Specific Disabilities and Approaches

Communication Services and Supports for Individuals With Severe Disabilities: FAQs

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I have a couple of students with autism on my caseload. What program should I use?

This is truly one of the more significant challenges facing speech-language pathologists and educators today. Recent writing (Woods & Wetherby, 2003) suggests that many of the well-known treatment approaches for teaching children with autism are effective. For example, the methodologies implemented in discrete trial, milieu, and SERTS training all have generated or are generating data illustrating gains in this population's communication/social abilities. In addition, other compensatory training strategies such as augmentative communication have growing bodies of literature supporting their use. A decision about which program to use with a specific child should be made while considering:

  1. Its match to the child's communication needs, age, and what will be functional for the child now and in the future;
  2. Reliable evidence that the program's teaching methods and its content (scope and sequence) are known to be or likely to be effective; and
  3. The program's characteristics and their match or lack of match with those who will use it and with the child who will receive it (e.g., the skills needed, intensity of training, actual teaching procedures, costs/materials, etc.).

Specific to communication, Wood and Wetherby (2003) note that it is not always the method/strategy chosen but other variables that dictate ultimate success. For example, these authors report that children receiving treatment before age 3 years have a better prognosis for communication success. Likewise, they suggest that children in "intensive" treatments (approximately 20 hours per week) are most likely to demonstrate meaningful improvements in communication skills.

Assuming that one begins intensive treatment early, a good practice for choosing a treatment method/strategy can be using the child's strengths/needs as your guide. For example, many children with autism have preferences for static, visual stimuli and may benefit from communication through AAC systems using photographs or line drawings. Other children present with behavioral challenges that make structured interventions like discrete trial or milieu training more preferred.

Finally, as you select a treatment for a child with autism, it is important to remember a few things. First, more natural treatments seem to generalize best to non-treatment settings. Second, all treatments work best if there is a network of providers planning, implementing, and evaluating methods/strategies. Finally, treatments must fit the family system of each child. Having family members invested and involved in all aspects of treatments efforts will contribute to positive outcomes.

For more information:

Ogletree, B. T., (1998). The communicative context of autism. In R. Simpson & B. Myles (Eds.) Educating children and youth with autism (pp. 141–172). Baltimore: ProEd. (Second edition in press)

Woods J., & Wetherby, A. M. (2003). Early identification of and intervention for infants and toddlers who are at risk for autism spectrum disorder. Language, Speech, and Hearing Services in Schools, 34, 180–193.

Why would a speech-language pathologist work with a child who doesn't talk?

A speech-language pathologist works with children and adults of all ages who have communication disorders. Speech-language pathologists do more than strictly help people pronounce speech sounds correctly or stop stuttering. A child who doesn't talk needs help from a speech-language pathologist, and other members of a team, including family and teachers, to build a functional system for communicating with others and understand the communication of others. In many cases, augmentative or alternative communication approaches will be designed to teach such a student who is not using speech to communicate. These systems might include, for example, the use of pictures, manual signs, or simple to complex electronic devices that speak for the student.

Communication services should be started just as soon as a communication delay or disorder is diagnosed. Long before we expect children to be talking, there are many important communication skills that should be developing. These early skills include how to interact with other people and things, how to understand spoken language, and how to communicate to others using gestures or symbols. A professional evaluation can determine if a child is developing appropriately in all these areas. If not, an intervention program can be designed to help the child develop these skills. To learn more about early intervention services required under Federal law, and to locate the early intervention agency in your state, go to the National Early Childhood Technical Assistance Center website.

See also: Can all children learn to communicate?

What is ABA and how is it applicable to communication training?

The acronym ABA refers to Applied Behavior Analysis. ABA has been defined as the systematic application and evaluation of principles of behavior management to the improvement of specific behaviors (Baer, Wolf, & Risley, 1968). The terms and principles of behavior management most often used in ABA include stimuli, responses, consequences, positive reinforcement, negative reinforcement, punishment, and extinction. The techniques used in ABA include prompting, cuing, modeling, chaining, differential reinforcement, and fading.

