Interventions for Nonverbal Interventions for Nonverbal Children with ASDChildren with ASD

Joan C. GrilloJoan C. Grillo

AgendaAgenda

Why we should interveneWhy we should interveneBarriers to communication in ASDBarriers to communication in ASD Introduce caseIntroduce caseDiscuss types of interventionsDiscuss types of interventions Interventions for this caseInterventions for this caseTake Home MessageTake Home Message

Focus on CommunicationFocus on Communication

In 2001, the National Research Council made In 2001, the National Research Council made spontaneous functional communicationspontaneous functional communication its its first educational priorityfirst educational priority for children with autism. for children with autism.

(Ingersoll et al., 2005) (Ingersoll et al., 2005)

In 2004, The Interagency Autism Coordinating In 2004, The Interagency Autism Coordinating Committee “roadmap” set a long-term goal of Committee “roadmap” set a long-term goal of helping 90% of children with autism spectrum helping 90% of children with autism spectrum disorders (ASD) to achieve disorders (ASD) to achieve useful speech by useful speech by elementary school ageelementary school age..

(Yoder & Stone, 2006)(Yoder & Stone, 2006)

Why?Why?

Language proficiency is one of the two Language proficiency is one of the two most important variables in predicting most important variables in predicting outcomes in autism (the other being IQ). outcomes in autism (the other being IQ).

(Rogers et al., 2006)(Rogers et al., 2006)

Several retrospective reports identify Several retrospective reports identify “useful speech by age 5” as a consistently “useful speech by age 5” as a consistently strong predictor of later adaptive strong predictor of later adaptive functioning in individuals with ASD.functioning in individuals with ASD.

(Yoder & Stone, 2006)(Yoder & Stone, 2006)

Useful Speech?Useful Speech?

““Useful speech” has been defined many ways. Useful speech” has been defined many ways. Collectively, the following definition results:Collectively, the following definition results:

Useful speech is speech that isUseful speech is speech that is FrequentFrequent CommunicativeCommunicative Non-imitativeNon-imitative ReferentialReferential(Yoder & Stone, 2006)(Yoder & Stone, 2006)

Why is this so hard?Why is this so hard?

Children with autism have two core Children with autism have two core deficits that cause problems with deficits that cause problems with communication:communication:

1.1. Joint AttentionJoint Attention

2.2. Symbol UseSymbol Use

(National Research Council, 2001)(National Research Council, 2001)

Joint AttentionJoint Attention

Joint attention means coordinating attention between Joint attention means coordinating attention between people and objects, and problems with it are evidenced people and objects, and problems with it are evidenced by deficits inby deficits in

orienting and attending to a social partner,orienting and attending to a social partner, shifting gaze between people and objects,shifting gaze between people and objects, sharing affect or emotional states with another person,sharing affect or emotional states with another person, following the gaze and point of another person, andfollowing the gaze and point of another person, and being able to draw another person’s attention to objects being able to draw another person’s attention to objects

or events for the purpose of sharing experiences.or events for the purpose of sharing experiences.

(National Research Council, 2001)(National Research Council, 2001)

Joint AttentionJoint Attention

“…“…pragmatic skills and, more specifically, pragmatic skills and, more specifically, acts used to establish and/or maintain acts used to establish and/or maintain shared attention constitute shared attention constitute the lever the lever which children use to pry open the which children use to pry open the complexities of other linguistic complexities of other linguistic accomplishmentsaccomplishments.”.”

(Rollins et al., 1998, p182)(Rollins et al., 1998, p182)

Joint AttentionJoint Attention

(Rollins et al., 1998)

Symbol UseSymbol Use

Symbol use is learning conventional or shared Symbol use is learning conventional or shared meanings for symbols. Problems with it are meanings for symbols. Problems with it are evidenced by deficits in evidenced by deficits in

using conventional gestures, using conventional gestures, learning conventional meanings for words, and learning conventional meanings for words, and using objects functionally and in symbolic play.using objects functionally and in symbolic play.

