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Autism Spectrum Disorder: Intervention


Is it the case that people with autism do not like other people? ... how skilled and talented your child may be, or how much knowledge he posses; ... – PowerPoint PPT presentation

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Title: Autism Spectrum Disorder: Intervention

Autism Spectrum DisorderIntervention
  • Thomas Layton, Ph.D., CCC-SLP
  • Grace Hao, Ph.D., M.D., CCC-SLP
  • North Carolina Central University

How much do you know about Autism?
  • Is everyone with autism the same?
  • Is Autism an emotional disorder?
  • Is Autism a rare disorder?
  • Does Autism only affect children?
  • Is it the case that people with autism do not
    like other people?
  • Is it true that all children with autism have
    special gifts?
  • Is Autism a life-long difficulty that can not be

Autism Spectrum Disorders Basic Groundwork
  • Neuro-
  • developmental
  • disability

Autism Spectrum Disorders Basic Groundwork
  • Prevalence
  • 3-5/10,000 (70s) CDC1/150 (2007)
  • Gender differences 4-5 boys/girl
  • Spectrum disorder

Diagnostic criteria (DSM-IV-TR)
  • Qualitative impairment in social interaction
  • Qualitative impairment in communication
  • Repetitive and restricted behavior, interests,
    and activities

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Qualitative impairment in social interaction
  • Impairment in social reciprocity, as seen in
  • Nonverbal behaviors
  • Peer relationships
  • Spontaneous sharing
  • Lack of social or emotional reciprocity
  • Poor emotional regulation

Qualitative impairment in communication
  • Delay in, or lack of, development of spoken
  • Impairment in conversation
  • Stereotyped language
  • No or limited make-believe play

Restricted repetitive behavior interests, and
  • Encompassing preoccupation
  • Inflexible routines
  • Stereotyped motor mannerism
  • Preoccupation with parts of objects

Language SubgroupGeneralized Low Performance
  • Low in language comprehension and production
  • Comprehension somewhat better than production
  • Poor oral and motor imitation
  • Mostly nonverbal
  • Progress in treatment is slow in all modes

Language Subgroup Verbal Imitators
  • Better comprehension than production
  • Performance in language skills good until 30
    months than drop off rapidly
  • Good oral and motor imitation
  • Mostly verbalsome words
  • Progress in treatment is good

Language Subgroup High language
  • Language production better than comprehension
  • High echolalia
  • Good oral and motor imitation
  • Pronoun confusion
  • Progress in treatment is good in all modes

but what about?
  • Autism vs. High Functioning Autism?
  • HFA vs. Aspergers syndrome?

Aspergers HFAutism
HFA vs Aspergers syndrome
  • Categorization questions for the next decade
  • Is Aspergers a separate syndrome, or is it the
    high end of the autism spectrum?
  • Are high functioning autism and Aspergers
    essentially the same?

  • Assessment Scale

  • Holistic Approach

What are the most important skills we should
  • No matter how skilled and talented your child may
    be, or how much knowledge he posses
  • If he is inflexible and cannot handle change
  • If he is disorganized and requires constant
  • If he obsesses on certain topics and cannot
    switch his attention
  • If he cannot follow directions or becomes
    resistant or angry when he is told what to do
  • -----he will sooner or later fail to keep a job
  • Division TEACCH

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Challenges related to autism
  • Challenges in Learning/thinking
  • Challenges in social interaction
  • Challenges in communication
  • Challenges in behavior/emotion
  • Challenges in feeding

Learning Challenges Related to Autism
Characteristics of thinking
  • Difficulty with the concept of meaning Central
    Coherence theory
  • Excessive focus on details (Spotlight focus)
  • Difficulty distinguishing the relevant from the
  • Difficulty combining or integrating ideas

  • My child sees the world in boxes. When he is
    watching a dog, he sees one box which is the
    eyes, and another box which is the tail, the
    boxes just are not connected
  • Mom of a 33 month old child

Characteristics of thinking and learning
  • Difficulties with theory of mind
  • Difficulty in generalizing
  • Concrete thinking
  • Visual skills often a strength and frequently
    better than auditory skills
  • Difficulties with imitation

Characteristics of thinking and learning
  • Executive function difficulties
  • Difficulty with organization and
  • Understanding finished
  • Set shifting/flexibility
  • Difficulty with transitions

How can we help?
  • Clearly define the environment according to
    activities and events physical structure
  • Develop routine ways of giving information about
    where to be and what to expect schedule and
    work system
  • Put visual supports in place visual structure

Five reasons for using structure
  • Understanding a receptive communication system
  • Helps autistic people remain calm
  • Helps autistic people learn better
  • Prosthetic device for independence
  • Behavior management