Descriptions of ABA as a training methodology appear throughout the seminal literature of speech-language pathology. Today's practitioners can choose from permutations of ABA that include strict applications of the techniques mentioned above (e.g., Discrete Trial Training) to more naturalistic technique applications (e.g., Hybrid, Milieu, or Contemporary ABA training). Those using the more traditional applications of ABA must guard against common training caveats including problems with prompt dependency and generalization. Also many practitioners have reported difficulty training more fluid targets such as communication. Increasingly, speech-language pathologists are using the techniques of ABA in natural training contexts to minimize the problems mentioned above.

For more information:

Baer, D.M., Wolf, M.M., & Risley, T.R. (1968). Some current dimensions of applied behavior analysis. Journal of Applied Behavior Analysis, 1, 91–97.

Information about ABA and its history and role in communication training:
Ogletree, B.T., & Oren, T. (2001). Application of ABA principles to general communication instruction. Focus on Autism and Other Developmental Disabilities, 16(2), 102–109.

What communication services are appropriate for children who are deaf-blind?

The best program for your child is one that considers you as an important partner on the educational team. Your child has unique hearing, vision, physical, and learning needs. The educational team will generally include a special educator, speech-language pathologist, and a physical and/or occupational therapist as key team members. The team will design an individualized program for your child that will meet your child's unique needs and that focuses on your priorities for his/her learning. The program will be individually designed with your input and carried out by the team via the Individualized Educational Plan (IEP). The services selected for your child will be those needed to ensure that the IEP can be implemented. In addition to a special education teacher, services might include a team member who will be a vision specialist, speech-language pathologist, and motor therapist (physical or occupational therapist), depending upon your child's needs.

Few generalizations can be made about deaf-blindness because "deaf-blind" refers to combined hearing and vision losses, and there are many possible combinations of these sensory losses. Some key ideas may be useful to consider:

  • Most students who are deaf-blind have and make use of some hearing and vision.
  • Students who are deaf-blind can participate in almost any activity and teaching environment.
  • Students who are deaf-blind communicate in a variety of ways.

Teamwork is essential for these students. A special educator, vision specialist, audiologist, and speech-language pathologist are essential team members. The communication services will be established and conducted collaboratively across the team. This collaboration is essential using the ecological approach, in which all aspects of the student's skills and needs are examined across the school day. The instructional needs: visual, auditory, tactile skills; learning styles; and physical capabilities of students with deaf-blindness differ enormously-no single team member can be expected to address all of these factors adequately when planning and implementing instruction. The sharing of expertise from each discipline aids each team member in delivering services.

It is essential to help the student who is deaf-blind to develop as many communication skills as possible. Communication services may include teaching the student to use finger spelling, forming letters into the hand, speech, gestures, Braille, tactile sign language, augmentative and alternative communication systems (objects, tactile, tangible symbols), amplification systems, and combinations of these methods.

For more information:

Heubner, Prickett, Welch, & Joffee (Eds). (1995). Hand in hand: Essentials of communication and orientation and mobility for your students who are deaf-blind. New York: AFB.

The National Information Clearinghouse on Children Who Are Deaf-Blind – Here you can locate many resources and the deaf-blind project staff in your state.

For deaf-blind fact sheets related to communication and other topics visit the National Consortium on Deaf-Blindness website.

Is it appropriate to work on communication skills if the child has a degenerative condition?

All children with communication disabilities are candidates for communication intervention. For most, treatment will target skill gains. For those with degenerative conditions, treatments may be directed at maintaining functional communication skills. One must remember that all individuals communicate. Even as a child with a degenerative condition loses symbolic then intentional communicative abilities, he or she continues to communicate with those around them through sounds, expressions, and movements. Often helping others recognize these important, though less definitive signals can become a focal point for the child with more significant impairment.

Although it might seem unproductive for a child with a degenerative condition to participate in communication-based treatment, each case should be evaluated individually. It may be that treatment can be conceptualized in ways that are less traditional, yet make a difference. For example, objectives could focus upon creating environments conducive to meeting communication needs. Likewise partners could be taught how to use strategies that anticipate and support communication efforts. These types of "consultative" and "other directed" treatment ideas would appear to have merit for all individuals, regardless of their functioning level. Of course, many children with degenerative conditions may benefit temporarily from treatments directed at specific communication abilities (e.g., expressive forms or comprehension). Again, decisions specific to treatment methodologies and desired outcomes should be made on an individual basis. In sum, all persons are deserving of the opportunity to communicate as effectively as possible throughout their lives.

