Language in Autism

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Chances are, pretty much any SLP in pediatric practice will have children with Autism Spectrum Disorder (ASD) on caseload, so this topic is a really important one for all of us. Autism is associated with unique profiles of strengths, abilities, and needs, all of which may affect the services we need to provide. We have to make sure the assessment and intervention methods we’re using are appropriate and effective—not just for students with language disorders in general, but for those with ASD in particular. The collected research reviews below describe the overall language profiles you may encounter in your clients with autism (expressive-receptive gap, anyone?), as well as narrative and social skills. After that, reviews of research on assessment practices and a variety of intervention techniques will give you ideas you can take back to your speech room on Monday.

Speech delay? Language delay? Measuring it, and what’s common in toddlers with autism

For all the SLPs who work with younger children with autism (so ages 2–4), this one’s for you! We’re going to review two studies from the last decade that can help you understand and characterize the various expressive language profiles you may see in these children, as well as brainstorm therapy!

The first paper reports on a meeting of experts in early autism and language development. (NOTE: If you tend to be a science groupie who gets googly-eyes for big names, pop on over and look at the author list; #sofamous). The purpose of the group was to create a list of measures of the expressive spoken language of children with autism from 12 to 48 months of age. These benchmarks can be used in assessment (as part of a comprehensive assessment including parent report, natural language samples, and/or direct assessment), or to guide intervention.

In the article, you’re provided with a chart (see Table 1) divided into “First Words (12–18 mos)”, “Word Combinations (18–30 mos)”, and “Sentences (30–48 mos)”. Then within each of those categories, you have measures for:

  • phonology

  • vocabulary

  • grammar

  • pragmatics

And within each of those categories, the child must meet at least one marker, at minimum, to be identified within that category.

So, for example, for the Sentences (30–48 mos)–Phonology section, markers are:

  • 70%+ intelligible from a speech–language sample

  • Consonant inventory of at least 16–24 different consonants (75% correct), from a speech­–language sample

  • Age equivalent score of at least 36 months on a standardized test (e.g. GFTA, Arizona, or similar)

…and the child must meet the intelligibility criteria or the standardized test criteria in order to be considered as meeting that benchmark. Then, you’d look across the other measures (so vocabulary, grammar, and pragmatics) to see where they fit.

This table is a really nice way to consider data across multiple sources (and, importantly, to know which pieces of data to prioritize). It serves as a helpful addition to SLPs’ toolkit for describing and understanding the spoken expressive language of kids with ASD. 

So, how would most kids with ASD “perform” with this set of benchmarks?

Aha! That’s what the next paper looked at.

The authors of this article evaluated over 100 kids ages 2–3 years old using the “Spoken Language Benchmarks” from the last paper. Here were their primary findings: 

Considering phonology, vocabulary/grammar, and pragmatics as three separate skill sets…

  • Most of the children’s lowest score was in pragmatics (of course, right?! They have autism…)

  • The two most common profiles were:

    • phonology > vocabulary/grammar > pragmatics

    • phonology = vocabulary/grammar > pragmatics

    • See Table 3 for six other profiles observed, too! That table is really fascinating seeing what’s most versus least common… 

So let’s chat about this! Basically, they found that, “… phonology tends to be relatively intact for most individuals whereas pragmatic difficulties are nearly universal…” and “… in terms of pragmatics, 88% of the children fell into the Prelinguistic group, which reflects a developmental level of less than 12 months of age.”

Nearly half of the kids achieved higher phonology scores than vocabulary/grammar and pragmatics. So it’s an area of relative strength. And when we think about kids with ASD on our caseloads, I’m sure you can remember many kids fitting this profile—good speech skills, and expressive language and/or pragmatics less so.

Overall, being able to weight relative strengths of phonology, vocabulary, grammar, and pragmatics for our kids with ASD helps inform treatment, and also could be quite helpful in identifying which types of treatment tend to help which types of children with ASD in both clinical and research work.  

Tager-Flusberg, H., Rogers, S., Cooper, J., Landa, R., Lord, C., Paul, R… Yoder, P. (2009). Defining Spoken Language Benchmarks and Selecting Measures of Expressive Language Development for Young Children With Autism Spectrum Disorders. Journal of Speech, Language, and Hearing Research. doi: 10.1044/1092-4388(2009/08-0136).