A successful schedule
  • Individualized around the child need and interest
  • Tangible
  • Flexibility built-in
  • Space out
  • Portable
  • Child involved
  • Restructure while keeping the consistence

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Individualizing Schedules
  • Type of visual cue (e.g., icon words or a
  • Length of schedule
  • Ability of schedule (e.g., on clipboard, in
    folder, or notebook that travels with student) or
    static (posted on wall, table or desk to which
    student returns.)
  • Location of schedule
  • Transitional cue (e.g., match name, color,
    symbol, give pencil, buzzer, bell, check
    schedule, etc.)
  • Ways of manipulating schedule (checking off)
  • It is OK to mix visual cues within a schedule!

How to Achieve Successful TransitionTeaching
  • Create visual and manipulative ways to teach
  • Break down an area of learning into small steps
  • Teach strategies for approaching problems that
    can be used for more than one assignment

What is a routine?
  • A routine is to know whenever something happens,
    go and check the schedule!
  • The best teaching is to teach adaptation

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Challenges in Communication
Best Practices
  • Communication goals should emphasize functional
  • Environmental arrangement should be primary
    strategy to foster initiations
  • Environmental supports promote active and
    independent participation
  • Approaches to challenging behavior should be
    fully integrated with communication
  • Peer mediated learning is essential
  • Level of emotional arousal and its effect on
    communication needs to be considered

Early Intervention Programs
  • Major Goals
  • Attention
  • Imitation
  • Social Interaction and intentional communication
  • Language Development
  • Emotional regulation

I Can
  • Look at someones face, listen to what they are
    saying, or speak
  • BUT
  • I can do only one of these at a time
  • Adult with autism (28 years old male with a
    master degree)

Communication Challenges
  • Ecolalia
  • Pronoun confusion
  • Pragmatics (lack taking others into
  • Initiation vs. responding
  • Turn-taking
  • Requesting
  • Describing
  • Demanding
  • Role-playing
  • dialogue

Challenges in Social Interaction
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Challenges in Social Interaction
  • Pragmatic skills
  • Perspective of others?
  • Behavioral issues

Promoting Social interaction/intentions
  • Reciprocity and social-affective signaling
  • Develop preverbal intentional communication
    means and functions
  • Opportunities for peer interactions and

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Challenges in Behavioral/Emotional Management
  • Behavior always happens for a reason
  • Our challenge to figure out the message
    underlying a behavior problem and respond to the
  • To understand the message, we need to be able to
    understand autism and the childs experience
  • To intervene, we need to be able to make changes
    and teach skills

How do we help?
  • Step 1 what is the problem?
  • Define and describe the behavior
  • Be specific

How do we help?
  • Step 2 Why is it happening?
  • Gather clues
  • Collect data on the A-B-Cs
  • (Antecedents/Behavior/Consequences)

How do we help?
  • Step 3 Generate theories. Why Is this behavior
  • Review the data
  • Use your knowledge of autism
  • Create icebergs (it is important to know what is
    going on underneath)

How do we help?
  • Step 4 Design and implement intervention
  • The intervention plan will be based on your
    theories, and will often include several
    components. Common strategies include
  • Modify the environment
  • Improve schedules
  • Modify tasks
  • Modify method of presentation
  • Teach skills, improve understanding
  • Use different consequences

Child Throws Banana Repeatedly
Go to the computer lab
Throws Banana on the floor
family/personal/ environmental factors
  • Consequences

Too much going on in the cafeteria
How to Manage Stress Level?
Early Intervention
  • Recognize early signs of distress
  • Maintain calm, quite demeanor
  • Decrease use of verbal language
  • Reduce environmental stimuli
  • Provide clear visual cues about what to do
  • Reduce time pressures, demands as needed
  • Cue to use coping strategy

Teach new strategies
  • Teach strategies to use in difficult situations
    and when stress level starts to rise
  • Practice them when all is calm
  • Use visual cues, guidelines, talk time,
    scripts, social stories

Managing a Crisis
  • Reduce language and sensory stimuli
  • Redirect to a quiet safe area
  • Cue to use learned calming routine
  • Remember to set up finished so that the escape
    time has a clear beginning and end
  • --gtand afterwards, figure out WHY the problem
    happened and act Preventatively

Reduce stress
  • Get away from the things/environment you do not
  • Give yourself a break from work Frequent breaks
  • Change of gears
  • Do something you like
  • Calming Activities
  • Do not do anything hard close to lunch time
  • Regular physical activity

  • Different Approaches

Applied Behavioral Analysis (ABA)
  • ABA is to teach prerequisites for a child to
  • One-on-one treatment for 40 hours per week
  • Discrete trial teachingchild provided stimulus,
    child acts, child then does task on own.
  • ABA goal minimize failures and maximize successes

  • Antecendent is what you do to make the student
    respond. This can be a question, a visual
    stimulus, a prompt or an event.
  • Behavior is the students response/or lack of
    response to the antecendent.
  • Consequence is the teachers response to the
    students behavior.