Does oral-motor treatment help with speech and communication development?

Exercises of the mouth are sometimes used to help people who have speech problems. This is known as oral-motor treatment. There are different types of oral-motor exercises. Typically, oral-motor treatment consists of three types of activities: active exercise, passive exercise, and external stimulation. Active exercise involves strength training and muscle stretching. For example, active exercises such as pushing the tongue tip against a tongue depressor may be used to strengthen and stretch the tongue and mouth muscles. Sometimes blowing exercises are used. Passive exercise involves clinician assistance and may involve massage, stroking, or tapping parts of the oral musculature. Clinicians also may use external stimulation, which includes hot and cold application, vibration, or electrical stimulation to the muscles involved in speech and swallowing. It's always a good idea to ask questions about the evidence available to support the use of a specific treatment product or procedure.

At this time, there is limited data-based evidence to support the use of oral-motor activities to help with speech production. Available evidence is based primarily on expert opinion; randomized clinical trials with a randomized control group, the highest level of evidence, have not been conducted. Data are available on the effectiveness of speech (articulatory and phonological) treatment. Thus, use of oral-motor treatment techniques may take time away from treatment approaches that are known to be effective, such as teaching the correct way to position the tongue to produce a correct speech sound.

Some researchers suggest that speech and language treatment should be task specific. That means that treatment techniques should be related to the desired outcomes. If improved speech is the goal, it follows that treatment techniques should be speech-specific. Oral-motor treatment techniques are sometimes applied based on the assumption that oral motor problems contribute to speech problems. However, this may not be an accurate assumption, particularly when no muscle weakness is apparent in the oral mechanism. There may be other reasons why an individual has speech problems.

For more information:

Clark, H. M. (2003). Neuromuscular treatments for speech and swallowing: A tutorial. American Journal of Speech-Language Pathology, 12, 400–415.

Forrest, K. (2002). Are oral-motor exercises useful in the treatment of phonological/articulatory disorders? Seminars in Speech and Language, 23, 15–25.

Moore, C. A., & Ruark, J. L. (1996). Does speech emerge from earlier appearing motor behaviors? Journal of Speech and Hearing Research, 39, 1034–1047.

What approach is best for enhancing communication skills for my child's syndrome or specific disability?

In all cases, the welfare of the child or adult with a communication problem must be held paramount. Typically, speech and language intervention is based on the specific communication behaviors and needs of the individual. Sometimes, the nature of the disorder may provide additional information about the type of approach to use.

You may hear from friends, teachers, or professionals about specific products or procedures for communication and/or swallowing problems. It can be perplexing to know what's right for you, your family member or an individual for whom you are caring. It's advisable not to rely solely on word of mouth or promotional articles.

If you want to learn more about a product or procedure, you should consult with a qualified professional, such as an ASHA-certified speech-language pathologist. You may also obtain generic information from the company or individual that developed the product or procedure by reviewing their website or published materials.

It's always a good idea to ask questions about specific treatment products or procedures. The following list of suggested questions may be helpful when deciding which treatment approaches to use:

  • Is a qualified professional providing the product or procedure?
    Qualified speech-language pathologists hold at least a master's degree, the certificate of clinical competence (CCC) from ASHA and state licensure, where required.
  • What is the specific application of this product or procedure and what is the expected outcome?
    You should have a clear understanding of the purpose of the product or procedure and the expected outcome and benefit.
  • For which client/population was the product or procedure developed?
    The material should state for what group (i.e., age and type of disorder) it was developed. Is there research-based evidence to support its effectiveness with this group or others? Is there research to support the use of the product or procedure on other populations?
  • How should the product or procedure be used?
    Does the product or procedure information clearly describe how it works and provide a rationale for why it works? Some products must be customized or individually fit to meet your specific needs.
  • What evidence does it give about how it improves communication or swallowing problems? What outcomes can I reasonably expect?
    Does it provide data about the outcomes of the product or procedure? Beware of "miracle cures" or claims of 100% success; keep in mind that outcomes may not be the same for everyone.
  • Has research about this product or procedure been published in peer reviewed professional journals?
    Research published in a professional journal has the most credibility. Claims made in promotional materials or reported in the popular press (i.e., newspapers, television and magazines) should be supported by research and interpreted with caution.
  • What is the credibility of the developers of the product or procedure?
    If it is a company, how long has it been in existence? Have there been complaints to state or local Better Business Bureaus or consumer protection agencies? If a professional developed the product or procedure, have there been complaints to the state licensing boards.
  • Are there similar products or procedures currently available? How do they compare in performance and cost?
    Performance should be your most important consideration. Cost may be a consideration if other less costly products or procedures are available, and if they compare favorably in benefits and credibility.
  • What are the potential risks/harms associated with this product or procedure?
    What possible negative outcomes could occur as a result of using this product or procedure weighed against the potential benefit?
  • Is there a need for specialized training or a need to supplement the product or procedure?
    Will you or your family member or caregiver need specialized training to use or gain benefit from this product or procedure? Is this a commitment that you or your family member or caregiver can make?
  • Is this product or procedure experimental?
    Some products and services may be in an experimental stage and can only be provided by specific researchers who have approval by the Institutional Review Board (IRB) for the Protection of Human Subjects.
  • Is the product approved by a government regulatory agency?
    Some products must have approval by a federal government regulatory agency. You may wish to call the Food and Drug Administration (FDA) at 800-532-4440 or another agency that may have regulatory authority over the specific product.
  • Is there a guarantee, return policy, or trial period?
    Check the product information for warranty, repair, and return policy. In many states there are trial period provisions and lemon laws. If there is a trial period associated with the product, find out the time limitations, policies, liability, and fees associated with return or damage to the product during the trial period.

How can I help providers understand my child and encourage communication, as he/she transitions into new classes at the beginning of the school year?

Transition is a process that occurs as children move from one classroom, program or educational setting to another. Careful planning for all transitions can ensure that your child's communication skills are supported and that new skills continue to develop. Sometimes children with severe disabilities communicate in ways that are best understood by familiar communication partners who know your child quite well. Practical strategies for providing information about how your child communicates include developing a list of things your child likes and dislikes so that communication can focus on those preferences, and a communication signal inventory that lists behaviors your child uses to communicate, what the behavior means, and how to respond to it meaningfully. Social Networks is another tool that can be used to provide a comprehensive overview of your child's communication abilities from the perspectives of persons who know your child best. It also helps identify areas that need further assessment, especially in a new situation. It uses a structured interview format to identify and document how a given child communicates (e. g., gestures, vocalization, AAC devices), the important communication partners in the child's daily life (family, friends, people at school), the topics your child likes to communicate about in conversations with various people, and the strategies people use to support the child's comprehension and use of communication.

For more information:

Blackstone, S., & Hunt-Berg, M. (2003). Social networks: A communication inventory for persons with complex communication needs and their communication partners. Monterey: Augmentative Communication.

Kent-Walsh, J., & Light, J. (2003). General education teacher's experiences with inclusion of students who use augmentative and alternative communication, AAC, 19, 104–124.

Augmentative Communication Inc.

Augmentative and Alternative Communication at the University of Washington, Seattle

What tools could be recommended for assessing a student with intellectual disability or autism spectrum disorder (ASD) who is low verbal?

Generally, practitioners use observational methods and structured procedures to assess the communication abilities and needs of persons with severe disability and ASD. Observations can provide invaluable information about individuals with disabilities as well as their partners and environments. They can be conducted casually (by simply observing interactions with familiar and unfamiliar partners) or more formally (by using checklists of target behaviors or reviewing educational/medical records). Observations may be most useful when examiners generate guiding questions before the observation period. Unfortunately, observations are limited to what happens during a given session or what appears in a written record. That is, a full range of behaviors needed to make judgments and decisions may be observable only through the application of more specific elicitation procedures.

Structured procedures include communication sampling, informant assessment, and standardized assessment. Structured communication sampling is a tool for eliciting emergent communication (both nonsymbolic and emergent symbolic). During structured sampling, the individual with disabilities is provided with tempting communication opportunities that make responses near obligatory. An example might be eating in front of an individual without offering food. There is a rich literature base supporting structured sampling with persons with severe disabilities and ASD. For guidance with structured sampling, see the references below.

Informant assessment typically involves questioning peers and family members about an assessment candidate's communication-related abilities, needs, and expectations. Informant assessment can be conducted in an interview format and frequently uses established tests designed for infants and toddlers (e.g., the Receptive-Expressive Emergent Language Scale [REEL]; Bzoch & League, 1990) . A caveat of informant-based procedures is the reliability of the informant. That is, informants often over- or underrepresent the communication abilities of persons with severe disabilities and ASD.

