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Section 7
Interventions to Facilitate Communication in Autism

Question 7 | Test | Table of Contents

Spontaneity, Initiations, and Functions of Language
In the area of autism, in contrast to other disabilities, lack of spontaneous verbal and nonverbal initiations appears to be a consistent problem. Regardless of communicative level, the number of communicative initiations and the expansion of specific functions of language seems to be particularly problematic. Thus, whether a child with autism uses verbal means of communication or uses augmentative and/or alternative systems of communication, intervention research focused on improving these skills is especially important.

For example, consider the small percentage of children who remain nonverbal and for whom a number of augmentative and alternative communicative (AAC) systems are now available. AAC systems can include sign language (Carr & Kologinsky, 1983; Horner & Day, 1991), photographs (Kozleski, 1991; Reichle et al., 1996), picture exchange systems (Bondy & Frost, 1998), communication books (Hunt, Alwell, Goetz, & Sailor, 1990), computer systems, and so on. Although teaching technologies are more clearly defined, spontaneity has been a problem. While these nonverbal children can show large degrees of success with initial acquisition, they exhibit difficulties with generalization of AAC systems (Mirenda & Mathy-Laikko, 1989; Schlosser, Belfloire, Nigam, Blischak, & Hetzroni, 1997; Storey & Provost, 1996; Stiebel, 1999; Udwin & Yule, 1990). They often require constant and consistent adult prompting and fail to demonstrate the spontaneous use of a variety of functions needed for communicative competence. Scientifically sound procedures related to teaching the spontaneous use of AAC outside of a clinical setting are clearly lacking in the literature. Although the likelihood of generalization from clinic to home settings increases if AAC is incorporated into family routines (Steibel, 1999), assessing the specific types of communicative intentions that are most useful, perhaps by incorporating a functional analysis, may increase the child’s use of AAC while reducing the demands on a parent or adult. Also, apraxia and difficulty with fine motor skills appear to be common in nonverbal children with autism who demonstrate difficulty with ACC systems (Seal & Bonvillian, 1997). Thus, research on the interrelationships between motor performance and communication may help determine the most appropriate AAC systems for nonverbal children who fail to acquire verbal language.

Similar issues regarding the lack of spontaneity, initiations, and functions of language exist for verbal children with autism. Wetherby and Prutting (1984) analyzed language samples of verbal children with autism and found them limited in both quantity and quality. Children with autism use language almost exclusively for requesting objects, requesting actions, and protesting. A growing body of research is demonstrating effective procedures for teaching children with autism to use absent or depressed language functions such as asking questions (Hung, 1977; L. K. Koegel, Camarata, Valdez-Menchaca, & Koegel, 1998; Taylor & Harris, 1995; Warren, Baxter, Anderson, Marshall, & Baer, 1981) and other verbal initiations (L. Koegel, Koegel, Shoshan, & McNerney, 1999). Spontaneous initiations are necessary for children with autism to be judged as socially competent during interactions. Research designed to develop intervention procedures to teach spontaneity and initiations and research assessing and defining the types and numbers of initiations children need to exhibit to appear communicatively competent will enhance our understanding of best intervention practices.

Precursors Related to Positive Outcomes and Measurement
The literature suggests that the single most important prognostic indicator for young children with autism is language ability (Schreibman, 1988). Specific information regarding the types and amounts of language precursors that lead to positive outcomes, both for verbal and preverbal children with autism, should greatly enhance our research base. For example, joint attention is consistently noted as important in prelinguistic development. For typical language learners the onset of joint attention appears to signal a new level of understanding, and to have an intrinsic motivational base, which is social in nature and is strongly correlated with the emergence of naming (Bates, Thal, & Marchman, 1991). Unfortunately, children with autism generally demonstrate a lack of, or a reduced number of, important referential gestures, such as showing, giving, and pointing, and using eye gaze to communicate (Stone, Ousley, Yoder, Hogan, & Hepburn, 1997). This deficit can be noted early in life in children with disabilities and appears to be an important milestone warranting research attention.

For verbal children with autism, a similar pervasive lack of social initiations appears to be a consistent pattern and likely precursor to communicative impairment during social interactions. A common utterance during initial lexical development in typical language development is "that?" (/daet/), often used in conjunction with pointing to items. This interrogative verbalization along with nonverbal cues, such as pointing, can be a specific prompt for a parent to label the item for the child (Halliday, 1975). Over time, this type of utterance becomes increasingly more sophisticated and varied, resulting in steadily more sophisticated questions (who, where, when, why, etc.). Rather than exhibiting these typical developmental linguistic milestones, children with autism emit fewer utterances and fail to use language as a means of social initiation (Calloway, Myles, & Earles, 1999).