““Christopher”Christopher” DOB 6/3/02 (now 5;9)DOB 6/3/02 (now 5;9) First evaluated here at age 3First evaluated here at age 3 First started receiving services here one year First started receiving services here one year

later (age 4)later (age 4) Mother reported that between ages 24-30 Mother reported that between ages 24-30

months, words began to disappear from daily months, words began to disappear from daily vocabularyvocabulary

Today, he has no words – significant regressionToday, he has no words – significant regression DxDx

Severe receptive/expressive disorderSevere receptive/expressive disorder AutismAutism

““Christopher”Christopher”

Receptive Communication Age at age 4: Receptive Communication Age at age 4: 16 months16 months

Expressive Communication Age at age 4: Expressive Communication Age at age 4: up to and including 16 monthsup to and including 16 months

Little to no joint attentionLittle to no joint attentionNo symbol recognition or useNo symbol recognition or use I started working with him at age 5;3I started working with him at age 5;3

InterventionsInterventions

There are three main approaches for There are three main approaches for language intervention for young children language intervention for young children with autism:with autism:

1.1. Didactic behavioral approachDidactic behavioral approach

2.2. Naturalistic behavioral approachNaturalistic behavioral approach

3.3. Developmental (social-pragmatic) Developmental (social-pragmatic) language approachlanguage approach

Behavioral ApproachBehavioral Approach

Oldest method, traditionalOldest method, traditionalLovaas approach, Applied Behavior Lovaas approach, Applied Behavior

Analysis (ABA), discrete trial teachingAnalysis (ABA), discrete trial teachingAdult-led, very structuredAdult-led, very structuredOne targeted behavior per trialOne targeted behavior per trialUses extrinsic reinforcersUses extrinsic reinforcersDrill and practice methodDrill and practice method

Behavioral ApproachBehavioral Approach

StrengthsStrengths Detailed proceduresDetailed procedures EfficaciousEfficacious Generalizes when Generalizes when

method is adaptedmethod is adapted Easy to administerEasy to administer Published curriculaPublished curricula Good outcomes, Good outcomes,

including higher IQincluding higher IQ Easy to collect dataEasy to collect data

WeaknessesWeaknesses Artificial learning Artificial learning

environment & interaction environment & interaction style limit generalization style limit generalization without additional without additional teachingteaching

Does not foster Does not foster communicative initiativecommunicative initiative

Does not result in Does not result in spontaneous speechspontaneous speech

Not based in current Not based in current science of communicative science of communicative developmentdevelopment

Behavioral ApproachBehavioral Approach Lovaas stated that “the training regime . . . its Lovaas stated that “the training regime . . . its

use of ‘unnatural’ reinforcers, and the like may use of ‘unnatural’ reinforcers, and the like may have been responsible for producing the very have been responsible for producing the very situation-specific, restricted verbal output which situation-specific, restricted verbal output which we observed in many of our children.”we observed in many of our children.”

““There is now a large body of empirical support There is now a large body of empirical support for more contemporary behavioral approaches for more contemporary behavioral approaches using naturalistic teaching methods that using naturalistic teaching methods that demonstrate efficacy for teaching not only demonstrate efficacy for teaching not only speech and language, but also communication.” speech and language, but also communication.” (National Research Council, 2001, p. 53)(National Research Council, 2001, p. 53)

Behavioral ApproachBehavioral Approach

Ingersoll et al. (2005) stated, “In response Ingersoll et al. (2005) stated, “In response to criticisms that highly structured, to criticisms that highly structured, behaviorally based programs may inhibit behaviorally based programs may inhibit the spontaneous use of skills in children the spontaneous use of skills in children with autism spectrum disorder (ASD), with autism spectrum disorder (ASD), there has been an increased interest in there has been an increased interest in approaches that target spontaneous approaches that target spontaneous communication.” (p. 214)communication.” (p. 214)

Naturalistic ApproachNaturalistic Approach

Incidental teaching; pivotal response training Incidental teaching; pivotal response training (PRT), milieu teaching(PRT), milieu teaching

Child-ledChild-led Naturalistic settings with attractive materials to Naturalistic settings with attractive materials to

draw child’s interest & motivate communicationdraw child’s interest & motivate communication Adult-child interactions are pragmatically Adult-child interactions are pragmatically

functional.functional. Trials are interspersed, but child interest and Trials are interspersed, but child interest and

engagement is main target for adultengagement is main target for adult

Naturalistic ApproachNaturalistic Approach

Adult creates a situation in which child Adult creates a situation in which child indicates desire for object or activity. Adult indicates desire for object or activity. Adult then follows the child’s lead with a prompt then follows the child’s lead with a prompt for a more mature communication.for a more mature communication.