Ellawadi, A.B., & Weismer, S.E. (2015). Using Spoken Language Benchmarks to Characterize the Expressive Language Skills of Young Children With Autism Spectrum Disorders. American Journal of Speech–Language Pathology. doi: 10.1044/2015_AJSLP-14-0190.


Language outcomes in children with ASD

Examining the language development of a large community-based sample of kids who were typically-developing, had DLD, or had ASD, this study found that even though the three groups started with different average baseline scores on the CELF-P2 or CELF-4, verbal children with ASD followed a trajectory of language development similar to TD and DLD groups between four and seven years of age when tested again using the CELF-4. Most children with ASD maintained stable language development, with smaller percentages showing accelerated or slowing language development (sounds kind of like a normal growth pattern, doesn’t it?).  

Other findings included:

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  • On average, the TD group had the highest language scores, the DLD group had the lowest, and the ASD group fell in between the two groups

  • Receptive language did not develop more slowly than expressive language in children with ASD (in contrast with other studies)

  • Baseline receptive/expressive language scores, gender, nonverbal IQ, and socioeconomic disadvantage predicted receptive language ability at 7 years for all three groups

  • Nonverbal IQ and receptive/expressive language scores at 4 years each predicted expressive language ability at 7 years for all three groups

  • Neither social ability nor a diagnosis of ASD at 4 years predicted language ability at age 7, once the authors controlled for baseline language scores, IQ, and gender

The authors caution that we should only apply the results of this study while predicting prognoses for ***verbal children with ASD with average intelligence who can complete language testing,*** and suggest further research on the language outcomes related to different levels of function in the ASD population.

Brignell, A., Williams, K., Jachno, K., Prior, M., Reilly, S., & Morgan, A. T. (2018). Patterns and predictors of language development from 4 to 7 years in verbal children with and without autism spectrum disorder. Journal of Autism and Developmental Disorders. doi: 10.1007/s10803-018-3565-2.

 

Expressive skills higher than receptive in autism

Have you ever had a student who scored higher on expressive language than receptive on a standardized test? If not yet, it’s something you’ll see sooner or later, and is more likely to happen in certain populations than others. Recall how Haebig & Sterling found this to be the case sometimes for autism, and also occasionally Fragile X? There are quite a few studies in the literature demonstrating this effect in children with autism, but expected proportions are all over the place. This month’s article importantly demonstrates that the receptive­–expressive discrepancy is age-dependent.
 
The data from this study is pooled from previous longitudinal studies. They examined Preschool Language Scale scores of children with autism, and found that the majority of children with autism had receptive language scores lower than expressive between ages two and three, but as they approached ages four and five, the discrepancy disappeared. Now, a few things to note:

  1. They didn’t examine children older than age 5 ½, so we don’t know if the discrepancy may reappear or not for some kids.

  2. This study included few toddlers with very-low language scores, and children with more severe language disorders may be less likely to show an expressive language advantage.

  3. When examining previous literature along with this, it appears that a clinician could expect to see approximately 1/3 to 1/2 of an early childhood caseload of children with autism to demonstrate an expressive language advantage. But—again—it depends entirely on exactly what ages you’re looking at, what language measures are used, the range of severity of children with autism you’re considering, and perhaps other factors as well.

 
In addition to examining the scores of children with autism, the authors also looked at scores of late talkers (who did not later receive an autism diagnosis) and found that the receptive scores of these children were all higher than expressive. This information can support clinicians in understanding the likely trajectory of early childhood students on their caseload.
 
The authors suggest, “…these results underscore the notion that best clinical practice is to consider both receptive and expressive language during assessment rather than just considering overall language level.” They also state, “…most treatments for ASD do not directly target comprehension, a point that has been previously criticized (Camarata, 2014),” and, “…parents and clinicians should concentrate on what toddlers with ASD understand as well as focusing on their language production.

Davidson, M.M., & Weismer, S.E. (2017). A discrepancy in comprehension and production in early language development in ASD? Is it clinically relevant? Journal of Autism and Developmental Disorders. doi: 10.3109/17549507.2013.858773.


Age-related social communication decline in ASD?

