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Autism Spectrum Disorders: Intervention for Non-Speakers
Rhea Paul, Ph.D., CCC-SLPSouthern Connecticut State University
Yale Child Study CenterFeb. 11-15, 2008
rhea.paul@yale.edu
Treatment Approaches No single approach is best for all individuals, or for
the same individual over time (NRC, 2001)
Select strategies based on the child’s needs at a given stage
Strategies depend on whether: New skills are to be taught (call for more structured,
direct teaching) Newly acquired skills need to be generalized (call for
more naturalistic context and incidental teaching) Whether the focus is on the child initiating or
responding Effective treatment:
Intensive, long-term, delivered directly to children, mostly one-to-one
Goals of Treatment for Prelinguistic Children with ASD
Social Interaction skillsSocial Interaction skills Imitation; Reciprocity Joint attention Play; peer relations
Communication skillsCommunication skills Gestures Vocalizations Speech, alternative mode Listening
Adaptive skills Learning to learn Self-help
Self-regulation, emotional regulation Preacademic skills appropriate to developmental
level
Developing Social Interaction Skills Imitation
Fundamental to learning Serious deficit in ASD
Begin with motor imitation: using ABA techniques Karin video
Progress to Small motor imitation Imitation with objects Imitating vocalizations Imitating words
Contingent Imitation Adult imitates child actions and
vocalizations. Led to increases in gaze toward
adult. One of the few demonstrations of
way to increase gaze behavior.
Joint Attention(Kasari, Sigman, Mundy, & Yirmiya, 1990)
Thought to be a fundamental deficit in ASD Supported joint attention (Yoder & McDuffie, 2006):
Adult manipulates object to get child attention Adult comments on object child is focused on Provides linguistic mapping for
objects and activities child shows interest in
Found to support the development of vocabulary (Siller & Sigman, 2002)
Associated with language development (Paul et al., in press; Wetherby et al., 2007)
Symbolic Play (Toth, K., Munson, Meltzoff, & Dawson, 2006)
Symbolic play is thought to be highly related to the development of language
Play behaviors taught by: Discrete trial imitation Physical guidance Modeling and practice in
using objects representa-tionally,
Referring to absent objects Attributing properties
to objects (hot!) Evidence shows these can be taught Evidence also shows children with more play skills
do better in other interventions for communication
Peer Group Entry Child is assigned a role to establish
group membership Child is prompted to initiate
interactions Child is given highly valued prop Child is taught five-step sequence
for entering group, using Visual Schedule
Peer Group Entry Walk over to your friend.
Watch your friend.
Get a toy like your friend is using.
Do the same thing as your friend.
Tell an idea.
Buddy Time
20 min. period during school day Each child assigned a buddy Buddies rotate Class is taught ‘buddy’ rules sequentially Both buddies receive reward if follow rules
for entire buddy period: STAY PLAY TALK: say name, talk about the play, respond to
partner, repeat then say more about it, ask a Q
Peer and Target TrainingPeer Training: Learn to play new game
(e.g., Ring around the Rosy, Hide and Seek)
Learn initiation strategies: Tap T on shoulder Say T’s name Say, “Would you like to
play..” name once choice while pointing to appropriate card
Target (T) Child Training: Learn new game Learn response
strategies: Say “yes” to peer Look at card Look at peer Play game
8 sessions prompted 8 sessions w/out
prompts
Communication
Speech-focusedSpeech-focused: aimed at getting child to use oral language
Communication-focusedCommunication-focused: aimed at getting child to engage in reciprocal social interactions; e.g., expressing communicative intent through gestures, gaze, vocalization, etc. Relationship-basedRelationship-based methods Skills-basedSkills-based methods Developmental/Pragmatic methods
Active Ingredients: Speech-Focused Methods
Clinician control Use of imitative response Tangible reinforcement Stimulus-response-
reinforcement sequence
Lovaas Young Autism Project (Lovaas, 1987)
19 preschoolers treated between 1970 1n 1984
Individual discrete trial training 40 hrs./week
Average IQ=84 Results reported ONLY for 9 BEST outcomes Later study applying same technique to
children with low IQs failed to show significant effect of the treatment
Sheinkopf & Siegel showed similar results obtained w/ 20 and 40 hours/week
Verbal behavior: Partington & Sundberg (1998) Traditional Skinnerian approach; increase
verbal imitation through use of reinforcement Highly effective for many children with
ASD (Ross & Greer; Yoder & Layton) Has difficulties always associated with
behavioral approaches re: generalization Many children with ASD do not imitate
vocalizations
Teach Me Language (Freeman& Dakes, 1996)
Mands Echoes Tacts Receptive Intraverbal