Finally, standardized tools should be considered when assessing emergent communication abilities. Practitioners may use instruments designed for infants and toddlers, such as the Infant-Toddler Language Scale (Rossetti , 1990) or the Communication and Symbolic Behavior Scales (CSBS) (Wetherby & Prizant, 1991). These tools apply (or allow for) elicitation procedures that generate data useful for decision making specific to treatment eligibility and direction. Instruments that have been designed specifically for persons with disabilities—such as Dimensions of Communication (Mar & Sall, 1999) , the Communication Matrix (Rowland, 2004), or the Programmed Acquisition of Language (PAL) (Owens, 1982)—are useful for individuals with less conventional communication abilities.

Just as with observations, there are limitations to structured assessment procedures, such as the unnaturalness of tasks/contexts and the unfamiliarity of examiners.

In conclusion, the most successful communication-based assessments for persons with severe disabilities and ASD use a combination of the practices reviewed above. Ogletree, Fischer, and Turowski (1996) Ogletree, Pierce, Harn, and Fischer (2002) have suggested that these practices can be combined to create an assessment protocol useful in describing communication abilities and formulating appropriate treatment directions.

The practices mentioned above typically are conducted by a speech-language pathologist working within a collaborative team model. Aside from these practices, communication-based assessment for persons with severe disabilities and/or ASD always should be conducted with several key principles in mind. First, individuals with disabilities are entitled to a communication assessment regardless of their functioning level. This is central to the Individuals with Disabilities Education Improvement Act of 2004 and a cornerstone of best practice as described by the National Joint Committee for the Communication Needs of Persons with Severe Disabilities. Second, assessment must generate reliable and representative findings. Simply stated, the process of assessment should be ongoing and yield data that accurately describe both communication abilities and needs. Third, assessment must be trifocused. Siegel-Causey and her colleagues promote communication-based assessment that includes not only the child and adult but also their communication partners and environments (Siegel-Causey & Bashinski, 1997; Siegel-Causey & Wetherby, 1993). This perspective recognizes the expansive nature of communication as it relates to all of us, including those we serve with developmental disabilities. Fourth, assessment should be family focused. Persons with severe disabilities and ASD come from families that know them well and possess valuable hopes and dreams specific to their futures. Needless to say, family input is critical. Fifth, assessment must be dynamic. Dynamic assessments yield findings that describe not only a person's functioning level but how he or she learns best. This relates directly to a final principle: Assessment should inform treatment. Communication-based assessment for individuals with severe disabilities and ASD must lead to meaningful treatments that target socially valid outcomes.

For more information:

Bzoch, K., & League, R. (1990). Receptive-Expressive Emergent Language Scale-Revised. Austin, TX: Pro-Ed.

Individuals with Disabilities Education Improvement Act of 2004, Pub. L. No. 108-446, 118 Stat. 2647 (2004).

Mar, H. H., & Sall, N. (1999). Dimensions of communication: An instrument to assess the communication skills and behaviors of individuals with disabilities. Paterson, NJ: St. Joseph's Hospital.

Ogletree, B., Fischer, M., & Turowski, M. (1996). Assessment targets and protocols for nonsymbolic communicators with profound disabilities. Focus on Autism and Other Developmental Disabilities, 11, 53–58.

Ogletree, B., Pierce, K., Harn, W. E., & Fischer, M. A. (2002). Assessment of communication and language in classical autism: Issues and practices. Assessment for Effective Intervention, 27 (1&2), 61–72.

Owens, R. (1982). Programmed Acquisition of Language With the Severely Handicapped. San Antonio, TX: Psychological Corporation.

Rossetti, L. (1990). Infant-Toddler Language Scale. East Moine, IL: LinguiSystems.

Rowland, C. (2004). Communication Matrix: A communication skill assessment. Portland, OR: Design to Learn Products.

Siegel-Causey, E., & Bashinski, S. M. (1997). Enhancing initial communication and responsiveness of learners with multiple disabilities: A tri-focus framework for partners. Focus on Autism and Other Developmental Disabilities, 12, 105–120.