How do the social skills of children with autism spectrum disorder (ASD) change over time? Previous research demonstrates mixed results on social skill stability, depending on what is measured, how, and with what tests. Some studies have found stability or improvement of social skills from early childhood through high school, while others have found decline across these years.

In this study of 324 children with autism spectrum disorders (ASD) and 438 typically-developing children (ages 4–29), data were collected from three sources:

  • Autism Diagnostic Interview—Revised (ADI-R), a “parent interview”

  • Autism Diagnostic Observation Schedule—2 (ADOS-2), a “semi-structured” observation

  • the Social Responsiveness Scale (SRS-2), an “informant report”

They found that, “...in parent-reported social–communicative functioning, children, adolescents, and young adults with ASD demonstrated a general pattern of age-related declines in these scores.” Now—could the social skills of children with ASD truly get worse over time? Possibly. However, we can’t quite jump to that conclusion. It could instead be that the older groups in the study had poorer access to early intervention. It could be that higher social expectations are put on older children, particularly in these tests. It could be that parents of typically-developing children over-estimate their child’s social skills, while parents of children with ASD under-estimate. It could be a combination of factors.

As clinicians, what this data does tell us is that we need to be particularly attentive to children with ASD's social–communicative skills as they grow older even if they’ve previously performed within normal limits (e.g. in the early elementary years). It’s not inconceivable that some of these children may need to come back onto our caseloads later.

Wallace, G.L., Dudley, K., Anthony, L., Pugliese, C.E., Orionzi, B., Clasen, L., ... Kenworthy, L. (2016). Divergence of age-related differences in social-communication: improvements for typically developing youth but declines for youth with autism spectrum disorder. Journal of Autism and Developmental Disorders. doi: 10.1007/s10803-016-2972-5.

 

Predictors of social success in children with autism

“There is a common misconception that all children with ASD experience negative social outcomes and require intense intervention supports in schools. While this may be true for many children with ASD, there are others who are well liked and socially connected.” (Locke et al., 2017)

Many children with autism experience social successes. Why is that? What is it about these kids, about what they’re doing or the environment they’re in, that makes them successful?

First, the authors of this study had to define success. So, what’s a “socially successful” kid? They chose to define it as one who:

  • demonstrates “more joint attention with peers during unstructured school periods (recess and lunch)…”

  • is rated by peers to have a relatively strong role within the classroom social environment; this is kind of like “popularity” except was measured by both individual and peer group popularity

Working with that definition, they looked at 148 kids with autism, ages 5–12, who spent at least half their day in a general education environment. Some things they found:

  1. Over half the children had “notable success on at least one social outcome” (so one of the two bullet points, above)

  2. Autism severity impacted social success; IQ didn’t

  3. Social success was easier for the younger kids, and harder for the older kids (and this finding is consistent with other studies, e.g. Rotherman-Fuller et al., 2010); more specifically, being a member of a peer group starts to decrease around age eight.

So the biggest take-homes for SLPs may be to note that many children with autism do have plenty of social success. Not all kids with autism need social support or goals! Then, also, that older elementary children tend to have less social success than the younger children. This doesn’t exactly tell us what to do with intervention, though. Does knowing that kids tend to have more social difficulties as they get older mean we should treat early to prevent it, or later when it’s really needed? Who knows... but we certainly shouldn't expect to "graduate" kids from their social goals as they age. Unfortunately, the social landscape changes substantially from early to late elementary ages.

What do the authors suggest we do? Again, this isn’t a treatment article, so nothing on treatment can be concluded from this study. But they do point to some options, such as intervention studies on SLPs putting together clubs and social groups (e.g. Kasari et al., 2016).

Locke, J., Williams, J., Shih, W., Kasari, C. (2017). Characteristics of socially successful elementary school-aged children with autism. The Journal of Child Psychology & Psychiatry. doi: 10.1111/jcpp.12636.

 

Narrative skills in verbal preschoolers with autism

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This study looked at verbal preschoolers with autism spectrum disorders’ (ASDs) ability to comprehend and retell oral narratives. Children listened to a short story twice while looking at pictures on a computer. Between readings, they were asked eight comprehension questions (factual and inferential wh-questions). Then, children were asked to retell the story (sans pictures).