With single word
Imitate speech sounds
Names reinforcers
Follows instruction to do a fun activity
Fill in words in songs
With reinforcer present
Imitates words
Names common objects
Follows instruction to look at a reinforcer
Fill in blanks in game activities
With reinforcer not present
Imitates phrases
Names people
Follows instruction to look at a common item
Say animal sounds
Without prompts
Imitates with prosody
Names pictures
Follows instruction to touch a reinforcer
Fill in words in common activities
Mands for action
Imitates with appropriate volume
Names ongoing actions
Follows instruction to touch a common item
Fill in items by feature, function, class
Rapid Motor Imitation Training (Tsouris & Greer, 2003)
Child imitates rapid motor imitation sequences of actions the child can already do, then a simple word for a preferred item is added to the end of the sequence to be used as a request
Later, a new word for a nonpreferred item is requiredas a label, then the preferred item is given as a reward
Results show both requests and labels are produced without prompts
Scripts and Script Fading (McClannahan & Krantz, 2005)
Use a ‘prompter adult’Teach names for preferred objects and activitiesRecord names on card readerTeach child to use cards to produce requestsEventually, require the child both to run the card AND repeat the word for a request functionGradually fade scriptsSome evidence published for efficacy in small number of Ss.
PROMPT (Hayden, 1984)
Prompts for Restructuring Oral Muscular Phonetic Targets (PROMPT)
Derived from program for adult apraxia Based on assumption that a major limiting factor in
speech development for children with ASD is apraxia
Structured tactile stimulation of articulators to induce appropriate articulatory postures and movements for speech.
Little empirical support in either apraxia or autism Rogers et al (in press): PROMPT did not result in
greater gains than more communication-focused approaches (single subject).
Hayden et al. (nd): Both PROMPT and general language stimulation yield similar results
Floortime(Greenspan & Weider, 1999) Goal is to foster intimacy and
interaction Follow child’s lead, open circle of
communication (child flips light, adult covers switch)
Efficacy supported through testimonials, case studies and vignettes
Goal is not to teach skills, but to develop pleasure in relating to others
Parents encouraged to be primary intervention agents; exclusive
Only support is anecdotal case review Recent study raises Qs
Relationship Development Intervention Goal is to engage the child in a social
relationship, not achieve a specific behavioral objective
Speech is NOT a focus Provides sequenced curriculum of
activities to achieve this first in dyadic relations, then groups
No published evidence of effectiveness
Website claims decrease in symptomotology on ADOS
Sign Language Several studies show nonverbal
children fail to use any signs functionally (Layton & Watson, 1995)
Grove & Dockrell (2000) showed that children with MR taught signs did not progress past Brown’s stage I.
Yoder & Layton (1988) in only direct comparison of speech and sign instruction in ASD found no advantage for Sign
Mirenda reports no advantage for Sign vs. graphic symbols
Aided Language Modeling (Drager et al., 2006)
Procedure: point to a referent in the environment point (within 2 s) to a graphic symbol of the referent simultaneously say the name of the referent
Multiple-baseline design across sets of symbol vocabulary used with 2 children who had autism. Four vocabulary items were taught in each of 3 legs
of the design, for each child. Both participants demonstrated increased symbol
comprehension and elicited symbol production. Symbol comprehension production was maintained
by both. For both children, symbol comprehension > symbol
production.
Other AAC Approaches(Millar, Light, & Schlosser, 2006)
Research review of use of a variety of AAC devices shows most are associated w/ modest improvements in speech production
No evidence AAC training inhibits speech
No direct comparison to speech treatment Most efficient method is not yet clear
Picture Exchange Communication System(Bondi & Frost, 1998)
Several studies (e.g., Charlop-Christy et al., 2002; Ganz & Simpson, 2004) show children with ASD taught PECS increase communication and speech,
but Magiati & Howlin (2003) found that although there were increases in PECS use, speech was much slower to show improvement
Tincani (2004) showed PECS and Sign were equally effective in eliciting requests for different children, but Sign elicited more vocalizations
Yoder & McDuffie (2002) showed PECS was better for children who communicated infrequently at intake; but not for those who communicated frequently
Yoder & Stone (2006) found growth was faster in the PECS group for children who began treatment with relatively high object exploration, but slower in the PECS group for children who began treatment with relatively low object exploration.