Uses some features of ABA, but goal is Uses some features of ABA, but goal is the initiation of speech for communicationthe initiation of speech for communication

Reinforcement is intrinsic to taskReinforcement is intrinsic to taskMany different behaviors can be reinforcedMany different behaviors can be reinforced

Naturalistic ApproachNaturalistic Approach

StrengthsStrengths EfficaciousEfficacious Natural teaching settings and Natural teaching settings and

interaction styles lead to interaction styles lead to maintenance and maintenance and generalization of learned generalization of learned behaviors across natural behaviors across natural settingssettings

Use of highly motivating Use of highly motivating materials and activities materials and activities promotes positive behaviorspromotes positive behaviors

Children initiate Children initiate communication frequentlycommunication frequently

Highlights pragmatic function Highlights pragmatic function of language and so is in line of language and so is in line with current sciencewith current science

WeaknessesWeaknesses More freedom in the approach More freedom in the approach

makes it more difficult therapy makes it more difficult therapy to learn and facilitateto learn and facilitate

Difficult to collect dataDifficult to collect data No published curriculumNo published curriculum No systematic treatment No systematic treatment

manuals availablemanuals available Technique is not appropriate Technique is not appropriate

for teaching skills for which for teaching skills for which there is no intrinsic there is no intrinsic reinforcementreinforcement

More limited supporting More limited supporting researchresearch

Developmental Social-Pragmatic Developmental Social-Pragmatic ApproachApproach

SCERTS model; Denver model; Hanen SCERTS model; Denver model; Hanen Program; floor time/DIR modelProgram; floor time/DIR model

Based on current pragmatics-based language Based on current pragmatics-based language development theorydevelopment theory

Natural settings involving meaningful activities Natural settings involving meaningful activities chosen to elicit children’s interest and motivate chosen to elicit children’s interest and motivate communicationcommunication

Interactions involve shared control, turn taking, Interactions involve shared control, turn taking, reciprocityreciprocity

Affectively rich and positive in natureAffectively rich and positive in nature

Developmental Social-Pragmatic Developmental Social-Pragmatic ApproachApproach

Wide range of communicative behaviors, Wide range of communicative behaviors, both verbal and nonverbal, are targetedboth verbal and nonverbal, are targeted

Effective communication for a variety of Effective communication for a variety of pragmatic functions is targetedpragmatic functions is targeted

Reinforcement is intrinsic to the taskReinforcement is intrinsic to the taskWide range of verbal and nonverbal Wide range of verbal and nonverbal

productions may be rewardedproductions may be rewarded

Developmental Social-Pragmatic Developmental Social-Pragmatic ApproachApproach

StrengthsStrengths Uses pragmatically typical Uses pragmatically typical

interaction exchangesinteraction exchanges Fits easily into natural routines Fits easily into natural routines

and settingsand settings Use of motivating materials Use of motivating materials

promotes positive behaviorspromotes positive behaviors Highlights pragmatic function Highlights pragmatic function

of language and so is in line of language and so is in line with current sciencewith current science

Fosters joint attention skillsFosters joint attention skills Strengthens relationship Strengthens relationship

between adult and childbetween adult and child Increases adult sensitivity to Increases adult sensitivity to

child’s communicationchild’s communication

WeaknessesWeaknesses Lacks large body of Lacks large body of

effectiveness dataeffectiveness data Difficult to collect dataDifficult to collect data Model is based on normal Model is based on normal

development – limited development – limited research showing it is effective research showing it is effective for children with autismfor children with autism

Few published treatment Few published treatment manuals for cliniciansmanuals for clinicians