Results showed that the children had low accuracy on the comprehension questions, with higher accuracy on factual than inferential questions. Five children did not produce a retell at all, four told an off-topic story, and one was excluded for unusually high performance. For the nineteen children whose retells were analyzed, microstructure was comparable to typically developing 4-year-olds’ in terms of length, number of different words, and MLU in morphemes, but was lower in grammatical accuracy. Children with autism included few macrostructure elements (e.g., setting, problem, plan, etc.). Most children, “…produced descriptive or action sequences, implying a lack of understanding of goal-directed behavior.”

Note that this is a small study that gives only descriptive information about narrative production. However, given that there is little existing research on narrative abilities of preschoolers with ASDs, the data give us a starting point for thinking about narrative assessment with these children. In particular, this study suggests that we need to look at narrative macrostructure (i.e., understanding the overall goal of the story), which may be hard for preschoolers with ASD even when their sentence-level language skills look relatively strong.

Westerveld, M. F. & Roberts, J. M. A. (2017). The oral narrative comprehension and production abilities of verbal preschoolers on the autism spectrum. Language, Speech, and Hearing Services in the Schools. doi: 10.1044/2017_LSHSS-17-0003.

 

Assessing the speech and language of children with autism

Two studies this month address communication assessment of children with autism spectrum disorders (ASD). One study focuses on evidence-based speech assessment, and a second study provides support for examining language at the discourse level.

SPEECH:

Broome et al. reviewed 21 studies on speech assessment for children with ASD. The authors initially identified 116 articles, but a large number of those studies referred too generally to the speech characteristics assessed (e.g. “vocalizations,” “verbalizations,” “babble”), and were therefore excluded. Then, the authors reviewed the participant-specific information in the remaining studies, and included only those in which they were confident about the children’s ASD diagnoses. The authors then grouped children from the remaining 21 studies into two groups: 1) prelinguistic communicators and 2) communicators using words in order to attempt to draw conclusions.

The researchers found that, across the literature, teams used a wide variety of assessment tasks and reporting standards, with heterogeneous participants. Due to these dissimilarities, the authors were unable to identify trends, and propose going back to methods proven for “speech assessment of a more general pediatric population.” Thus, in order to do your best at implementing evidence-based speech assessment, you’ll have to apply those methods the best you can to children with ASD.

The authors propose a set of guidelines for speech assessment for children with ASD, summarized as a checklist (see article Table 4). This checklist condenses the core components of assessment so that you can quickly determine how to collect data (think oral motor assessment, connected speech sample, stimulability testing, etc.) and how to analyze that data (think phonetic repertoire, syllable shape analysis, stress pattern analysis, and more), specific to whether you’re assessing a prelinguistic child or a verbal child. This checklist could be very handy both when preparing to collect data, as well as when analyzing and reporting the data.

LANGUAGE:

Volden et al. make the case for assessing language “beyond sentences”, using narratives, so that we can better evaluate high-level language skills that might be overlooked when we assess school-aged children with ASD at the word or sentence level.

Within a larger sample of children with ASD from a multisite longitudinal study, the researchers examined 74 eight- and nine-year-olds’ performance on the Expression, Reception, and Recall of Narrative Instrument (ERRNI) and the Clinical Evaluation of Language Fundamentals–4 (CELF). Using 1.5 standard deviations below the mean as a cutoff for identifying “clinical concern”, the researchers found that 58% of the sample would be identified using both the ERRNI and the CELF, as compared to 53% that would be identified using the ERRNI alone, or 20% of the sample that would be identified using the CELF alone (whoa!) A similar pattern was noted when using 2 standard deviations below the mean as a cutoff (e.g. 41% of the sample would be identified using both tests, whereas 36% would be identified using only the ERRNI, and 14% would be identified using only the CELF).

A caveat: this study’s sample included “intellectually able eight- and nine-year-olds with ASD who have age-appropriate word- and sentence-level syntactic and semantic skills.” Thus, this is a restricted portion of the larger population of children with ASD. Nonetheless, the takeaway is powerful—that we should think about assessing more broadly than a sentence-level language assessment like the CELF, and look at the discourse level. The authors suggest that a narrative-based test, like the ERRNI, should be used in conjunction with pragmatic assessment and a language sample.

