Language in Infants, Toddlers and Preschoolers:Creative Solutions to Common Problems: Working With Children With ASD

Joanne Gerenser Ph.D.Executive Director, Eden II Programs 

Mareile Koenig Ph.D.Associate Professor, West Chester U 

Arlene Kaye MSSpeech-Language Pathologist, Cheshire, CT

Public Schools 

Tracy Vail MSDirector, Let's Talk Sp & Lang Svcs Inc 

Basic Assumptions About Autism

• Stimulus Overselectivity

– There is a large body of research that suggests children with autism may respond to an overly restrictive portion of complex stimuli(e.g., Lovaas, Koegel, & Schreibman, 1979; Koegel, Koegel, Freg, & Smith, 1995)

Purpose

• To review basic literature on unique learning characteristics of learners with autism

• To review how these learning characteristics can challenge learners in acquiring skills

• To present a series of case studies that illustrate strategies for addressing the unique learning characteristics of learners with autism in acquiring skills ranging from basic receptive language to complex use of pronouns and asking questions

Autism• Stereotypic and Repetitive Behavior

– Behavior identified as self-stimulatory appear to interfere with relationships, learning, and neurological development(Koegel,Valdez-Menchaca, & Koegel, 1994)

– There appears to be an inverse relationship between stereotypy and appropriate behaviors(Kern, Koegel, & Dunlop, 1984)

Self-Stimulatory Behavior

High stereotypy

Impaired learning

Fewer skills acquired

Continued absence of alternative behaviors

Autism

• Process Environment Differently

– Difficulty processing transient input(Schuler, 1995)

– Difficulty processing multiple cues(Lovaas, Schreibman, Koegel, & Rehm, 1971)

– Reduced awareness of theory of mind(Baron-Cohen, Leslie, & Frith, 1985)

Autism

• Issues with Motivation

– Do not respond to social reinforcers in the beginning

– Difficult to determine what child is responding to in the environment: may have limited reinforcement repertoire

Autism

• Reduced Observational Learning

– Children with autism typically have a great deal of difficulty with imitation

– Children with autism have great difficulty “picking things up” from the environment

Autism

• Disorder versus Delay

– Scattered profile

– Splinter skills

Implications

• Children with autism present complex learning profiles

• Many deficits unique to autism challenge our existing curricula, teaching skills, and traditional problem solving methods

Case Studies: Basic Receptive LanguageJoanne Gerenser, Ph.D., CCC-SLP

The Eden II Programswww.eden2.org

jgerenser@eden2.org

Case Study 1

• Child mastered one direction in isolation

• Child mastered second direction in isolation

• Breakdown occurred in discrimination

one step commands

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stand up

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Case Study 1

Action Taken

• Evaluate reinforcement

• Evaluate intensity

• Alter commands to maximize differences– Stand– Touch your feet

• No changes in performance

Evaluation of Problem

• Visual programs progressing well– Matching objects, pictures, shapes– Non verbal motor imitations

• Excellent eye contact

• Hypothesis– Failure to attend to relevant stimuli

(verbal)– Overselecting on irrelevant stimuli

(visual)

Solution

• Must evaluate prompt to direct learner’s attention to relevant stimuli

• Use of an intra-stimulus prompt would make the relevant stimuli (speech) more salient and strengthen SD – P – Response relationship

Intonation Prompts

• Utilize suprasegmental (intonation) features as a cue to promote attending to segmental features (speech)

• Select 3 commands and create three distinct corresponding intonational patterns

• Programming must be consistent and fading must be systematic

Case Study 1

• ProgramStep One:– Three one step commands

introduced in discrimination:

Wave bye bye

Touch feetClap

Case Study 1

• ProgramStep Two:

– Fade intonation when all three are mastered

– Fade intonation one command at a time

Case Study 1

intonation prompts

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clap, touch your head, standup

fade stand up

fade touch your head

Case Study 2

• Mastered 10-12 one step commands

• Unable to receptively discriminate objects

• Begin with removal of carrier phrase – E.g., remove “give me” or “touch” and

simply state object name (car, shoe, etc.)

