The document discusses interventions for nonverbal children with autism spectrum disorder (ASD). It describes three main approaches: the behavioral approach, naturalistic behavioral approach, and developmental social-pragmatic approach. It then discusses a case study of a 5-year-old nonverbal boy named Christopher and his lack of progress using a naturalistic behavioral intervention. The take home message is that there is no single intervention approach that works for all children with ASD, and an intervention needs to be carefully selected based on the child's individual strengths, weaknesses, and characteristics.

1. Interventions for Nonverbal Children with ASD Joan C. Grillo

2. Agenda Why we should intervene Barriers to communication in ASD Introduce case Discuss types of interventions Interventions for this case Take Home Message

3. Focus on Communication In 2001, the National Research Council made spontaneous functional communication its first educational priority for children with autism. (Ingersoll et al., 2005) In 2004, The Interagency Autism Coordinating Committee “roadmap” set a long-term goal of helping 90% of children with autism spectrum disorders (ASD) to achieve useful speech by elementary school age . (Yoder & Stone, 2006)

4. Why? Language proficiency is one of the two most important variables in predicting outcomes in autism (the other being IQ). (Rogers et al., 2006) Several retrospective reports identify “useful speech by age 5” as a consistently strong predictor of later adaptive functioning in individuals with ASD. (Yoder & Stone, 2006)

5. Useful Speech? “ Useful speech” has been defined many ways. Collectively, the following definition results: Useful speech is speech that is Frequent Communicative Non-imitative Referential (Yoder & Stone, 2006)

6. Why is this so hard? Children with autism have two core deficits that cause problems with communication: Joint Attention Symbol Use (National Research Council, 2001)

7. Joint Attention Joint attention means coordinating attention between people and objects, and problems with it are evidenced by deficits in orienting and attending to a social partner, shifting gaze between people and objects, sharing affect or emotional states with another person, following the gaze and point of another person, and being able to draw another person’s attention to objects or events for the purpose of sharing experiences. (National Research Council, 2001)

8. Joint Attention “…pragmatic skills and, more specifically, acts used to establish and/or maintain shared attention constitute the lever which children use to pry open the complexities of other linguistic accomplishments .” (Rollins et al., 1998, p182)

9. Joint Attention (Rollins et al., 1998)

10. Symbol Use Symbol use is learning conventional or shared meanings for symbols. Problems with it are evidenced by deficits in using conventional gestures, learning conventional meanings for words, and using objects functionally and in symbolic play.

11. “Christopher” DOB 6/3/02 (now 5;9) First evaluated here at age 3 First started receiving services here one year later (age 4) Mother reported that between ages 24-30 months, words began to disappear from daily vocabulary Today, he has no words – significant regression Dx Severe receptive/expressive disorder Autism

12. “Christopher” Receptive Communication Age at age 4: 16 months Expressive Communication Age at age 4: up to and including 16 months Little to no joint attention No symbol recognition or use I started working with him at age 5;3

13. Interventions There are three main approaches for language intervention for young children with autism: Didactic behavioral approach Naturalistic behavioral approach Developmental (social-pragmatic) language approach

14. Behavioral Approach Oldest method, traditional Lovaas approach, Applied Behavior Analysis (ABA), discrete trial teaching Adult-led, very structured One targeted behavior per trial Uses extrinsic reinforcers Drill and practice method

15. Behavioral Approach Strengths Detailed procedures Efficacious Generalizes when method is adapted Easy to administer Published curricula Good outcomes, including higher IQ Easy to collect data Weaknesses Artificial learning environment & interaction style limit generalization without additional teaching Does not foster communicative initiative Does not result in spontaneous speech Not based in current science of communicative development

16. Behavioral Approach Lovaas stated that “the training regime . . . its use of ‘unnatural’ reinforcers, and the like may have been responsible for producing the very situation-specific, restricted verbal output which we observed in many of our children.” “ There is now a large body of empirical support for more contemporary behavioral approaches using naturalistic teaching methods that demonstrate efficacy for teaching not only speech and language, but also communication.” (National Research Council, 2001, p. 53)

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

18. Naturalistic Approach Incidental teaching; pivotal response training (PRT), milieu teaching Child-led Naturalistic settings with attractive materials to draw child’s interest & motivate communication Adult-child interactions are pragmatically functional. Trials are interspersed, but child interest and engagement is main target for adult