Broome, K., McCabe, P., Docking, K., & Doble, M. (2017). A systematic review of speech assessments for children with Autism Spectrum Disorder: Recommendations for best practice. American Journal of Speech-Language Pathology. doi: 10.1044/2017_AJSLP-16-0014.

Volden, J., Dodd, E., Engel, K., Smith, I. M., Szatmari, P., Fombonne, E., … Duku, E. (2017). Beyond sentences: Using the Expression, Reception, and Recall of Narratives Instrument to assess communication in school-aged children with autism spectrum disorder. Journal of Speech, Language, and Hearing Research. doi: 10.1044/2017_JSLHR-L-16-0168.

 

Improving personal narrative skills in young adults with autism

People with autism may have difficulties with several aspects of language and social communication; one common challenge is in the production of personal narratives. A personal narrative is a true story of something that happened in the person’s life, past or recent. It’s a fundamental part of social communication, and crucial for being able to engage in conversation with others, explain your point of view, and advocate for yourself.

For this study, the researchers enrolled ten people with autism (15–25 years old), and their parents, and split them into a treatment group and a wait-list control group. At baseline, the ten young adults with autism produced narratives with quality ratings equivalent to a child under six years old.

The parents in the treatment group participated in a two-hour training program to teach them how to better support narrative development in their young adult children. The authors list and describe the ten topics the parents were trained on. For example, topic #4 was:

“Ask plenty of wh questions and few yes/no questions. As part of this, ask questions about the context or setting of the events, especially where and when they took place.”

Following training, the authors found that parents were more elaborative in their communicative interactions with their children, and the young adults with ASD produced significantly more elaborative narratives as well, indicating that this may be a promising therapeutic technique. The researchers indicate plans to examine the use of this technique with parents of younger children in the future.

McCabe, A., Hillier, A., DaSilva, C., Queenan, A., Tauras, M. (2016). Parental Mediation in the Improvement of Narrative Skills of High-Functioning Individuals With Autism Spectrum Disorder. Communication Disorders Quarterly. doi: 10.1177/1525740116669114.

 

Narrative intervention for ASD (and free stuff!)

SLPs see a lot of children who have difficulty with narrative tasks. While typically developing preschoolers are beginning to understand story grammar, children with autism and/or developmental language disorders often struggle well into elementary years, affecting them both academically and socially. Narrative comprehension and generation are also a focus of the Common Core standards, as the authors of this paper explain:

“[Per Common Core] kindergartners should be able to tell a story in time order; second graders should be able to give details of actions, thoughts, and feelings; and fourth graders should be able to effectively recount subtleties of narrative events. Students must be able to meet these rigorous expectations that are now guiding instruction and evaluation across the United States.”

Need narrative assessment and intervention resources to help your students jump this high bar? Petersen and colleagues have you covered. They have created the CUBED assessment for narrative language, which can be downloaded for free here, are currently norming the DYMOND (see their guest review on that), and tested a narrative intervention in this study here.

Three boys ages 6–8 with ASD were assessed using a previous version of the CUBED assessment and then participated in 12 intervention sessions to see if the treatment improved their story grammar and linguistic complexity in personal narratives. Story grammar (e.g., internal response, problem, action, consequence, etc.) and linguistic complexity targets (e.g., causality, temporal conjunctions, adverbs, subordinate clauses, etc.) were chosen for each boy based on his performance on the initial assessment.

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The general framework of the intervention includes 8 steps (4 addressing narrative re-telling, 4 addressing narrative generation) completed in order.

  1. Clinician tells model story, providing story grammar icons for visual support

  2. Child re-tells the model story, with full support from clinician

  3. Child re-tells the model story, with fading support

  4. Child independently re-tells the model story

  5. Child generates a personal narrative related to model story while clinician sketches visual cues

  6. Child re-tells narrative with full support

  7. Child re-tells narrative with fading support

  8. Child independently re-tells narrative after brief “break” (clean-up)

That looks pretty reasonable, but did it work? After analyzing the students’ final narratives, the authors found that all three students increased the story grammar elements and linguistic complexity of their narratives immediately after intervention, but maintenance of these improvements was inconsistent. The authors suggested that “it is likely that greater numbers of individualized narrative intervention sessions are necessary to maintain global gains for children with autism.” So while this intervention is promising, it’s not a quick fix.