Case Study 2

• If that fails, then try object related commands

• Hypothesis:– The learner is unable to integrate

the addition of a visual component to the receptive language task

• Use existing skill to master novel skill

Object Related Commands

• Select several highly familiar common objects that have clear functions (e.g., juice, car, book, hat)

• Conduct typical one concept command program with mastered commands

• Use an object with its function as the new one concept command

Object Related Commands

• Phase 1

– Mastered commands: stand up touch head clap hands touch ears stomp feet etc. – New command: “eat pretzel”

Object Related Commands

• May need to leave object in isolation on table but would be better to begin with several objects serving as distractors

Object Related Commands

• Phase 2

– introduce new object related commands until approximately 7-10 object related commands are mastered in discrimination with each other as well as the mastered one concept commands

Object Related Commands

• Phase 3– Begin systematically fading the

function or action

stand up eat pretzel clap car jump drink juice

Object Related Commands

• Phase 4

– Introduce the actual Sd after all objects are mastered without function or action carrier phrase

stand up give me car clap give me cookie give me shoe jump

Receptive Object Identification

• Phase 5

– Introduce all mastered objects from the object related commands without function or action carrier phrase in a receptive identification format

give me car point to shoe give me cookie point to juice

Case StudyAbby Requesting Information

Tracy Vail,MS,CCC/SLPSpeech/Language Pathologist

tlvail@mindspring.com

What’s the Problem?

• Abby has been taught to formulate sentences but does not use them functionally or under the appropriate conditions in a wide variety of contexts.

Learner Characteristics of Abby

• Reinforced by silly sounds and exaggerated facial expressions

• Tends to become agitated when corrected

• Diagnosed with severe Verbal Apraxia at 4- non-vocal till 6 years of age

• Tends to respond to visual stimuli over verbal – difficulty responding to multiple stimuli

What’s Missing?

• Stimulus conditions reflecting when people are motivated to ask questions.

• Gaining information is not valuable to her (not paired with reinforcement)

What’s Missing?

• Teaching multiple questions forms with the same set of stimuli. (requiring conditional discriminations of which question form is needed)

• Teaching the same question forms under multiple conditions. (generalization)

Strategy

1. Clearly define the conditions under which people are motivated to ask questions.

2. Determine multiple reinforcing

conditions for Abby

3. Pair gaining information with reinforcement.

Strategy

4. Teach multiple question forms using the same stimuli.

5. Teach under a wide variety of contexts (generalization)

Why Do People Ask Questions?

• What- to gain information about the name of an object that is either unknown or unable to be discriminated.

• Who- to gain information about a person who is either unknown or unable to be discriminated.

• Whose- To gain information about the ownership of an item.

• Where- to gain information about the location of an object, person or activity that is not visible.

Why Do People Ask Questions?

• When- To gain information regarding some measurement of time.

• Why- To gain information about the reason something is occurring or has occurred.

• Which- To gain clarification about 2 or more items.

• How – To gain information about a process or procedure

Reinforcing Conditions for Abby

• Playing with pretend food• Playing with card games• Obtaining items needed for story

kits• Obtaining primary reinforcers

(candy)• Obtaining highly preferred

activities when requested

Teaching Procedure

• Contrive a situation designed to evoke a specific question form.

• Fully prompt the use of the appropriate question form then fade the prompt. (most to least prompting)

• Correct any errors by presenting the condition again, fully prompting, then fading the prompt. (error correction procedure)

Teaching Procedure

• Deliver the information necessary to gain the reinforcer immediately after the question is asked. Reinforcement should initially be delivered within 30 seconds.

• Criterion for mastery- contrived situation evokes question on the first opportunity over 3 consecutive sessions.

• Immediately following mastery, add another question form to the same context.

Results

• Abby is asking questions with minimal to no prompting in a wide variety of contrived contexts.

• Abby is using question forms with no prompting when engaged in reinforcing activities with family and friends.

• Abby is beginning to generalize the use of questions to untaught contexts such as pretend play with siblings and when engaged in conversations.

Teaching “Which?”

Where, Who, Which

What…color, kind, do…

Facilitation of conversational turn-taking and pronoun use with children who demonstrate echolalic behaviors.

Arlene Dworkin Kaye, M.S., CCCSpeech and Language Pathologist

akaye36718@aol.com

A definition of “echolalia”

The repetition of utterances heard in the immediate of distant past.”

(Koegel &Koegel, 1975)

• Echolalia has been identified as a feature prevalent in the utterances of 75% of verbal children with autism.

