(Notes from April NSSLHA meeting)
Gwendolyn Meier works at Villa Esperanza, which mostly serves children with severe communication disorders (often autism), aged 2-22. Many children come to them because they can’t be managed in their own school district. They have a Speech-Language center adjacent to the school. It’s a very specialized place, because they see very few stuttering or voice disorders, or even articulation unless it is a verbal apraxia in conjunction with autism.
Autism is a behaviorally-defined disorder. There is no medical battery given to confirm it; it is characterized by behavioral symptoms. It was first talked about in 1943. The incidence estimates have significantly increased from 1 in 10,000 in 1980 to 1 in 100 today.
Key aspects of an autism diagnosis:
1) Limited social interaction—including eye contact, response to communication, initiation of interaction (e.g. peek-a-boo)
2) Communication—verbal communication may be disordered, with words used unusually and, the developmental progression won’t be ordered typically. For example, the first words might be requests instead of comments (unlike typically-developing children).
3) Restrictive, repetitive, stereotyped behavior—including self-stimulation. We think this might be due to sensory stimulation, although it may serve some sort of purpose (we don’t know much about this).
Symptoms may appear to different degrees and affect different areas of functioning. There is reduced connectivity shown between brain regions (association tracts); these are underdeveloped and don’t work as a whole system.
The core deficits of ASD affect many areas of function. For example, an inability to shift attention easy can result in stereotyped behaviors. Impaired use of symbols (shared meanings) especially affects abstract concepts.
There are very few standardized measures that look at the core deficits of autism. We know that standardized measures usually look at form and content, which are often disordered. However, this might not be their biggest area of need, e.g. Can they use. back-and-forth interaction with another child?
Language functions, initiation and rate of communication are very different from a typically-developing child. Requests are the easiest to teach, while commenting is much more difficult. Few resources aid us in evaluating pre-intentional, preverbal and non-verbal communication. PECS (Picture Exchange Communication System) is one example of an AAC strategy, but there is little guidance on selecting and implementing such intervention.
Other important factors:
1) Communication mode—e.g. using eyes or sounds to communicate, even if these don’t seem intentional to a casual observer
2) Rate—we need to look at rate of initiation vs. response. Do we need to ask questions differently in order to get a response?
3) Communicative functions—do they comment/show/share at all? These may be absent, especially for younger children
a. Request
i. Object/activity
ii. Information
b. Response
c. Comment
d. Express feelings
e. Prosocial statement
f. Conversational skill
4) Non-verbal communication—eye gaze and facial expression for social regulation, regulating interaction, gaining info—e.g. looking at someone for a request to spin around
5) Social communication—the most basic is back-and-forth between mom and baby’s smiles, up to more abstract, such as appropriate ways to interrupt mom when she’s on the phone. A high-functioning intervention are “social inferencing” questions. Register-switching is also under this category.
6) Language content and form—although the more foundational skills are basic turn-taking and conversational abilities that enable them to make friends and have interaction!
Aided language stimulation/visually cued instruction—gives visual cues along with oral language input, building off their visual sense and using an intransient form of communication.
Assessment:
- Context- have natural communication exchanges (Wetherby et al. 1997)
- Who the individual is interacting with
- What cueing is helpful; including what parents are doing
- Motivation to communicate
- Hidden abilities or inroads—where can these kids function? Some grow up and write that actually, they understood much more than we realized. Non-verbal children may learn how to type or use visual forms of communication.
- Multiple sources of information, such as interviews with parents or teachers, observations of everyday situations.
Treatment
1. Functional communication (basic wants and needs)—including understanding of cause and effect, reducing learned helplessness by reinforcing any type of communication. For the adult, these skills might include toileting skills, identification of feelings, school readliness, yes/no responses, labeling. However for the child, these are most likely to be foods, toys and activities at the very beginning.
2. Initiation and Motivation
Motivation drives communication—first teach cause and effect, then expand communicative functions. Increasing functional equivalents to challenging behavior have been shown to reduce such problems. Find out what is reinforcing and personally meaningful to the child.
3. Language development
Language is learned in interaction with others. Competence is much more than vocabulary and sentence structure; we want to teach warm communicative interactions. Pragmatic functions make children stand out vs. blending in- much more dramatically than proper grammar or complete sentences. Interaction skills may be more important to real-world functioning than other language skills.
4. Plan for and practice generalization from the very start.
Online resources:
Indiana Resource Center for Autism
http://www.iidc.indiana.edu/irca/IRCAarticles/fcommunicationarticles.html
Susan Stokes Autism Articles and IEP goals
http://www.specialed.us/autism/index2.htm
Autism Inspiration Sensory Ideas
http://www.autisminspiration.com/public/department44.cfm
WIRED magazine article
http://www.wired.com/medtech/health/magazine/16-03/ff_autism