No direct comparison available between PECS and explicit speech training
Graphic symbols
Several studies have looked at use of non-PECS communication boards (e.g., Garrison-Harrell et al., 1997), BUT Millar et al., (2000) meta-analysis: Looked
for evidence that speech development resulted from AAC training.
No evidence that Sign or other AAC is more likely to lead to speech development. Both led to modest gains.
Voice Output Communication Aids(Brady, 2000)
Improve PA and spelling in nonspeaking children with ASD
Using these to request functional activities in preschool resulted in spontaneous use with teachers, but not peers
Anecdotal analysis of 58 children using VOCAs showed 53% used them successfully.
Prelinguistic Milieu Teaching (Yoder & Warren, 2001)
In sight but out of reach Uses expectant waiting, focusing
on objects of child interest Associated with increased ability to
initiate communication, increases in the frequency, spontaneity and elaboration of language,
Some nonverbal children have developed speech w/ PMT (Yoder & Stone, 2006);
Works best for children w/ little play, but more communicative acts and gaze to face
Prelinguistic Milieu Techniques Withhold materials of interest Give inadequate materials,
portions Sabotage familiar routines Violate expectations Protest child actions Create silly, unexpected situations Misuse, misname, misplace
objects
Parent-delivered PMT: Techniques (Kashinath et al., 2006)
Arranging the environment: Put preferred toys out of reach but in sight, requiring children to request assistance.
Natural reinforcement: Verbally acknowledges communication attempts and provide access to objects only in response to child's requests.
Time delay: Present object of interest to the child (e.g., an unopened toy) and waits briefly (3–5 s) before giving the child a verbal prompt to respond.
Imitating contingently: Imitate child actions immediately
Modeling: Provide verbal models describing activity or labeling objects that the child is interested in, but do not ask child to imitate.
Gestural/visual cuing: Use gestures and visual prompts to prompt child participation in a routine.
Parent-delivered PMT METHOD
Five preschool children with autism participated in intervention with a parent within daily routines in the family's home. Parents learned to include 2 teaching strategies in target routines to address their child's communication objectives. Generalization data were collected by measuring strategy use in untrained routines. A multiple baseline design across teaching strategies was used to assess experimental effects.
RESULTS All parents demonstrated proficient use of
teaching strategies and generalized their use across routines. The intervention had some positive effects on child communication outcomes.
BUT…(Keen et al., 2007)
Pilot study investigated the effects of a parent-delivered social-pragmatic intervention on the communication and symbolic abilities of 16 children, 2-4 years, with autism.
Standardized measures of communication and symbolic behavior conducted by independent observers pre- and post-intervention
Changes in some communication and symbolic behaviors occurred, according to parent report.
BUT improvements based on ratings by independent observers were not significant.
Active Ingredients: Developmental Approaches
Target prelinguistic foundations for speech
Focus on teaching communication, not speech specifically
Provide intervention in “natural environments”
Follow the child’s lead
Communication-focused Interventions: Developmental/Pragmatic
Use the normal sequence of development to provide goals.
Provide intensified opportunities engage in activities that similar to those of peers, in the belief that these are the most effective contexts for learning social and communication skills.
Use learning opportunities that naturally arise, rather than relying on a predetermined curriculum.
‘Facilitate’ interactions, including symbolic play, rather than addressing teacher-chosen goals, by focus on what a child is already interested in model ways to communicate about activities child
chooses expand on what the child produces spontaneously
Target functional goals
Communication-focused interventions
Use environmental arrangement Use natural reinforcers Respond to ALL child communicative
attempts Treat behavior as if it were communicative Emphasize appropriate affect model
language w/out requiring imitation Imitate the child Train parents to deliver intervention
Communication-focused interventions: Evidence
These techniques can lead to increases in communication, joint attention, and play skills
Parents can implement the interventions successfully
Center-based intensive programs using these approaches are also successful
SCERTS (Prizant et al., 2006) Social Communication,
Emotional Regulation, Transactional Support Combines both child-centered, relationship-based
components with naturalistic hybrid components (PMT)
SC goals include prelinguistic communication such as joint attention
ER goals include arousing through physical activities, calming through swinging, etc.