  • ABA

Applied Behavioral Analysis (ABA)
  • Attention
  • Sessions are often broken into tiny steps.
    Allows child to focus on task.
  • Imitation and Initiation
  • Directly addresses imitation and initiation.
  • Social Interaction and intentional communication
  • Objective is reward child for socially
    appropriate behaviors
  • Parents participate with home activities
  • Language development
  • Goal is on task development and imitation, less
    on spontaneous expressive language
  • Emotional regulation
  • Does not directly promote self-regulation.

ABA Therapy Goals
  • Attending Skills
  • Usually addressed first
  • Readying self for table work
  • Readying self for instruction
  • Attending jointly with another

ABA Therapy Goals
  • Imitation Skills
  • Imitating motor actions
  • Imitating vocalizations
  • Complex imitation

ABA Therapy Goals
  • Language and Communication Skills
  • Imitating vocalizations
  • Following directions
  • Making requests
  • Labeling
  • Conversation

ABA Therapy Goals
  • Motor Skills
  • Gross motor
  • Fine motor
  • Oral motor

ABA Therapy Goals
  • Adaptive and Self-Help Skills
  • Eating
  • Dressing
  • Hygiene
  • Toileting
  • Chores
  • Safety

ABA Therapy Goals
  • Play and Leisure Skills
  • Social Games
  • Pretend Play
  • Board Games
  • Sports and Physical Play
  • Music and Singing
  • Arts and Crafts

ABA Therapy Goals
  • Pre-Academic and Academic Skills
  • Matching
  • Sorting
  • Sequencing
  • Alphabet
  • Numbers
  • Counting and Quantity
  • Mathematics
  • Reading

  • ABA video


  • TEACCH focuses on development and areas of most
    concern to families
  • Highly structured learning environment that
    includes vocational, social and living skills.
  • TEACCH focus on attention and communication.

  • Individual plan to reduce autism related
    behaviors that interfere with independence.
  • Classroom is arranged to avoid distractions.
  • Materials are clearly marked and arranged.
  • Schedules are requiredhelp to overcome
    difficulties with sequential memory and
    organization of time.
  • Prompts and reinforcement are used.
  • Directions are given both verbally and with
    alternate forms.
  • Focus of teaching is on strengths and to
    remediate difficulties.
  • Prepare individuals to live and work more
    effectively at home, at school, and in the

  • Attention
  • Focuses on attention to objects, people and
  • Imitation and Initiation
  • Begins with elicited imitation and toward
    spontaneous speech.
  • Social Interaction and intentional communication
  • Goal is help child understand what to do to
  • Social-effective signaling allows intentional
  • Language development
  • Five language dimensions purpose, contexts,
    categories, specific words, and form.
  • Emotional regulation
  • Highly structured with little self-regulation.

  • TEACCH video


Some History (Mirenda Erickson, 2000)
  • Margaret Creedon (1973) is often cited as the
    first report of the successful use of manual
    signs speech (aka simultaneous or total
    communication) with children with autism
  • Language development in nonverbal autistic
    children using a simultaneous system, presented
    to the Society for Research in Child Development,
    Philadelphia, PA.
  • Many published reports followed shortly thereafter

  • In the 1970s and 1980s, manual signing speech
    was the AAC technique used most often with people
    with autism and/or intellectual disabilities in
    countries such as
  • United States (Layton,1987, 1988 Matas,
    Mathy-Laikko, Beukelman, Legresley, 1985)
  • United Kingdom (Kiernan, 1983) Australia (Iacono
    Parsons, 1986)

  • During this time, research evidence related to
    the use of manual signs with children with autism
    accumulated in four main areas
  • Verbal imitation
  • Fine motor skills
  • Iconicity
  • Intelligibility

Verbal Imitation
  • Carr, Layton, and colleagues described two groups
    of children with autism who did not speak good
    and poor verbal imitators
  • In general, good verbal imitators were found to
    make greater receptive and expressive language
    gains with manual signing than poor imitators
  • In addition, speech development concurrent with
    signing is much more likely to occur in good but
    not poor verbal imitators
  • In a study of the predictors of spoken vocabulary
    development following sign language instruction,
    Yoder Layton (1988) found that verbal imitation
    alone accounted for 63 of the variance and that
    adding age and IQ to the mix accounted for 78