19. Naturalistic Approach Adult creates a situation in which child indicates desire for object or activity. Adult then follows the child’s lead with a prompt for a more mature communication. Uses some features of ABA, but goal is the initiation of speech for communication Reinforcement is intrinsic to task Many different behaviors can be reinforced

20. Naturalistic Approach Strengths Efficacious Natural teaching settings and interaction styles lead to maintenance and generalization of learned behaviors across natural settings Use of highly motivating materials and activities promotes positive behaviors Children initiate communication frequently Highlights pragmatic function of language and so is in line with current science Weaknesses More freedom in the approach makes it more difficult therapy to learn and facilitate Difficult to collect data No published curriculum No systematic treatment manuals available Technique is not appropriate for teaching skills for which there is no intrinsic reinforcement More limited supporting research

21. Developmental Social-Pragmatic Approach SCERTS model; Denver model; Hanen Program; floor time/DIR model Based on current pragmatics-based language development theory Natural settings involving meaningful activities chosen to elicit children’s interest and motivate communication Interactions involve shared control, turn taking, reciprocity Affectively rich and positive in nature

22. Developmental Social-Pragmatic Approach Wide range of communicative behaviors, both verbal and nonverbal, are targeted Effective communication for a variety of pragmatic functions is targeted Reinforcement is intrinsic to the task Wide range of verbal and nonverbal productions may be rewarded

23. Developmental Social-Pragmatic Approach Strengths Uses pragmatically typical interaction exchanges Fits easily into natural routines and settings Use of motivating materials promotes positive behaviors Highlights pragmatic function of language and so is in line with current science Fosters joint attention skills Strengthens relationship between adult and child Increases adult sensitivity to child’s communication Weaknesses Lacks large body of effectiveness data Difficult to collect data Model is based on normal development – limited research showing it is effective for children with autism Few published treatment manuals for clinicians Most complex therapy to deliver because of multiple communicative behaviors and functions that are targeted

24. Developmental Social-Pragmatic Approach Many DSP interventions involve parent education and then parent facilitation with occasional feedback from clinicians One study (Ingersoll et al., 2005) used a DSP model in the clinic once a week on three children with autism, without training the parents

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

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

27. Christopher’s Intervention Naturalistic behavioral approach No verbal or motoric imitation Took inventory of motivational items/activities Worked on joint attention & imitation Tried to elicit maintained interest in anything Tried to elicit phonation Attempted PECS for AAC but it was unsuccessful due to his inability to differentiate between the picture symbols

28. Christopher’s Intervention Very little progress No goals met Attempting to teach modified PECS for AAC now using more realistic pictures Shows interest in a few toys for sustained periods intermittently He would be excluded from most treatment studies because of his lack of communicative intent and imitation skills, or other characteristics that make him a difficult case to treat

29. Take Home Message There is no “ one size fits all” intervention for children with ASD!

30. Take Home Message Take careful inventory of child’s strengths and weaknesses Thoroughly review the literature, paying special attention to which particular skills the children with the most success had in treatment efficacy studies Pay attention to which children were excluded from studies and why Compare the skills of the child you are treating with the skills of the children in the studies Be open-minded and willing to try different methods if you are having little success

31. Special Thanks: Cassandra Chapman, MS, CCC-SLP Stephen Camarata, PhD Kayla Jackson, MS, CCC-SLP

32. References Aldred, C., Green, J., & Adams, C. (2004). A new social communication intervention for children with autism: Pilot randomized controlled treatment study suggesting effectiveness. Journal of Child Psychology and Psychiatry, 45, 1420-1430. Charman, T. & Stone, W. (Eds.). (2006). Social and Communication Development in Autism Spectrum Disorders: Early Identification, Diagnosis, & Intervention New York: The Guilford Press. Francis, K. (2005). Autism interventions: A critical update. Developmental Medicine & Child Neurology, 47, 493-499. 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 Disorders. Focus on Autism and Other Developmental Disabilities, 20, 213-222. More Than Words: The Hanen Program for Parents of Children with Autism Spectrum Disorder – Research Summary . The Hanen Centre, 2008. National Research Council (2001). Educating Children with Autism. Washington, DC: National Academy Press. 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. Journal of Autism and Developmental Disorders, 36, 1007-1024. Rollins, P., Wambacq, I., Dowell, D., Mathews, L., & Reese, P. (1998). An intervention technique for children with Autistic Spectrum Disorder: Joint attentional routines. Journal of Communication Disorders, 31, 181-193. 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. Journal of Speech, Language, and Hearing Research, 49, 698-711.