Most complex therapy to Most complex therapy to deliver because of multiple deliver because of multiple communicative behaviors and communicative behaviors and functions that are targetedfunctions that are targeted

Developmental Social-Pragmatic Developmental Social-Pragmatic ApproachApproach

Many DSP interventions involve parent Many DSP interventions involve parent education and then parent facilitation with education and then parent facilitation with occasional feedback from cliniciansoccasional feedback from clinicians

One study (Ingersoll et al., 2005) used a One study (Ingersoll et al., 2005) used a DSP model in the clinic once a week on DSP model in the clinic once a week on three children with autism, without training three children with autism, without training the parents the parents

Developmental Social-Pragmatic Developmental Social-Pragmatic ApproachApproach

““It is especially exciting that David, the nonverbal It is especially exciting that David, the nonverbal child, made gains in his use of language using child, made gains in his use of language using this approach. Several researchers have this approach. Several researchers have suggested that children with autism who are suggested that children with autism who are nonverbal may require a more structured nonverbal may require a more structured approach to learn prerequisite skills such as approach to learn prerequisite skills such as verbal imitation prior to receiving a less verbal imitation prior to receiving a less structured approach . . . The nonverbal child in structured approach . . . The nonverbal child in this study made gains in spontaneous language, this study made gains in spontaneous language, which suggests that DSP interventions may be which suggests that DSP interventions may be appropriate for nonverbal children with ASD.” appropriate for nonverbal children with ASD.” (p. 219).(p. 219).

Developmental Social-Pragmatic Developmental Social-Pragmatic ApproachApproach

““Lack of social engagement, joint Lack of social engagement, joint attention, imitative ability, and presence of attention, imitative ability, and presence of cognitive impairments are assumed to play cognitive impairments are assumed to play pivotal roles in poor language acquisition, pivotal roles in poor language acquisition, and developmentally oriented treatments and developmentally oriented treatments focus on increasing social engagement, focus on increasing social engagement, imitation skills, means-end concepts, and imitation skills, means-end concepts, and understanding of language in order to understanding of language in order to develop spoken language.” (Rogers et al., develop spoken language.” (Rogers et al., 2006, p. 1008)2006, p. 1008)

Christopher’s InterventionChristopher’s Intervention

Naturalistic behavioral approachNaturalistic behavioral approach No verbal or motoric imitationNo verbal or motoric imitation Took inventory of motivational items/activitiesTook inventory of motivational items/activities Worked on joint attention & imitationWorked on joint attention & imitation Tried to elicit maintained interest in anythingTried to elicit maintained interest in anything Tried to elicit phonationTried to elicit phonation Attempted PECS for AAC but it was Attempted PECS for AAC but it was

unsuccessful due to his inability to differentiate unsuccessful due to his inability to differentiate between the picture symbolsbetween the picture symbols

Christopher’s InterventionChristopher’s Intervention

Very little progressVery little progress No goals metNo goals met Attempting to teach modified PECS for AAC now Attempting to teach modified PECS for AAC now

using more realistic picturesusing more realistic pictures Shows interest in a few toys for sustained Shows interest in a few toys for sustained

periods intermittentlyperiods intermittently He would be excluded from most treatment He would be excluded from most treatment

studies because of his lack of communicative studies because of his lack of communicative intent and imitation skills, or other characteristics intent and imitation skills, or other characteristics that make him a difficult case to treatthat make him a difficult case to treat

Take Home MessageTake Home Message

There is no There is no

““one size fits all” one size fits all” intervention for children intervention for children

with ASD!with ASD!