Siegel-Causey, E., & Wetherby, A. (1993). Nonsymbolic communication. In M. E. Snell (Ed.), Instruction of students with severe disabilities (4th ed., pp. 290–318). New York: Macmillan.

Wetherby, A., & Prizant, B. (1991). Communication and Symbolic Behavior Scales. Chicago: Riverside.

What are the recommended assessment and intervention strategies for individuals with Down syndrome?

Like all individuals with severe disabilities, those with Down syndrome will show individual patterns of strengths and weaknesses. Assessment and interventions should match the individual's developmental level. For example, if the person is nonverbal, then assessments aimed at describing the communication forms and functions present in his or her current communication would help inform an intervention approach aimed at increasing forms and functions across meaningful contexts. Probably the most pervasive and persistent communication problem associated with Down syndrome is poor intelligibility. That is, the speech of individuals with Down syndrome is often difficult to understand. Two compatible intervention approaches can help address these intelligibility concerns: interventions aimed at improving speech sound production and interventions aimed at improving child communication success through augmentative and alternative communication. For example, an individual may speak with familiar communication partners but need to augment speech with pictures or print when communicating with unfamiliar partners. In addition, use of contextual supports may help children compensate for memory problems that may affect language development and use.

Some research seems to indicate that individuals with Down syndrome have more severe language impairments than one would expect, based on other cognitive skills. For example, young children may appear to have better comprehension skills than what can be measured objectively. It is important to carefully evaluate both receptive and expressive communication needs as one is planning a comprehensive intervention plan for individuals with Down syndrome.

For more information:

Brady, N., & Warren, S. (2003). Language interventions for children with mental retardation. In L. Abbeduto (Ed.), Language and communication in mental retardation (Vol. 27, pp. 231–250). Amsterdam: Academic Press.

Chapman, R. (2003). Language and communication in individuals with Down syndrome. In L. Abbeduto (Ed.), Language and communication in mental retardation. Amsterdam: Academic Press.

Kumin, L., Goodman, M., & Councill, C. (1996). Comprehensive speech and language intervention for school-aged children with Down syndrome. Down Syndrome Quarterly, 1(1), 1–8.

What can be said to those who want a formal communication system for an individual with severe intellectual disabilities who does not want to change from a gestural/concrete method?

All individuals, including those with severe disabilities, get comfortable with a system of communication that works for them. When that system is ignored or dropped in favor of a more sophisticated system, it can mean that the person is less able to communicate with others and get the same outcomes. We see this sometimes when individuals use problem behavior to communicate; the recommended intervention is to replace the problem behavior with a message that has the same functional meaning as the problem behavior, such as teaching a person to show a "break" card in place of self-injurious behavior (hitting one's head) in order to end an activity and to request a change in activities. Initially, during this type of intervention (called functional communication training), students may increase their problem behavior, but teachers/others must prompt the new form and reinforce it immediately with the identified outcome (take a break from the activity), while also ignoring the problem behavior and not letting it "work" to get the desired outcome (of ending/changing the activity).

A similar situation occurs when students are using nonsymbolic forms other than problem behavior to communicate (e.g., personalized gestures, vocalizations, facial expressions) and teachers/others decide to drop/ignore their personalized system of communication and teach a symbolic system (e.g., picture exchange, signing, words). While this decision may be made with the good intention of helping the person become a more effective communicator, the person initially may be without a means of communicating. A better approach is to carefully describe the person's current personalized vocabulary and gradually teach symbolic replacement forms, starting with forms that represent highly preferred activities, some familiar and some new. The other personalized forms will continue to be recognized.

To describe the person's personalized vocabulary, all individuals who know the person well should observe and reflect on the current forms that the student uses and his or her functions at home, school, and in the community. Sometimes videotapes of familiar routines help remind the team members of ways that they automatically respond to the student's personalized communication forms. What follows is an example of a communication dictionary for Derrick, a 5-year-old with autism who did not speak, used only a few picture symbols, and relied instead on these forms to communicate.