Fine Motor Skills
  • Several researchers have described fine motor
    (hand) coordination problems in children with
    autism (e.g., Jones Prior, 1985)
  • In a recent study, manual sign vocabulary size
    and the accuracy of sign formation were both
    highly correlated with measures of fine motor
    (hand) ability in 14 individuals with autism
    (Seal Bonvillian, 1997)
  • In another study, motor apraxia was strongly
    correlated with sign language production rates in
    children with autism (Soorya, 2004)
  • In a third study, no imitation-sign language
    relationship was apparent (Anderson, 2002)

  • Konstantareas, Oxman, Webster (1978) provided
    evidence that, for children with autism, symbols
    that visually resemble their referents (i.e.,
    transparent symbols) are easier to learn and
    remember than symbols that do not not (i.e.,
    translucent or opaque symbols)
  • Many of the most common functional signs are
    translucent or opaque (e.g., more, help, play,
    toilet, like, cookie, juice)

  • Unfamiliar communication partners are typically
    unable to communicate with individuals with
    autism who use manual signs, without an
  • Rotholz et al. (1989) taught two adolescents with
    autism to order fast food from unfamiliar wait
  • 0-25 of manual sign requests were understood
  • 80-100 of PCS requests were understood

  • Good verbal imitation skills are related to more
    receptive and expressive language gains with
    manual signing
  • Speech development concurrent with manual sign
    instruction is also related to good verbal
    imitation skills
  • Optimal manual sign outcomes require good fine
    motor (hand) skills
  • Transparent manual signs are more likely to be
    learned and retained many functional words are
    not transparent
  • Manual signs limit independent communication with
    unfamiliar partners

  • Layton and Watson (1995) concluded that even
    after intensive training with signs, a
    significant number of nonverbal children with
    autism continue to be mute and acquire only a
    few useful signs (p. 81)
  • Between 1980 and the mid-1990s, manual signing
    speech for individuals with autism was gradually
    supplanted by graphic symbols speech in many
    places as the result of both research conclusions
    and clinical concerns

Sign Language-candidates
  • Has oral-motor difficulties
  • Over five years of age
  • Less than 25 functional words
  • Needs a communicative system

Sign Language
  • Auditory-vocal areas poor, visual-motor
  • area may be successful
  • Several guidelines for using sign
  • Functional, self reinforcing signs
  • Signs can be produced before they are understood
  • Sign enhances linguistic output
  • Signing is fast
  • Signing limitations someone must interpret,
    child with motor problems may not form clear
    signs, iconic and abstract
  • Signing does facilitate spoken words

  • Beginning cookie sign
  • Show child cookietake childs hands and shape
    the sign for cookiereward child by giving child
    piece of cookie
  • Follow this procedure with other objects.
  • After child has learned 10 signs, learn to wait.
  • Show child cookie, wait for child to signif
    child does not sign, then prompt by touching
  • When child is signing independently, begin to use
    two sign combinationsverb object for example,
    eat cookie
  • Next step would be to use sentencesfor example,
  • I want ____ or I see ____.

Sign Language
  • Useful beginning signs
  • Food and drink objects 4/5 items
  • Toy objects 3/4 items
  • People mom, dad
  • Actions eat, want, see
  • Demands no, stop

Sign Language
  • Attention
  • Does not focus, attentional focus per se.
  • Imitation and Initiation
  • Children who do and do not imitate can learn
  • Social Interaction and intentional communication
  • Signing allows child to socially interact and to
    initiate communication.
  • Language development
  • Acquire both receptive and expressive language.
  • Emotional regulation
  • After signing ASD children have improved

  • Signing video

  • PECS

Alternative Treatment Strategies
  • Picture Exchange Communication System (PECS)
  • Object Exchange
  • Augmentative communication aids
  • Auditory Integration Therapy (AIT)

  • PECS is a unique Augmentative / Alternative
    Communication System.
  • Augmentative / Alternative Communication systems
    are a collection of methods and/or devices that
    allow persons with severe communication
    impairments to communicate
  • Augmentative and Alternative Communication is
    used when speech, gestures, and writing will not
    or can not sufficiently accomplish ones
    communication needs

  • Initial language program for lower functioning
  • Begins by teaching spontaneous requests
  • Proceeds to communicative functions, responding
    to questions and comments
  • Child is required to pick up picture and hand it
    to teacher, who exchanges picture for real item.