Take Home MessageTake Home Message Take careful inventory of child’s strengths and Take careful inventory of child’s strengths and

weaknessesweaknesses Thoroughly review the literature, paying special Thoroughly review the literature, paying special

attention to which particular skills the children attention to which particular skills the children with the most success had in treatment efficacy with the most success had in treatment efficacy studiesstudies

Pay attention to which children were excluded Pay attention to which children were excluded from studies and whyfrom studies and why

Compare the skills of the child you are treating Compare the skills of the child you are treating with the skills of the children in the studieswith the skills of the children in the studies

Be open-minded and willing to try different Be open-minded and willing to try different methods if you are having little successmethods if you are having little success

Special Thanks:Special Thanks:

Cassandra Chapman, MS, CCC-SLPCassandra Chapman, MS, CCC-SLPStephen Camarata, PhDStephen Camarata, PhDKayla Jackson, MS, CCC-SLPKayla Jackson, MS, CCC-SLP

ReferencesReferencesAldred, C., Green, J., & Adams, C. (2004). A new social communication intervention for children with autism: Pilot Aldred, C., Green, J., & Adams, C. (2004). A new social communication intervention for children with autism: Pilot

randomized controlled treatment study suggesting effectiveness. randomized controlled treatment study suggesting effectiveness. Journal of Child Psychology and Psychiatry, 45, Journal of Child Psychology and Psychiatry, 45, 1420-1430.1420-1430.

Charman, T. & Stone, W. (Eds.). (2006). Charman, T. & Stone, W. (Eds.). (2006). Social and Communication Development in Autism Spectrum Disorders: Early Social and Communication Development in Autism Spectrum Disorders: Early Identification, Diagnosis, & InterventionIdentification, Diagnosis, & Intervention New York: The Guilford Press. New York: The Guilford Press.

Francis, K. (2005). Autism interventions: A critical update. Francis, K. (2005). Autism interventions: A critical update. Developmental Medicine & Child Neurology, 47, Developmental Medicine & Child Neurology, 47, 493-499. 493-499.

Ingersoll, B., Dvortcsak, A., Whalen, C., & Sikora, D. (2005). The effects of a developmental, social-pragmatic Ingersoll, B., Dvortcsak, A., Whalen, C., & Sikora, D. (2005). The effects of a developmental, social-pragmatic language intervention on rate of expressive language production in young children with Autistic Spectrum language intervention on rate of expressive language production in young children with Autistic Spectrum Disorders. Disorders. Focus on Autism and Other Developmental Disabilities, 20, Focus on Autism and Other Developmental Disabilities, 20, 213-222. 213-222.

More Than Words: The Hanen Program for Parents of Children with Autism Spectrum Disorder – Research SummaryMore Than Words: The Hanen Program for Parents of Children with Autism Spectrum Disorder – Research Summary . . The Hanen Centre, 2008. The Hanen Centre, 2008.

National Research Council (2001). National Research Council (2001). Educating Children with Autism. Educating Children with Autism. Washington, DC: National Academy Press. Washington, DC: National Academy Press.

Rogers, S., Hayden, D., Hepburn, S., Charlifue-Smith, R., Hall, T., Hayes, A. (2006). Teaching young nonverbal Rogers, S., Hayden, D., Hepburn, S., Charlifue-Smith, R., Hall, T., Hayes, A. (2006). Teaching young nonverbal children with Autism useful speech: A pilot study of the Denver Model and PROMPT interventions. children with Autism useful speech: A pilot study of the Denver Model and PROMPT interventions. Journal of Journal of Autism and Developmental Disorders, 36, Autism and Developmental Disorders, 36, 1007-1024. 1007-1024.

Rollins, P., Wambacq, I., Dowell, D., Mathews, L., & Reese, P. (1998). An intervention technique for children with Rollins, P., Wambacq, I., Dowell, D., Mathews, L., & Reese, P. (1998). An intervention technique for children with Autistic Spectrum Disorder: Joint attentional routines. Autistic Spectrum Disorder: Joint attentional routines. Journal of Communication Disorders, 31, Journal of Communication Disorders, 31, 181-193. 181-193.

Yoder, P. & Stone, W. (2006). A randomized comparison of the effect of two prelinguistic communication Yoder, P. & Stone, W. (2006). A randomized comparison of the effect of two prelinguistic communication interventions on the acquisition of spoken communication in preschoolers with ASD. interventions on the acquisition of spoken communication in preschoolers with ASD. Journal of Speech, Journal of Speech, Language, and Hearing Research, 49, Language, and Hearing Research, 49, 698-711. 698-711.