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

Fostering Peer Relations Peer Group Entry Buddy Time Peer and Target Training

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

Speech-Focused 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

RMIA Video

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

Communication-focused Interventions: Relationship-based Methods

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

Communication-focused Interventions: Skills-based

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

Picture Exchange Communication System Video

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

Prelinguistic Milieu Video

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.

Developmental and Pragmatic Methods

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

Practicing Task Analysis

Activity:Task analysis for teaching shoe tying

Emotional Regulation Avoid triggers Use distraction Use soothing techniques (voice,

touch, rocking) NEVER reward