In a preliminary study, L. Koegel et al. (1999) compared archival data of adolescents who were diagnosed as having autism with extremely favorable versus extremely poor outcomes following intervention. Analyses included pragmatic ratings during social interactions, school and community functioning (including academic functioning, social circles, and extracurricular activities), and adaptive behavior composites. At baseline, when the children were preschoolers, all exhibited characteristics associated with the likelihood of a favorable post-intervention outcome, such as high verbal intelligence quotients (IQ above 60) and the presence of functional speech before 5 years of age (DeMyer et al., 1973; Freeman, Ritvo, Needleman, & Yokota, 1985; Gillberg & Steffenburg, 1987; Lotter, 1974; Venter et al., 1992).

However, after long-term intensive intervention programs, which were similar across all participants, the data showed very different outcomes. Preliminary data analyses suggested that the children who had the most positive outcomes also exhibited the greatest numbers of social initiations prior to intervention, whereas the children with the least favorable outcomes exhibited few or no social initiations prior to intervention.

Such assessment data on joint attention and initiations have led researchers to begin to develop intervention procedures to teach these potentially important prerequisites. For example, Yoder and Warren (1999) have begun to develop interventions to increase the generalized use of self-initiated proto-declaratives and proto-imperatives in prelinguistic children with developmental disabilities (some of whom present with symptoms of autism). Others (Hung, 1977; L. Koegel, Camarata, Valdez-Menchaca & Koegel, 1998; Taylor & Harris, 1995; Warren et al., 1981) have designed intervention programs to improve the use of self-initiated questions and other spontaneous verbalizations. Preliminary data suggest that teaching these linguistic skills may result in more widespread clinical gains and more favorable long-term outcomes.

The literature strongly suggests that without adequate early social input, the neurological and behavioral development of children with autism may be further deflected from a typical developmental path (Mundy & Crowson, 1997). There appear to be large individual differences in joint attention and social-verbal initiations across children diagnosed as having autism. Improved precision in measuring the nature of early social communication in children with autism, as well as comprehensive outcome measures, appears to be a productive avenue for future research.

It is important, however, that information regarding prognostic indicators not be used to deny services to very young children who do not exhibit positive indicators (Parisy, 1999). Instead, determination of the variety of verbal and nonverbal behaviors that lead to improved prognoses through more precise and comprehensive longitudinal studies should help improve outcomes. Research identifying critical communicative behaviors that need to be targeted is likely to result in more efficient interventions for greater numbers of children.
- Koegel, LK; Interventions to facilitate communication in autism; Journal of Autism and Developmental Disorders, Oct. 2000, Vol. 30.

Therapies for Children with Autism Spectrum Disorder:
Behavioral Interventions Update

- Vanderbilt Evidence-based Practice Center. (2014). Therapies for Children with Autism Spectrum Disorder: Behavioral Interventions Update. Agency for Healthcare Research and Quality.

Personal Reflection Exercise Explanation
The Goal of this Home Study Course is to create a learning experience that enhances your clinical skills. We encourage you to discuss the Personal Reflection Journaling Activities, found at the end of each Section, with your colleagues. Thus, you are provided with an opportunity for a Group Discussion experience. Case Study examples might include: family background, socio-economic status, education, occupation, social/emotional issues, legal/financial issues, death/dying/health, home management, parenting, etc. as you deem appropriate. A Case Study is to be approximately 225 words in length. However, since the content of these “Personal Reflection” Journaling Exercises is intended for your future reference, they may contain confidential information and are to be applied as a “work in progress.” You will not be required to provide us with these Journaling Activities.

Personal Reflection Exercise #1
The preceding section contained information about interventions to facilitate communication in autism.  Write three case study examples regarding how you might use the content of this section in your practice.

Update
Balovaptan vs Placebo for Social
Communication in Childhood
Autism Spectrum Disorder:
A Randomized Clinical Trial

- Hollander, E., Jacob, S., Jou, R., McNamara, N., Sikich, L., Tobe, R., Smith, J., Sanders, K., Squassante, L., Murtagh, L., Gleissl, T., Wandel, C., & Veenstra-VanderWeele, J. (2022). Balovaptan vs Placebo for Social Communication in Childhood Autism Spectrum Disorder: A Randomized Clinical Trial. JAMA psychiatry, 79(8), 760–769.

Peer-Reviewed Journal Article References:
Blackman, A. L., Jimenez-Gomez, C., & Shvarts, S. (2020). Comparison of the efficacy of online versus in-vivo behavior analytic training for parents of children with autism spectrum disorder. Behavior Analysis: Research and Practice, 20(1), 13–23.

Guest, J. D., & Ohrt, J. H. (2018). Utilizing child-centered play therapy with children diagnosed with autism spectrum disorder and endured trauma: A case example. International Journal of Play Therapy, 27(3), 157–165.

Harris, B., McClain, M. B., Haverkamp, C. R., Cruz, R. A., Benallie, K. J., & Benney, C. M. (2019). School-based assessment of autism spectrum disorder among culturally and linguistically diverse children. Professional Psychology: Research and Practice, 50(5), 323–332.

QUESTION 7
What behaviors are common in nonverbal children with autism who demonstrate difficulty with ACC systems? To select and enter your answer go to Test.