(Rutter, 1968; Wing, 1971)

“Echolalia appears to serve important communicative and cognitive functions”

(Prizant,Schuler, Wetherby & Rydell, 1977)

Interactive Fuctions of Immediate Echolalia (Prizant & Duchan, 1981)

1. TURN TAKING: turn fillers in alternating verbal exchange.

2. DECLARATIVE: providing labels for objects, locations or actions (may be paired with physical act)

Interactive Fuctions of Immediate Echolalia (Prizant & Duchan, 1981)

3. YES ANSWER: affirmative response to utterance heard

4. REQUEST: attempt to ask for object or perfromance of an action

If echolalia serves a communicative purpose, then why try to change it?

Echolalia is not efficient.Echolalia is, often, not

effective.Echolalia is a socially

inappropriate behaviorEcholalia generally interferes

with functional communication.

Why do children with autism reverse pronouns?

• Is it a grammatical error?

These children don’t confuse case markings for personal pronouns.

(me vs. my) (Tager-Flusberg, 1994)

• Is it that the reference changes with the identity of the speaker?

Children with autism comprehended referents of personal pronouns in much the same way as their non-autistic counterparts. (Lee and Chiat, 1994)

These authors suggest that there is a breakdown of understanding linked to social/conversational demands.

Two specific language functions affected by echolalic behavior are:

1. Correct use of pronouns

2. Reciprocity in conversation

“Because pronoun reversal is reported almost exclusively for autism, it can be considered syndrome specific.”

( Wilkinson, 1998)

So…

Now that we’ve identified some

challengingbehaviors in need of

change, how do we change them?

Some currently available strategies:

Mcmorrow & Foxx (1986) “Cues-Pause-Point Method” and “Alternated Modeling”

• Select 10 questions for each of following 3 content areas:

Identification Interaction Factual

• Establish a baseline

• Familiarize the student with word cards whose names match

Some currently available strategies:

Mcmorrow & Foxx (1986) “Cues-Pause-Point Method” and “Alternated Modeling”

• Training consists of asking each question and prompting the answer with the written answer.

• If the student tries to talk during instruction the therapist is to hold their finger up prominently” and say “SHHH”.

• Prompting is faded during steps 5 and 6.

• Step 7 is maintenance.

Schreibman & Carr (1978) “I don’t know” method.

• Students are verbally prompted to respond “I don’t know” to a single “what”, “how” or “who questions.

• Once the student is able to respond Using the “I don’t know” without prompting, other questions are added. (Recommended in the “Me Book” (Lovaas, 1981)

Eliminating Echolalia and Establishing the use of Turn-Taking Patterns.

Students who rarely produce non-echolalic utterances when interacting with conversational partners, need to develop the following abilities:

• Attending to their conversational partner’s message and cue’s that indicate that it’s time to shift speakers.

• Remaining quiet while their conversational partner is speaking.

• Offering a response that is both content and latency appropriate

These core skills will enhance abilities to generalize new verbal behavior to novel situations and speakers.

USING SINGLE MESSAGE VOICE OUTPUT COMMUNICATION DEVICES TO PROMOTE SPEECH INITIATION AND APPROPRIATE USE OF PERSONAL PRONOUNS WITH CHILDREN EXHIBITING ECHOLALIC

LANGUAGE BEHAVIORS:

A Work In Progress!

(Arlene Dworkin Kaye)

This technique requires the use of:

A series of single message VOICE OUTPUT COMMUNICATION DEVICES

“VOCA”’S

Visual Prompts to identify the message on each VOCA.

A visual cue representing “no talking”

Identified reinforcers

What have we learned so far?

1. The use of echolalia and presence of pronoun reversal are behaviors commonly observed in children with autism. These behaviors are among those that separate them from non-autistic peers with other types of disabilities.

2. Children with autism are able to demonstrate an understanding of personal pronouns when tested, but can’t use them appropriately in conversation.

3.Echolalia can have a functional purpose for children with autism and may demonstrate a level of syntactic understanding.

Some Commonly used VOCA’s

Bigmack/Littlemac/iTalk2 (Able Net) Easy to program, volume control, 5 colors available, snap

caps.

Chipper (Adaptivations) Similar to “macs”. Smaller activation surface. Overlay

pockets.

Talking Buddy (Tash) Similar to “macs”. Available in 2 colors

Talking Symbols NotePad (Able Net)

Affordable, easy to manipulate, no volume control

Single Message Communicator (Enabling Devices)

Can be cumbersome. May not be considered visually appealing.

I’ve got my materials organized. I have a student to work with.

NOW WHAT?????

STEP ONE

• Place the icon or picture you’ve selected, on the face of each VOCA.

Even if you choose not to pair visuals with each VOCA, be sure to number or identify it in some way, so you don’t confuse the devices.