TS goals include peer support, environmental arrangement and support to families
Argues for doing all interventions within the context of every day routines
Argues against using discrete trial approaches No empirical support
Treatment and Education of Autistic and Communicatively Handicapped Children: TEACCH
State-wide program for children with ASD Combines relationship-based and skills-
based approaches Focuses on improving adaptive functioning
and modifying the environment to accommodate ASD characteristics (TS)
Uses structured teaching and curriculum, modified environment and visual schedules
Some limited empirical support (Mesibov, 1997)
Eclectic Programs Denver Douglass DD Center, Princeton Child Development Institute, Learning Experiences Alternative Program Pivotal Response Training
New Findings: Howard et al., 2005 Compared intensive ABA/hybrid program(25-30
hours/week <3, 35-40 hr./wk >3; 1:1 ratio) to Eclectic program of similar intensity (25-30 hrs./wk.) General preschool SpecEd program (15 hours/week;
1:6 ratio) Found significantly greater growth in IBA
program in all areas IBA group achieved near-normal learning rates;
other groups showed below-normal learning rate IBA group showed greater gains in all domains than
either contrast group G group showed least gain
Quotes from Howard et al., 2005:
“Young children with ASD who received IBA for 14 mo. Outperformed comparable children who received eclectic intervention services”
Intensive eclectic treatment “did not prove effective”
“At least 30 hours/ week of competently delivered, intensive behavior analytic intervention produced large improvement.”
ABA vs. DIR (Hilton & Seal, 2007)
Two yr. old MZ twins; one treated w/ DIR, one w/ discrete trial for receptive labels
CSBS scores pre/post Child in DT showed greater gains, but
had more crying Parents opted to continue both in DIR,
despite data
Summary
Both ABA and more naturalistic speech-focused approaches (PMT) have established efficacy in eliciting first words
Developmental-pragmatic approaches aimed more broadly at social communication and interaction have a less well-established empirical track record for eliciting first words, although they have been shown to increase preverbal behaviors such as imitation and joint attention.
AAC methods have been shown to be compatible with the development of speech, although efficiency relative to straightforward speech treatment has not yet been established.
There are few direct comparisons, so it is not possible to say that one method is more effective than another.
Pre-Rx child characteristics are related to outcomes. Initial frequency of intentional communication and
object play predict lexical density growth (Yoder, 2006)
Words said, verbal imitation, pretend play, and the number of gestures to initiate joint attention predict children with most rapid expressive vocabulary growth (Smith et al., 2007).
Relation between amount of intervention and gain in language age depended on ability to respond to bids for joint attention and initial language skills. (Bono et al., 2004).
THEREFORE: Characteristics of children effect relations between interventions and outcomes
What is to be done? Speech is
Most viable form of communication Most closely related to outcome in ASD
Make every effort to elicit speech as primary mode of communication Use or support use of discrete trial
approaches for emerging speech; for many kids, they work
Augment structured direct speech training with other communication-focused activities
BUT hybrid activities (e.g., PMT) so far appear to be the most effective supplements in early stages
The Bottom Line
Match child characteristics to therapeutic approach, based on what is known
Intensive Rx is necessary to effect significant change.
Supplement ABA/DT for speech w/ more naturalistic and AAC methods for communication, BUT
Mixed approaches are not effective unless therapists are highly trained in whatever approach they use; THEREFORE, it may be necessary to have
different highly trained therapists for each approach used
Adaptive, Preacademic Skills
Use task analysis Identify the task to be analysed. Break this down into between 4 and 8 subtasks. These
subtasks should be specified in terms of objectives and, between them, should cover the whole area of interest.
Draw the subtasks as a layered diagram ensuring that it is complete.
Decide upon the level of detail. Produce a written account as well as diagram. Present the analysis to someone else who has not been
involved in the decomposition but who knows the tasks well enough to check.
Sample Task AnalysisBrushing Teeth
Pick up the tooth brush Wet the brush Take the cap off the tube Put paste on the brush Brush the outside of the bottom row of teeth Brush the outside of the top row of teeth Brush the biting surface of the top row of teeth Brush the biting surface of the bottom row of teeth Try to make yourself understood while answering the question of someone outside the door Brush the inside surface of the bottom row of teeth Brush the inside surface of the top row of teeth Spit Rinse the brush Replace the brush in the holder Grasp cup Fill cup with water Rinse teeth with water Spit Replace cup in holder Wipe mouth on sleeve Screw cap back on tube