COMMUNICATION

Children who have been diagnosed with Autism seldom engage in effective communication.  Approximately 50 percent of autistic children never develop speech, while others develop early forms of communication and social interaction.

Language refers to the body of words, patterns of sounds, structures and forms used to construct speech.  Communication implies using language in a social context to request something, comment on an event, describe an action or acknowledge the presence of another individual.   It occurs verbally or non-verbally through the use of spoken words, gestures, signs, or by pointing to printed words or symbols.

To be effective communicators, individuals must first be able to understand cause and effect relations, have a desire to communicate, have someone to communicate with, have something to communicate about, and have a means of expressing themselves. Communicative exchanges involve both receptive and expressive language skills.

As children develop, they begin to attend to items and others for longer periods of time and pay more attention to detail.  Through exploring their environment they begin to understand that their actions cause other events to occur. This is also the time that children begin to respond to simple commands, gestures and expressions.  Most autistic children tend to be responders to communication, rather than initiators.  The majority of their communicative behaviors are limited to requests or rejections for food/drink, toys or help. They seldom communicate about their own feelings or respond empathetically to the needs of others. During times of choice making, autistic children will communicate their negative desire by a head nod from side to side, but will seldom give gestures indicating affirmative choices.

Psychologists who work with autistic children have developed methods of building speech from the simpliest sounds. Initially, they are taught to attend to others, maintain eye contact and imitate  sounds.  The sounds are then blended into words.  Each tiny step is rewarded to reinforce success.  Other behavioral psychologists concentrate on managing communication through everyday situations.

By the time most  non-verbal autistic children attend school programs, they have already been assessed by a speech therapist, attended children's play therapy, or have had individual sessions to foster communication.  It is imperative that the child's progress continue to be monitored by a speech therapist within the school setting and options for alternative communication by explored.

ESTABLISHING OBJECTIVES FOR COMMUNICATION

One of the most significant goals for an autistic child's individual program plan is to foster increased communication. Prior to determining appropriate objectives and goals, a base level of interpretable communication must be established by observing the child within the school setting.  An observer records all non-verbal communicative attempts of the child over a two hour span, or if preferred a total of fifty acts.  They are then analyzed to determine why, how, where and with whom the child has communicated.  The information is then combined with observations from parents and therapists to determine the most desired methods to use for helping the child become an effective communicator.  An information sheet filled out by the parent may provide additional information about the child's interests and skill levels.  Early vocabulary relating to concepts, action words, locations, and recurrence can then be introduced to the child.  It may even be necessary for the child to learn a new form of communication in relation to already established skills, before being introduced to new ones.

The following is a list of possible objectives for non-verbal autistic children:

-  Look in direction of sound source
-  Look at adult/peers when approached or spoken to
-  Attend  to actions or gestures of others
-  Attend to printed images
-  Attend to task
-  Reach out to touch others
-  Establish eye contact with others
-  Approach adult for assistance
-  Approach adult for comfort
-  Sit among peers during large group times
-  Hold hands with others
-  Smile at self in mirror
-  Respond to own name
-  Identify own body parts by pointing to upon request
-  Identify self in mirror by pointing to or smiling at upon request
-  Point to objects when requested
-  Indicate preferences or objections (non-verbally)
-  Engage in turn-taking activities with peers
-  Respond to simple (1-2 part) verbal commands
-  Respond to gestural cues
-  Imitate simple gestural signs
-  Initiate simple gestural signs
-  Understand  simple concepts (big/little)

INTERVENTION STRATEGIES

Research over the years indicates that autistic children learn better when teaching methods include the use of consistent daily routines, consequences for inappropriate behaviors and task organization.  These intervention techniques lead to increased attending skills, a better understanding of cause and effect relations and the ability to relate to others.  Stereotypical behaviors become less frequent as the autistic child engages in meaningful activities.

While it is important for the child to be integrated into a regular classroom, it is equally important for them to receive appropriate teaching for their develop- mental level. If a separate room or sectioned off part of a classroom is made available, the assistant is able to provide brief 1:1 teaching sessions throughout each day.  A variety of techniques are used to solicit eye contact and expand on play situations. Items such as balloons, pinwheels, transparent drawing boards and bubbles all help draw attention to the adult's face during activities.  Additional items used for this purpose are push toys, musical instruments, pom-poms, mechanical toys, rattles and squeaky toys.  In order for a  child to learn reciprical action, balls, blocks in a form box, train on tracks or puppets are useful.  When the child attempts to grab an item, the assistant momentarily holds the item, thereby creating another opportunity for turn taking and eye contact. When the child vocalizes while playing with toys,  the assistant may imitate/exaggerate their actions, or respond in more challenging ways to challenge the child.