• Program each VOCA to speak the utterance you want the student to produce.

Some students respond more quickly if the voice on the recording is not their instructors’. For other’s, the voice used is a non-issue. If using an alternate speaking voice, it should be novel to the student. Matching the recording to your student’s age and sex works very well.

STEP TWO

Familiarize (don’t teach) the student with the conversational script or song that you will be

working with.

• This process should not be extraordinarily time consuming. It is not necessary, and may be counterproductive to “overteach”

• The student only needs a basic sense of the “flow” of the turn-taking task.

Step Three

Turn the VOCA on and adjust to the desired volume.

Line up the VOCA’S in the desired order, NEAR, but out of reach of your

student.

• To facilitate a more natural conversational flow, sit “knee to knee” with the student and position the VOCA’s on a side table.

• Volume control can be tricky, so you may want to mark desired settings on the control knob.

Step Four

Initiate the conversation or song.

• Your student will want treat this as a choral experience. It’s your job to make it clear that only ONE of you can speak at a time.

• Each time the student begins to echo your speech, discontinue the activity, hold the icon at the level of their mouth but within their visual field. Pair this action with the directive “Quiet”

Step Four Continued

• Your student will probably echo “Quiet” when you deliver the verbal prompt.

• Ignore this behavior and leave the icon in place for approximately 5 seconds. Then initiate the dialogue again.

• When your student echo’s your words the next time (and they WILL), present the icon, but delay the verbal pairing. Wait and begin the dialogue again.

Step Five

Immediately following your conversational turn, allow your student to access the VOCA.

• Initial trials may require complete physical prompt. It’s preferable to provide a full prompt and then fade it, as your student will get a sense of acceptable latency between conversational interactions.

“Sidebar”

• This process can be tricky at first. If the VOCA get’s jostled or your hand is misplaced, the device may “misfire”. Ignore the misfire and prompt the student to access the device.

• If possible, it is helpful to hold the “quiet” icon in front of your mouth during the student’s turn. Just make sure the picture side is facing your student.

Step SixRepeat this process until the song or script is

completed.Then deliver reinforcement.

• At least 2 VOCA’s are required if “turn taking” is your objective. MLU’s of each “turn” should be limited to allow reinforcement delivery to be timely.

• Even if your student can work for extended

periods of time before reinforcement delivery and/or is reinforced by the activity itself, it is recommended to limit the number of VOCA’s to 3 or 4, as managing the devices can be cumbersome.

Step Seven

Introduction of Initiation

• Once your student is able to complete the activity without VOCA support and with acceptable response latency for 3 consecutive days, have them initiate the interaction.

• This process should follow the same process followed during instructor initiation.

• After 2 student initiated trials, return to instructor initiation for one maintenance trial.

Step Seven (cont.)

Introduction of Initiation

• Remember, that this will require a second series of VOCA’s or re-programming of your current devices.

• It is preferable to have 2 sets of VOCA’s, as prompting may be required during maintenance stage.

Reinforcement Strategies

• Be certain you are providing reinforcement that is valuable to your student.

• The VOCA’s themselves are a form of “token economy”! Place your reinforcer or a visual representation at the end of the row of VOCA’s and “voila”.

• Turn taking songs, rhyming games or riddles are fun ways to teach this skill and may be innately reinforcing.

• YOU can become your students’ reinforcement. Remember what they enjoy (tickles, high fives, etc.) and deliver it.

Method’s of Prompt Fading using the VOCA’s

Fade the physical prompt

Reduce the volume of the VOCA’s

Reduce the verbal prompts using the VOCA’s

Increase the latency of delivery of VOCA prompt

Forward or Backward Chain using the VOCA’s

• My student is able to turn-take and initiate interactions in the absence of echolalia.NOW WHAT?

CONGRATULATIONS!Your student is beginning to learn

that communication is fun!

Generalize to other people, adults and children

Generalize to other environmentsExpand the repertoire of social

scripts, songs, riddles and/or rhymes

Does the same strategy work for pronoun reversal?

Yes it does.

• Use the same procedures. It can be useful to label VOCA’s using the child’s picture to establish “ownership” when the referent shifts from person to person.

***The use of this technique is only limited by your imagination. Use it to teach reciprocal greetings, responses during game play, or any other verbal interaction.

Julia’s appropriate wait and respond behaviors during song play

A comparison of appropriate "wait and respond behaviors using verbal and physical prompts vsl the

same behaviors using VOCA Prompts

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