See the paper’s appendices for treatment steps, a scoring rubric, and model story examples. For more information on sketching visual supports from children’s narratives, see here.

Petersen, D. B., Brown, C., L, Ukrainetz, T. A., Wise, C., Spencer, T. D., & Zebre, J. (2014). Systematic individualized narrative language intervention on the personal narratives of children with autism. Language, Speech, and Hearing Services in Schools. doi: 10.1044/2013_LSHSS-12-0099.

 

How our language may affect their language

The use of telegraphic speech with children who have Autism Spectrum Disorder (ASD), by both parents and clinicians, is common. Is this a good thing or a bad thing? Does it affect language development?

First: What exactly is telegraphic speech anyway? Telegraphic speech is a normal part of a child’s linguistic development. It is the use of primary content words, such as: ball go, daddy jump, want cup. Many intervention approaches for our clients with autism explicitly incorporate the use of telegraphic speech for teaching language, so they can be exposed to telegraphic speech more frequently than other children (Venker et al. 2015, p. 1735).

This study tested children at 3.5 and 4.5 years old by watching interactions with their parents during play. They focused on how many determiners (articles, possessive pronouns) were omitted from noun phrases in which they were needed. For example, “Eat the cookie” became “Eat cookie.” The parents in this study omitted these determiners at varying levels—some often, others rarely. The researchers measured mean length utterance (MLU) and number of different words (NDW) from each interaction and compared them.

Here’s what they found: The number of determiners that parents omitted from their speech predicted the diversity and complexity of the child’s language skills (which was evident in the measurements of NDW). Therefore, it is possible that using telegraphic speech could be detrimental to the development of a child’s lexicon. Using grammatically incorrect forms with children overall may possibly slow their language processing and limit opportunities to imitate  grammatically correct forms. However, do note—this study did not determine cause and effect. It could be that parents’ language doesn’t cause the children’s language, but that the relationship is bidirectional. The authors pose another possible explanation: that, “…parents who use higher levels of telegraphic speech may also exhibit other behaviors that negatively affect children’s language learning,” and this is only one of many possible explanations.

This guest post was written by Lauren Bender-Stringham, a graduate student at Clarion University.

Venker, C. E., Bolt, D. M., Meyer, A., Sindberg, H., Ellis Weismer, S., & Tager-Flusber, H. (2015). Parent telegraphic speech use and spoken language in preschoolers with ASD. Journal of Speech, Language, and Hearing Research. doi: 10.1044/2015_JSLHR-L-14-0291.

 

Training siblings to provide language intervention for autism

As clinicians we try to provide “naturalistic” language therapy as much as possible. But how natural is it really for kids to sit in a sterile closet… ahem, speech and language office... and play with toys only the therapist owns, with an adult at least three times their age? It’s soooo natural… said no one ever.  

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So how can we make therapy more functional and natural for children with autism? Spector & Charlop suggest that sibling-mediated interventions could be effective. After all, siblings are present in the day-to-day life of children with ASD, and they work for free (or at least for snacks). There isn’t much research on this idea, but anecdotally, it has been reported that siblings enjoy teaching, and children with ASD are responsive to their siblings. Obviously this intervention requires that the child with ASD have a typically-developing sibling who is able and willing to learn (and the therapist also needs access to the sibling).

In this study, the researchers trained siblings of three 6–9 year-olds with autism in the Natural Language Paradigm—a relatively simple, evidence-based language intervention that can be used to increase spontaneous language production, expand utterances, or refine grammar. The siblings were between 7 and 11 years old and learned to implement the intervention in a 25-minute training session by watching a video and role-playing with a therapist. During the intervention, the child with ASD  chose a preferred toy to play with, and the trained sibling facilitated turn-taking with the toy while repeating various target phrases.

Two of the three children with autism doubled their percentage of verbal behavior after two sessions working with their brother or sister and showed increased happiness and joint attention post-intervention. The siblings were reported to have enjoyed the interactions as well. The third child had many interfering behaviors which prevented him from fully participating.

Whether you work in a private practice and could ask a sibling to join your session, or work in a public school and could pull a sibling out of class a few times, incorporating siblings into therapy seems to show promising evidence. And the potential for some adorable, heartwarming moments? It reminds us why we do what we do.