Other Strategies used to Encourage and Enhance Communicative Attempts:

-  Observe and respond to all non-verbal attempts
-  Imitate all sounds the child makes  (tongue clicking, etc.)
-  Maintain close proximity of the child  (face to face, eye level)
-  Follow the child's lead rather than anticipate their every need
-  Wait 5-10 seconds for child to respond to request
-  Choose speech carefully (limit quantity, stress key words)
-  Use simple language (do not assume the child knows)
-  Provide verbal models from the child's perspective, not the adults
-  Verbally label actions as they occur
-  Identify toys - explain their function in simple words
-  Use child's name often
-  Sort, match and name items
-  Make up songs or tunes to accompany routines  (increases attending)
-  Use action songs and fingerplays
-  Name articles of clothing as they are put on
-  Provide objects which make a variety of sounds (bells, whistles, horns, singing,
   music box, noise making toys)
-  Place favorite toy in/out/over/under/beside/behind/in front
-  Teach socially acceptable ways to protest or reject items or activities
-  Use simple social stories to teach routines (Carol Gray stories)
-  Use simple picture books (clear images, non- cartoon style drawings)
-  Laminate pictures of family members, pets, routines; name objects in pictures
-  Act as interpreter to others in order for 2 way communication to continue
-  Place interesting objects inside a jar that is difficult to open or out of reach.
   Wait for child to use gaze, or gesture to indicate their desires, then give the
    item immediately to them
-  Use objects which require another persons help (balloon, pinwheels, bubbles,
    wind-up toy, train on tracks)
 -  During floor play, have the child sit cross-legged directly across from the
    assistant (this is particularly useful if the child crawls or turns away in an
    attempt to avoid relating to others)
 

AUGMENTED COMMUNICATION

Augmented communication is any symbol system that supports speech, aided
or unaided using forms such as speech, sign language, communication boards, photos, pictographs, computer images or print.  Clinical research and practices recommend the use of visual cues as instructional support for structured and natural learning situations. Sytems using spoken words require rather complex retrieval systems and motor responses, whereas symbols provide a high degree of visual reinforcement.  Most autistic children learn to communicate, interact and develop self control quicker if pictographs or written cues are provided.

Several considerations must be taken into account when selecting a desired form of augmented communication for the child.  It is important to determine the cognitive abilities of the child, and to ascertain whether they have reached the stage of object permanence and have knowledge of cause-effect relations. Their attending skills may be minimal, knowledge limited, and eye contact non-existent. It is important to determine which sense the child uses the majority of time to learn about the world around them. Non-verbal actions and vocalizations must be assessed for their communication intent.  The time and interest that the family is willing to spend assisting their child with communication, as well as personal preferences must be taken into consideration when developing augmented communication strategies.
 

Speech

Many autistic children ignore speech, with the exception of a few select words.  It may take them years to recognize and respond to their own name.  Later on they begin to acquire limited comprehension of speech and are able to obey simple instructions.  Only a few autistic children learn to use speech effectively.  They seldom learn more than a few words; often repeating the last word/words of sentences spoken by others in exactly the same tone.  This echoing of words is called "echolalia". "Delayed echolalia" is when children repeat selected words previously said by others.  Seldom do these words and phrases bare  appropriate meaning to the activities at hand.  These are produced with great effort and  contain many contextual and grammatical errors.  Autistic children experience difficulty with words usually occurring in pairs such as on/off", "brush/comb", "sock/shoe", or "Mommy/
Daddy".  Their sentences vary in tone, however appear very mechanical sounding, are loud, and consist of very few words.

Sign Language

If an autistic child is able to attend for brief periods of time, focus on the face of other individuals and possess imitative motor skills, signing may be selected as the most appropriate form of augmented communication.