What Derrick does (signals) What it means (functions) What we do
Covers his ears Too loud Comment and turn noise down
Looks away Not interested? Try to learn what he means
Comes close, looks in your eyes Interested Comment, offer a choice, give a hug, explore what he wants
Makes "happy" noises while also looking at you Interested? Wants something wants more? Comment, offer a choice, give a hug, explore what he wants
Takes your hand and pulls it to something Wants help Comment and offer help
Hands you something Wants help? Comment and offer help
Looks at something, reaches for and maybe gets something, points and touches Wants to hold/have the item Comment and offer help
Makes sounds and looks unhappy   Try to figure out why he is unhappy
Hits himself; may also make unhappy noises Wants activity to stop, wants to leave the situation, wants help; sometimes wants an object or activity? Comment and offer help or stop/remove from activity; provide object/activity; ideally, we calm him, then prompt signal that means the same thing and fulfill request
Is aggressive to another person (scratches, pulls their hair) Does not want the activity to continue; does not want the person to be there Tell him no, possibly a very short time out, but when calm prompt better way to make request and fulfill it
Shakes head as if saying yes May mean yes but also may be "give me help" or "want more" Try to learn what he means
Picks up a picture or a symbol and hands it to you He wants that item or more of that item Comment and fill his request
Cries Unhappy, does not feel good, tired, medication effect Try to learn why he is unhappy

The team should study the dictionary, reach agreement on which form should be replaced first, and make plans for (a) identifying communication forms that the individual can perform and (b) instituting a method for teaching those replacement forms. Problem behavior is always a priority for early replacement teaching, but the team will need to carry out a functional behavioral assessment first to identify the function of the problem behavior so a replacement symbolic form can be identified that matches the new symbolic form to be taught in function. Horner and his colleagues (2011) provided explicit suggestions for teaching symbolic forms to replace problem behavior that a person uses to communicate. Downing (2005, 2011) provided excellent details on steps a team should take to expand an individual's means of communicating. She suggested starting with a person-centered approach where the individual's interests and motivations, the family's preferences, and the natural settings with typical peers can be identified as the first steps for expanding a person's communication methods. Communication is social in nature and teaching may be most effective and yield more functional outcomes if it is conducted in motivating socially responsive contexts. Downing, along with many others in the field, also suggested that individuals at this emerging stage of symbolic communication should be taught multiple modes of communication rather than focusing only on a single mode.

Work by Keen, Sigafoos, and Woodyatt (2001) found that a simple method for teaching more appropriate communication forms to replace less appropriate forms (too vague or problem behavior) was effective in four individuals with autism. The acronym OAR stands for the three steps teachers use to teach these replacement communication forms:

  • Opportunity: Select an existing opportunity where the communication form is used by the student, or create an opportunity to teach the new form.
  • Acknowledge or prompt after waiting 10 seconds.
    • If the student responds with the new form, acknowledge ("nice signing 'me'") and state the form's function ("you want a turn").
    • If the student does not respond with the new form, prompt the new form.
      • Use a system of least prompts starting with a consistent verbal model, and, as needed, physical guidance of the replacement form ("Sign 'me' if you want a turn" while modeling the sign).
  • React within 3 seconds.
    • React in a way consistent with the student's presumed function and that is reinforcing to the student (e.g., immediately give a turn).

For example, for Dave, who was 7 years old, two old forms and their functions were identified along with two new and appropriate forms; the team also identified the activity and opportunity for teaching these new replacement forms.

Function Activity Opportunity Prelinguistic behavior (old form) Replacement behavior (new form)
Greet Group time Look at him and say "Hello Dave." Look at person Wave
Request Morning snack Place 2 photos on table: 1 food, No card Randomly points to both photos Point to photo of food & choose matching food


Downing, J. E. (2005). Teaching communication skills to students with severe disabilities (2nd ed.). Baltimore, MD: Brookes.

Downing, J. E. (2011). Teaching communication skills. In M. E. Snell & F. Brown (Eds.), Instruction of students with severe disabilities (7th ed.; pp. 461–491). Upper Saddle River, NJ: Merrill/Prentice Hall.

Horner, R. H., Albin, R. W., Todd, A. W., Newton, J. S., & Sprague, J. R. (2011). Designing and implementing individualized positive behavior support. In M. E. Snell & F. Brown (Eds.), Instruction of students with severe disabilities (7th ed.; pp. 257–303). Upper Saddle River, NJ: Merrill/Prentice Hall.

Keen, D., Sigafoos, J., & Woodyatt, G. (2001). Replacing prelinguistic behaviors with functional communication. Journal of Autism and Developmental Disabilities, 31, 385–398.

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