Side note: This month, Toseeb et al. published evidence (not reviewed by TISLP but available here) that children with ASD are more likely to be bullied by (and to bully) their siblings. Pure speculation here, but maybe peer-mediated language intervention could support positive sibling relationships? Scientists, take note!

Spektor, V., & Charlop, M.H. (2018) A sibling-mediated intervention for children with autism spectrum disorder: Using the natural language paradigm (NLP). Journal of Autism and Developmental Disorders. doi: 10.1007/s10803-017-3404-x.



Toddlers with ASD can use verbal input (without visuals!) to learn

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Using visuals with toddlers with ASD is practically the gold standard in early intervention. Temple Grandin taught us that some people with ASD can more easily understand a picture than a sentence. However, Fitch et al. showed that toddlers with ASD can use verbal information to update their expectations of the world.

This study focused on mental representations, which is just a fancy term for pictures or concepts in our head. If a parent said to you “Jackson took three steps yesterday” you would probably form a mental representation of Jackson toddling along in his living room. If the parent then said “it happened at the park” you would update your mental representation to include the park as the setting, instead of the living room.

This seems simple for us, but it’s actually pretty complex, and typical infants can do this by their 2nd birthdays. For verbal updating to occur, the child must be able to understand that language can refer to something that is absent or that they cannot see. They must also retrieve the prior representation, comprehend the new verbal input, and then manipulate their representation to incorporate new information.

This study found that toddlers with ASD, who had significant language delays, were able to learn with solely verbal information just as well as typically developing peers.  The authors suggested that verbal comprehension abilities may be underestimated using traditional language testing in toddlers. And as an SLP, I personally might interpret these results as supporting use of narration and language modeling even in the absence of visual referents with toddlers, as they may actually be listening, learning and updating their knowledge.

Side note—the authors used a really interesting eye-tracking method to measure whether infants understood verbal information, so check out the original article for more information on that!      

Fitch, A., Valadez, A., Ganea, P.A., Carter, A.S., & Kaldy, Z. (2018). Toddlers with autism spectrum disorder can use language to update their expectations about the world. Journal of Autism and Developmental Disorders. doi: 10.1007/s10803-018-3706-7

 

Play skills: Not just for early childhood!

As a school-based SLP, working on play skills is not often my top priority for minimally verbal children with ASD over the age of 5. Chang et al. report that the majority of research related to this population is focused on reducing challenging behaviors and increasing language, which I can definitely relate to. However, targeted interventions focusing specifically on symbolic play can be effective in both improving play skills and increasing expressive language skills.

Why is play important? Play is inherently motivating for children. It provides a context for learning, and most importantly, it is associated with stronger cognitive and language development. We know that children with autism often struggle with play. Their play tends to be more object focused, and they are often less jointly engaged with their social partners. When they do engage in symbolic play, it tends to be scripted or prompted.

The researchers behind this study found a group of children ages 5–8 with a diagnosis of autism and fewer than 20 spontaneous words. All children received targeted intervention focusing on symbolic play, a combination of approaches which the authors called JASPER + EMT (JASPER = Joint Attention, Symbolic Play, Engagement and Regulation; EMT = Enhanced Milieu Training). A detailed description of these interventions can be found here.

Some key features of the intervention approach include:

  • Creating meaningful opportunities for learning and communication by "responding to the child's actions and communication bids"

  • "Modeling and expanding play and communication"

  • Working on joint attention

  • Using motivating toys

After a 6-month intervention period, the children improved their play skills during therapy sessions. The children also generalized these gains to a novel environment—the Structured Play Assessment—where play skills were assessed by independent, blind testers. Symbolic play skills were also positively related to expressive language, as measured by:

  • The number of spontaneous communicative utterances, and

  • The total number of different words used by the child

Unfortunately, this study did not include a control group, so it’s hard to determine if this intervention would be more effective than another type of intervention. The authors also did not examine whether the effects generalized outside the clinic environment. Nevertheless, this article reminds us about the importance of play, even for school-aged children.

Chang, Y., Shih, W., Landa, R., Kaiser, A., & Kasari, C. (2018). Symbolic play in school-aged minimally verbal children with autism spectrum disorder. Journal of Autism and Developmental Disorders. doi: 10.1007/s10803-017-3388-6.



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