  • Children are taught to travel to a communicative
    partner to be persistent in their request.
  • Next step is for child to acquire phrasesthrough
    use of sentence stripsI want ____ is written.
  • Teacher then faces the strip toward child and
    reads it back to them, while delivering the item.
  • Next, child is taught to answer questions, such
    as What do you see?

Behavioral Analysis
  • ABA utilizes the same M-S-R-SR principle from
    Skinners theory, in conjunction with
  • An individualized plan for each child
  • Small attainable goals
  • Fading Stimulus
  • Highly structured environment
  • PECS uses concepts from Skinners Verbal
    Behaviors and ABA therapy to facilitate new
    communication behaviors with autistic children

PECS Phase1
  • The most important factor in beginning PECS
    training is identifying an object that will
    motivate the child.
  • Next a card/picture is created to represent the
    motivating object.
  • The object is then shown to the child. The child
    may reach for the object or exhibit other
    behaviors that indicate they want the object.

PECS Phase 1
  • Phase one of PECS training requires two persons
    in addition to the child.
  • One person to serve as the initial communicative
    partner, and the other the to assist the child
    with communicative acts.
  • Once the child indicates his interest in the
    object, the communicative assistant physically
    directs and assists the child in picking up the
    picture card representing the desired object

PECS Phase 1
  • Once the communicative partner receives the
    picture from the child, he or she immediately
    gives the desired object to the child along with
    verbal praise.
  • The process is repeated several times while
    slowly fading the childs need for communicative
  • The child will eventually begin exchanging
    pictures independently.
  • To promote generalization and carry over of this
    new behavior, the communicative partner and
    communicative assistant often switch places

PECS Phase 2
  • Phase 2 encourages greater spontaneity,
    persistence, and generalization of the skills
    acquired in phase 1.
  • The child continues to request the motivating
    object, however the communicative partner is
    positioned further away from the child.
  • This process is gradual, starting with a few feet
    and progressing to the CP being in different

PECS Phase 2
  • The communicative act is carried out in a variety
    of settings to encourage generalization .
  • Recommended settings include the classroom, the
    home, the store, and the park.
  • The communicative partner is changed frequently,
    and will often include teachers, schoolmates,
    parents, grandparents, and siblings.

PECS Phase 2
  • It is at this point that the child also begins to
    expand his/her vocabulary.
  • The fist few objects introduced should continue
    to be objects that will motivate and/or please
    the child.
  • It is important not to over stimulate the child
    too quickly. Only one picture should be available
    to the child at a time.

PECS Phase 3
  • Phase three requires the child to discriminate
    among multiple pictures when requesting an item
  • The child must first locate the correct picture
    for the item or activity they want
  • For some learners this is easy, for others it is
    much tougher.
  • Some learners learn best with photos of objects,
    while others do better with graphic images that
    approximate the appearance of an object.

PECS Phase 3
  • Phase three also encourages the child to make
    choices about what he or she wants and/or would
    like to do.
  • The child begins by answering questions such as
    what do you want or what would you like to
    play with
  • The child must locate the picture among several
    pictures, initially two or three progressing to
    multiple pictures on multiple pages.

PECS Phase 4
  • Once a child is comfortable discriminating
    between and making requests for a variety of
    items, to a variety of people, and in a variety
    of settings and environments, the program begins
    to focus on sentence structure.

PECS Phase 4
  • Phase four starts learners in the process of
    building sentences through the use of sentence
  • The child will start combining a picture for I
    want with a picture of the requested item or
  • The two pictures would be attached to a sentence
    strip, and the entire strip would be exchanged
    with the communicative partner for the pictured
    item or activity.

PECS Phase 5
  • Phase five challenges the child to build more
    complex sentences and questions.
  • Adjectives and other words can be added to the
    childs repertoire to help the child further
    refine requests.
  • Examples include moving from sentences such as I
    want candy to I want three green candies

PECS Phase 6
  • In phase six, the child is taught to comment on
    the world around them.
  • Communicative behaviors move from requesting
    behaviors to commenting or questioning behaviors
  • The child is prompted with questions such as
    what do you see or what do you hear

PECS Phase 6
  • The childs initial responses maybe similar to
    the big red ball or The birds singing
  • However new picture cards are introduced to
    facilitate the childs use of more complete
  • These new cards will include phrases such as I
    hear, I see, I feel, and I smell

PECS Phase 6
  • Phase six is a fundamental shift in the childs
  • By this phase the childs communication should be
  • The child should be able to communicate with
    multiple partners in multiple settings
  • The child is now able to communicate on various
    levels by making requests, commenting on their
    environment, and expressing their feelings.