American Sign Language is used because the signs are similiar to gestures used in everday situations, and are relatively simple to initiate.  However, retrieval and choice making are more difficult with this system.  Generally, the consulting speech therapist provides training to the assistant on how to model a few simple signs relating to the needs of the specific child.  The signs taught should reflect typical requests by the child, with some general action commands such as "stop", "come", "sit down", "stand", and "no". Auditory speech and facial expressions should be used in conjunction with signs to provide additional cues for the child. Most words are signed with your dominant hand with both hands being used primarily for action words.  Basic knowledge of alphabetical letter signs is necessary in order to understand illustrations of words contained within American Sign Language manuals. Proficiency in signing is not essential, since autistic children start at the beginning and progress very slowly.  It may be necessary for the assistant to hold the child's hands and move them into approximations of the desired sign until they show slight movements with
their own hands.  Parents, family members and principle caregivers should also be trained to model and interpret a few relevant signs.  It is hoped that after much repetition and modelling the child will spontaneously use signs to indicate their desires.
 

Communication Boards

The simpliest type of communication aid is the communication board or books where children touch or point to a symbol, photograph, drawing or words to indicate a desired activity. Some children require the use of three dimensional miniature objects due to their limited cognitive abilities.  As the child's attending skills and comprehension increase, various versions of boards may be explored.

Object boards should be displayed in a central location and at child's height.  Immediately prior to each activity, the child is led over to the object board and prompted by the assistant to point or touch the corresponding item. The child
then carries out the activity in a desired location.  The item or symbol may also be placed nearby to provide added visual cues during the activity.  When the activity is completed, the child then takes the item or symbol back to the location of the object board to be discarded into an "All Done" box.  The prompt hierarcy should then be used and prompts faded as the child becomes more aware of the representations.  When the object board is first introduced there should only be one item displayed in the upper left-hand section.  As time progresses, more items indicative of the daily schedule may be displayed horizontally.

Communication boards/books  must be durable enough  to withstand repeated daily use by the child.  Miniature items must be safe, sanitary and replacable. Close up photographs may be used and laminated for continual use.  Colored symbols (pictographs) or black/white  lined drawings with words written underneath, are mounted on 2" square index cards and laminated.

The main display board can be constructed using a large sheet of colored bristol board.  Allow a 3" space along the top for the title.  Using  a permanent marker, draw a line down the middle, and then make several smaller sections on both the right and left hand sides.  The board is then laminated and small velcro tabs or partial plastic sleeves are attached to each section.

( Refer to illustrations #1-3 immediately following)

Picture Exchange Communication System   (PECS)

PECS was initially developed by two speech therapists (Bondy & Frost) from the Delaware Autistic Program for use with preschool autistic children.  Since then it has become widely accepted as a viable system for use with individuals of all ages with social communication deficits.

Although it uses many aspects of previously developed augmented communication, the main difference is in the delivery of the social exchange.  Instead of having children point to items in response to an  adult request, children select an item or symbol and hand it to an adult in exchange for activity materials.  To aid in the initiation process, verbal prompts are not used.  Through a process of 6 phases, children progress from symbol discrimination to more advanced stages of actually forming simple symbol sentences.

A comprehensive training manual outlining training protocol can be obtained through consulting speech therapists.

Computers

Very little research exists on the use of computers for non-verbal autistic children, however these studies suggest that some children may benefit in areas of language learning and social communicative interactions.  Children also learn to track, expand their attending skills and learn cause and effect relationships.  Software programs relating to shape/color/size discrimination, or visually enhanced stories may be used in conjunction with verbal commands given by the assistant.  For the children who have trouble with motor controlled tasks, a roller ball with a separate button for clicking can be used instead of a mouse.  A paper arrow (similiar to the curser) can be taped on to the mouse for greater association.

Facilitated Communication

Another strategy used to enhance communication of non-verbal individuals is the faciliatated communication method.  The somewhat controversial method was first developed for use with cerebral palsy individuals, and since adopted for use with other developmentally disabled individuals.

The role of the facilitator is to physically support the person's hand, wrist or forearm and to isolate the index finger as they operate communicative devices such as typewriters, communication boards or  electronically controlled ones.

Word Cards

Some non-verbal children have achieved functional communication of first words by means of word cards.  When visual representations or product labels are paired with written words children receive additional visual cues.  Several may be joined together for instructional sequences.

If children are able to use visual symbols, programmable speech devices such as the IntroTalker, McCaw or Wolf (voice along with word cards) may be of additional assistance to the child.  If the child has a tendency to only push the buttons of the device, encorporating instructions for their favorite routines may entice them to use it in a more meaningful way.

When  selecting a communication device for a particular child, consideration must be given to the child's age, manual dexterity, intellectual abilities and learning style.

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