Autism Spectrum Disorders: Intervention for Non-Speakers Rhea Paul, Ph.D., CCC-SLP Southern Connecticut State University

1. Autism Spectrum Disorders: Intervention for Non-Speakers Rhea Paul, Ph.D., CCC-SLP Southern Connecticut State University Yale Child Study Center Feb. 11-15, 2008 rhea.paul@yale.edu

2. 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

3. Goals of Treatment for Prelinguistic Children with ASD • Social Interaction skills • Imitation; Reciprocity • Joint attention • Play; peer relations • Communication skills • Gestures • Vocalizations • Speech, alternative mode • Listening • Adaptive skills • Learning to learn • Self-help • Self-regulation, emotional regulation • Preacademic skills appropriate to developmental level

4. 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

5. 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.

6. 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)

7. 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 propertiesto objects (hot!) • Evidence shows these can be taught • Evidence also shows children with more play skills do better in other interventions for communication

8. Fostering Peer Relations • Peer Group Entry • Buddy Time • Peer and Target Training

9. 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

10. 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.

11. 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

12. Peer 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 Peer and Target Training

13. Communication • Speech-focused: aimed at getting child to use oral language • Communication-focused: aimed at getting child to engage in reciprocal social interactions; e.g., expressing communicative intent through gestures, gaze, vocalization, etc. • Relationship-based methods • Skills-based methods • Developmental/Pragmatic methods

14. Speech-Focused Methods

15. Active Ingredients: Speech-Focused Methods • Clinician control • Use of imitative response • Tangible reinforcement • Stimulus-response-reinforcement sequence

16. 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

17. 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

18. 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 Teach Me Language (Freeman& Dakes, 1996)

19. 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

20. RMIA Video

21. Scripts and Script Fading(McClannahan & Krantz, 2005) • Use a ‘prompter adult’ • Teach names for preferred objects and activities • Record names on card reader • Teach child to use cards to produce requests • Eventually, require the child both to run the card AND repeat the word for a request function • Gradually fade scripts • Some evidence published for efficacy in small number of Ss.

22. 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

23. Communication-focused Interventions: Relationship-based Methods

24. 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

25. 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

26. Communication-focused Interventions: Skills-based

27. 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

28. 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.

29. 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

30. 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

31. Picture Exchange Communication System Video

32. 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.

33. 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.

34. 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

35. 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

36. Prelinguistic Milieu Video

37. 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.

38. 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.

39. 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.

40. Developmental and Pragmatic Methods

41. 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

42. 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

43. 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

44. 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

45. 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

46. 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)

47. Eclectic Programs • Denver • Douglass DD Center, • Princeton Child Development Institute, • Learning Experiences Alternative Program • Pivotal Response Training

48. 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

49. 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.”

50. 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