  • The PECS program may take several months or
    several years to complete
  • The amount of time depends on the child, and how
    well they adapt to this style of communication
  • Time may also be extended with those children who
    have other cognitive, developmental, and/or
    physical impairments and/or disorders

  • Selection of picture type and size is dependent
    on individual needs
  • The pictures used with the PECS program may be
    photographs in color or black and white, white
    lines drawings, or even tangible items or objects
  • There are many companies that produce pictures
    and objects that may be used with the PECS
    program, or the user can opt to create their own

  • Some children begin to spontaneously use speech
    while involved in the PECS program
  • Although PECS is primarily used with children who
    are non verbal, it could be used with those who
    are ecolalic, unintelligible, and/or those with
    expressive language delays

Success With PECS
  • The PECS system has been successful with person
    with a variety of communicative, cognitive, and
    physical difficulties
  • PECS is thought to be ideal for those with autism
    because typically they are visual learners, and
    PECS is a visual orientated program

Success With PECS
  • To be successful in teaching PECS there are three
    basic rules to follow.
  • Start slow with high use symbols such as toys,
    drink, food ect
  • Be consistent and maintain reasonable
  • Be patient, dont give up, and stick with it!

Success With PECS
  • PECS has been successful with a variety of ages
    including preschool, adolescents, and adults
  • A PECS candidate should be an intentional
    communicator, meaning the child/adult is aware of
    his/her need to communicate messages to others.
  • The individual should have some personal

Success With PECS
  • Personal Preferences are key in PECS training.
  • Personal preferences provide the initial
    motivation needed to implement the PECS program.
  • Picture discrimination is helpful, but is not a
    pre-requisite for candidacy

(No Transcript)
Object Exchange
  • Use of miniature objects.
  • Similar to PECS except rather than using pictures
    objects are made available.
  • Child retrieves object from display and gives it
    to teacher, who exchanges it for real item.

  • Signs vs PECS
  • (Adapted from Pat Mirenda)

Gail, Ramon, and Ben(Ganz Simpson, 2004)
  • All three children spoke few words (15-30),
    little functional use of speech, echolalia
  • Gail, age 58, severe autism, ESL family
    half-day kindergarten
  • Ramon, age 72, developmental delay,
    mild-moderate autism, speech/language impairment
    grade 1 classroom
  • Ben, age 39, developmental delay, severe autism,
    speech/language impairment half-day ECSE

  • Taught to make requests with coloured line
    drawings and photos using standard PECS
    procedures for Phases 1-4 (I want)
  • Measures taken of
  • trails to independent mastery for each phase
  • number of words spoken per trial and
  • presence/absence of non-word vocalizations per

Results Gail(447 trials total)
Results Ramon (292 trials total)
Results Ben (300 trials total)
Signs vs. Graphic Symbols
  • Two studies with adults with mild to profound
    intellectual disability (Sundberg Sundberg,
    1990 Wraikat, Sundberg, Michael, 1991)
  • Taught manual signs and graphic symbols for
    nonsense words (e.g., doof) in response to
    Whats this? and Whats doof? (i.e.,
    tacts/labels not mands/requests)
  • For most (but not all) participants, manual signs
    required fewer teaching trials than pictures,
    with varying degrees of difference

Signs vs. Graphic Symbols Requesting (Adkins
Axelrod, 2001)
  • One boy with PDD and ADHD
  • Desirable objects identified and matched with
    regard to preference and iconicity
  • Picture use was taught using standard PECS
    instruction, Phases 1-3
  • Manual signs were taught using modeling and
    physical prompts, approximating the three phases
    of PECS
  • Required an average of 7.1 trials per picture and
    15.7 trials per sign to meet criterion
  • More spontaneous, better generalization with
    pictures as well

Brian, Chris, Jenny, Mandi(Chambers Rehfeldt
, 2003)
  • Brian 19 years old, severe intellectual
    disability (ID), autism
  • Chris 26 years old, severe ID, cerebral palsy,
    seizure disorder
  • Jenny 40 years old, profound ID, Down syndrome,
    seizure disorder
  • Mandi 36 years old, severe ID
  • None had functional communication, all lived in a
    developmental training center

  • Preferred foods, leisure items identified for
    each person
  • All items taught via both manual signing and
    picture symbols
  • Picture use was taught using standard PECS
    instruction, Phases 1-3
  • Manual signs were taught using modeling and
    physical prompts, approximating the three phases
    of PECS

