals increasing communication demands (McNaughton &
Light, 2013).
The present case study emphasizes the need for systematic
selection of an appropriate AAC system based on the clients
preference combined with appropriate use of intervention strategies
to allow for the development of a range of communicative functions
beyond expressing basic wants and needs. Results provide evidence
to suggest that a structured behavioral intervention enabled Ian to
learn to use an iPad-based SGD for specific communicative skills
and as he developed an understanding of the meaning and purpose of
these communicative interactions, they gradually became spontaneous
and generalized to a wider range of communicative functions used
within naturally occurring communicative exchanges.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) disclosed receipt of the following financial
support for the research, authorship, and/or publi-cation of this
article: Preparation of this chapter was supported by a grant from
the New Zealand Government through the Marsden Fund Council,
administered by the Royal Society of New Zealand; and by Victoria
University of Wellington, The University of Canterbury, and The New
Zealand Institute of Language, Brain & Behaviour.
Notes
1. Apple iPod/iPad/iPad Mini are a registered trademark of the
Apple Corporation, Cupertino California, www.apple.com
2. Proloquo2Go is a registered trademark of AssistiveWare B.V.,
Amsterdam, the Netherlands, www.assistiveware.com
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Author Biographies
Larah van der Meer, PhD, is a post-doctoral research fellow in
the School of Educational Psychology at Victoria University of
Wellington, New Zealand. Her research focuses on
preference-enhanced communi-cation intervention for children with
autism spectrum disorders.
Jeff Sigafoos, PhD, is a professor in the School of Educational
Psychology at Victoria University of Wellington, New Zealand. His
research focuses on communication intervention for individuals with
devel-opmental and physical disabilities.
Dean Sutherland, PhD, is a senior lecturer in the School of
Health Sciences at the University of Canterbury, New Zealand. His
research focuses on communication, augmentative and alternative
communication and children with autism spectrum disorder.
Laurie McLay, PhD, is a lecturer in the School of Health
Sciences at the University of Canterbury, New Zealand. Her research
interests include evidence-based practice for children with
developmental disabili-ties, applied behavior analysis, functional
behavior assessment, and AAC.
Russell Lang, PhD, BCBA-D, is an assistant professor in the
Department of Curriculum and Instruction at Texas State University
in San Marcos. He is the executive director of the Clinic for
Autism Research
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Van der Meer et al. 295
Evaluation and Support (CARES) where he conducts research on the
treatment of challenging behavior in children with
neurodevelopmental disabilities.
Giulio E. Lancioni, PhD, is a professor in the Department of
Neuroscience and Sense Organs, University of Bari, Italy. His
research focuses on assistive technology interventions for
individuals with multiple disabilities.
Mark F. OReilly, PhD, is the Audrey Rogers Myers Centennial
Professor in Education, College of Education and professor and
chair of the Department of Special Education at The University of
Texas at Austin. His research focuses on assessment and treatment
of challenging behavior and use of assistive tech-nologies with
individuals with severe disabilities.
Peter B. Marschik, DPhil, PhD, DMsc, is an associate professor
at the Institute of Physiology at Medical University of Graz,
Austria. His interdisciplinary research focuses inter alia on
typical and atypical speech-language and communicative
development.
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