Signs vs. Graphic Symbols Requesting and Speech
(Anderson, 2002)
  • John, age 211, PDD-NOS, NVMA 16 mo, 3 words
  • Cory, age 23, severe autism, NVMA 17 mo, no
  • Alex, age 27, severe autism, NVMA 15 mo, no
  • Maya, age 210, severe autism, NVMA 16 mo, 4
  • Ryan, age 411, severe autism, NVMA 19 mo, 4
  • Sara, age 111, mild-moderate autism, NVMA 15 mo,
    no speech

  • Preferred foods, leisure items identified for
    each child
  • Rank ordered by preference and assigned
    sequentially to sign or PCS conditions (coin toss
    for each child used to assign 1)
  • PCS use was taught using standard PECS protocol,
    Phases 1-3
  • Manual signs were taught using modeling and
    physical prompts, approximating the three phases
    of PECS

Some items were mastered by speech alone
Results Speech
Carl and Jennifer(Tincani, 2004)
  • Carl, age 510, autism and intellectual
  • Jennifer, age 68, PDD-NOS and intellectual
  • Both could imitate some words but never used them
    to communicate without prompts
  • Preference assessment done to identify 10-12
    motivating foods, drinks, toys for each child

  • Manual signs taught for half the items PECS
    taught for the other half
  • Protocol from Sundberg Partington (1998) used
    to teach signs
  • Modified slightly for Carl after 5 training
  • Protocol from Frost Bondy (2002) used to teach
    PECS, through Phase 3
  • Best treatment then used to teach mands (i.e.,
    requests) for all items

Results Carl
Speech Words
Results Jennifer
Speech Words
  • In the short-term, both manual signs and PECS can
    result in
  • Functional requesting
  • Natural speech production
  • Vocal imitation skills appear to be related to
    speech production, regardless of symbol modality
  • No studies have examined functions beyond
  • No long-term comparative studies exist

The Debate
  • In 1993, applied behavior analysts who ascribe to
    Skinners theory of verbal behavior published two
    papers comparing the utility of
    topography-based AAC systems such as manual
    signs and selection-based systems such as
    graphic symbols (Shafer, 1993 Sundberg, 1993)
  • They (and others) claim that there is
    considerable research evidence to support the
    superiority of manual signs for individuals with
    autism with regard to
  • Functional communication in general
  • Natural speech development in particular

The Evidence (Mirenda, 2003)
  • Research studies in both AAC and verbal
    behavior/ABA were reviewed using a narrative
  • Studies were not evaluated using stringent
    criteria to assess reliability, validity, etc.
  • A face value approach was used to summarize
    existing research
  • Several additional studies have been published
    since 2003, but the results do not change the

  • Augmentative Communication
  • (Adapted from Pat Mirenda)

Speech-Generating Devices (SGDs)
  • Only a few studies have documented the utility of
    SGDs with individuals with autism (see Schlosser
    Blischak, 2001 and Schlosser, 2003 for reviews)
  • Generally, there is suggestive evidence that SGDs
    can be useful with individuals with autism to
  • Literacy skills (e.g., Schlosser, Blischak,
    Belfiore, Bartley, Barnett, 1998)
  • Communicative requests (e.g., Sigafoos, Didden,
    OReilly, 2003)
  • Communicative repairs (Sigafoos et al., 2004)
  • Social comments (e.g., Schepis, Reid, Behrmann,
    Sutton, 1998)
  • Receptive labels (e.g., Brady, 2000)

  • There is also some evidence that SGDs can have
    positive effects on
  • Reducing the frequency of problem behavior (e.g.,
    Durand, 1999)
  • Generative (i.e., non-echolalic) speech
    production (e.g., Hetzroni Tannous, 2004
    Sigafoos et al., 2003)
  • Finally, there are several case study and other
    reports documenting SGDs has positive affects on
    day-to-day communication abilities of individuals
    with autism (e.g., Bornman Alant, 1999 Light,
    Roberts, Dimarco, Greiner, 1998)

Retrospective Study(Mirenda, Wilk, Carson,
  • Retrospective study of 63 students with autism in
    British Columbia, Canada (age 5-17) who used
    static display SGDs in school over a 5-year
  • Success scores were assigned to annual follow-up
  • 0-1 no or little success
  • 2-3 some or limited success
  • 4-5 successful or very successful

SGD Success Scores
SGD Users by Success Scores and Age
SGD Users by Success Scores and Cognitive
SGDs and Speech
  • Seven SGD users (11) developed sufficient speech
    that they no longer needed SGDs and traded them
    in for computers software
  • Five 5-8 year-olds, one 9-11, one 13
  • All had limited functional speech prior to
    service all but one used prior low-tech AAC
  • Cognitive abilities 3 average, 2 mild ID, 1
    moderate ID, 1 severe ID
  • Variety of static display SGDs (IntroTalker,
    Macaw, etc.)
  • No data on lesser degrees of speech development

  • SCD vacuum video

  • Relationship Development Intervention

Relationship Development Intervention (RDI)
  • Elements of social competence (Gutstein
    Whitney, 2002)
  • Secure attachment (tie of infants to parents)
  • Baby falls and reaches to be comforted
  • Stranger cause infant to run to mom

Relationship Development Intervention (RDI)
  • Elements of social competence (Gutstein
    Whitney, 2002)
  • Instrumental social learning (social actions to
    achieve a specific social end)
  • Pointing to obtain a toy
  • Following classroom rules to get a reward
  • Inviting child to play checkers so you can win

Relationship Development Intervention (RDI)
  • Elements of social competence (Gutstein
    Whitney, 2002)
  • Experience sharing relationships (reciprocal
    playmate, value others view point, emotion-based
  • Friendship
  • Consoling a friend after losing a game
  • Telling silly jokes that make you laugh together
  • Celebrating finishing a job with friends after
    feeling closeness and camaraderie

Relationship Development Intervention (RDI)
  • Social skills much be taught within the context
    of meaning
  • Research shown over and over again that isolated
    social skills training does not help without
    connection to context
  • Experienced based relationship intervention
  • Shift from survival oriented behaviors
  • Guided experiences to socially adapt,
    co-regulate, and coordinate actions, perceptions
    and feelings with social partners

  • None of the approaches should harm the child.
  • Some may be valueless for an individual.
  • It is hoped that the reviews are helpful and will
    provide parents and professionals clearer choices.

Case study
  • Jill, 5 year old, picky eater, dislike meat,
  • History of pneumonia
  • Losing weight
  • Gagging
  • Coughing after eating
  • Wet sounds
  • Drooling
  • Pocketing
  • Food stuck in palate
  • Multiple swallows

Case study
  • Jill, 5 year old
  • Tx Oral motor exercises
  • Improve strength and/or mobility of tougue, lips,
    cheeks, and jaw
  • Passive, assistive, active movement

Case study
  • Samuel 4 years old
  • Uncomfortable with touch-brushing, kissing,
    washing face, getting food on lips
  • Limited food texture yogurt or smoothy only
  • Gagging often
  • Does like like any strong smell food

Case study
  • Samuel 4 years old
  • Tx desensitize feeding hierachy
  • Tolerates
  • Interacts with food
  • Smell
  • Touch
  • Tastes
  • Eats
  • swallows

Case Study--Albert
  • Albert (age 5 years) good comprehension
    highly echolalic.
  • Cannot initiate
  • Cannot generate novel utterances
  • Cannot describe
  • Can list
  • Repeats easily

Case Study--Albert
  • Treatment
  • Work on social routine utterances, like I want
  • Modify routine utterances, like I want xx and
    xx, or May I have xxx.
  • Impose alternatives in routine, like I want ball
    (show pencil) Model No this is not a ball, this
    is a ball (show ball.) Follow routine until
    Allen makes adjustments.
  • Rotate routines between alternates and routines.
  • Model alternate- expand-revise

Case Study--Chip
  • Chip (age 5 years) verbal, high pitch/monotone,
    rigid/lacks transitions, some delayed echolalia,
    retells events like he was quoting from a story

Case Study--Chip
  • Treatment
  • Flexibility in conversation. Model different
    ways of requesting, describing, demanding. Set
    up routines where each is practiced. Adjust so
    that spontaneous use of conversation occurs.
  • Role Playing. Use others (parent) or stuffed
    animals as models for requesting, describing, and
    demanding. Have stuffed animal make mistakes.
    Help Charlie to explain by example how to correct
    the mistake.
  • Use story books with different intonation
    patterns, like Three Little Pigs or
    Goldilocks, to teach stress, rising pitch, and
  • Use people pictures with different expressions,
    like happy, sad, surprise, confused, angry/mad,
    tired. Have Charlie describe each and model the
    expression using a mirror. Follow through by
    having parent/teacher demonstrate the

Case Study-Mark
  • Mark (age 5 years) Adopted from Eastern Europe,
    verbal, quiet/inhibited, inflexible, concrete.

Case Study-Mark
  • Treatment
  • Executive function skills organization,
    flexibility, retrieval, retelling events,
    generating novel events, defining.
  • Use picture adapted story books, with sentences
    adapted and pictures scanned. Read story book,
    unscramble picture to follow the story event
    (from memory), match scrambled sentences to the
    pictures. Retell the story from the pictures.
  • Use story events to acquire new vocabulary and
    concepts, like learning the concept of first,
    second, and third.