January 19, 2010 Features

Children with Autism Spectrum Disorders: Three Case Studies

Speech-language pathologists play a critical role in screening, assessing, diagnosing, and treating the language and social communication disorders of individuals with autism spectrum disorders (ASD). People with ASD use a variety of communication modes including speech, facial expressions, conventional gestures (e.g., pointing), unconventional signals (e.g., hand-flapping), vocalizations, picture symbols, and assistive technology (e.g., speech-generating devices). SLPs have an opportunity to use their clients' strengths to help determine the most effective communication modes.

Because a wide range of communication approaches is used—often in combination—clinical decisions about unaided and aided augmentative and alternative communication (AAC) techniques should be made on an individual basis using the principles of evidence-based practice (i.e., the quality and relevance of available evidence, clinical expertise, and the perspective of the client and the client's family). Given the variability of symptoms and deficits in ASD and an individual's changing needs related to communication, it is important for clinicians to explore many AAC options.

ASHA's Guidelines for Speech-Language Pathologists in Diagnosis, Assessment, and Treatment of Autism Spectrum Disorders Across the Life Span provides information related to assessment and intervention including a focus on AAC. The guidelines recognize that AAC choices must be based upon an individual's needs, including learning strengths andweaknesses, level of social communication skills, and motor abilities. These guidelines and other ASHA policy documents are now a part of a continuing education program (see sidebar below). These policy documents can help clinicians navigate the case studies presented below and assist with their own decisions about assessment and intervention tools and strategies.

The following case studies present three different children with ASD and describe the SLP's strategies to enhance communication and quality of life. The three case studies demonstrate various options in AAC intervention that can be used by children of different ages.

—Ann-Mari Pierotti, MS, CCC-SLP

Case Study 1: Anderson | Case Study 2: Tait | Case Study 3: Sam

Anderson: Excitement and Joy Through Pictures and Speech

by Sylvia Diehl

Anderson is a 3-year-old boy with ASD who was referred to a university speech and hearing center by a local school district. He attended a morning preschool at the university center for one year in addition to his school placement. 

History

Birth and Development

Anderson was a full-term baby delivered with no complications. Anderson's mother reported that as a baby and toddler, he was healthy and his motor development was within normal limits for the major milestones of sitting, standing, and walking. At age 3 he was described as low tone with awkward motor skills and inconsistent imitation skills. His communication development was delayed; he began using vocalizations at 3 months of age but had developed no words by 3 years.

Communication Profile at Baseline

Anderson communicated through nonverbal means and used communication solely for behavioral regulation. He communicated requests primarily by reaching for the communication partner's hand and placing it on the desired object. When cued, he used an approximation of the "more" sign when grabbing the hand along with a verbal production of /m/.

He knew about 10 approximate signs when asked to label, but these were not used in a communicative fashion. Protests were demonstrated most often through pushing hands. Anderson played functionally with toys when seated and used eye gaze appropriately during cause-and-effect play, but otherwise eye gaze was absent. He often appeared to be non-engaged and responded inconsistently to his name. 

Assessment

The Communication Symbolic and Behavior Scales Developmental Profile (CSBS DP; Wetherby & Prizant, 1993) was used to determine communicative competence. This norm-referenced instrument for children 6–24 months old is characterized by outstanding psychometric data (i.e., sensitivity=89.4%–94.4%; specificity=89.4%). Although Anderson was 36 months old, this tool was chosen because it provides salient information about social communication development for children from 6 months to 6 years old.

Intervention

Anderson's team and family members developed communication goals that included spontaneously using a consistent communication system for a variety of communicative functions and initiating and responding to bids for joint attention. Research suggests that joint attention is essential to the development of social, cognitive, and verbal abilities (Mundy & Neal, 2001).

Because Anderson could not meet his needs through verbal communication, AAC was considered. He had been taught some signs but did not use them communicatively. More importantly, his motor imitation skills were so poor that it was difficult to differentiate his signs. His communication partners would need to learn not only standard signs, but Anderson's idiosyncratic signs. Therefore, the Picture Exchange Communication System (PECS; Bondy & Frost, 1994) was chosen to provide him with a consistent communication system. Additionally, a visual schedule was used at home and school to aid in transitions and to increase his symbolization.

Incidental teaching methods including choices and incomplete activities were embedded in home and preschool routines. In addition, a variety of joint activity routines (e.g., singing and moving to "Ring Around the Rosie" or "Row Your Boat" while holding hands) that were socially pleasing to Anderson were identified. These were infused throughout his day in various settings and with various people. Picture representations of these play routines also were represented in his PECS book.

Research

Several evidence-based strategies were chosen to support intervention, including PECS (Carr & Felce, 2007; Ganz & Simpson, 2004; Temple, 2007), visual supports (Bryan & Gast 2000; Krantz, MacDuff, & McClannahan, 1993), and incidental teaching (Cowan & Allen, 2007; Miranda-Linne & Melin, 1992).

Outcomes

By the end of the year, a video taken at preschool showed that Anderson was spontaneously using PECS for requests and protests. He was using speech along with his PECS requests in the "I want" format. He also used speech alone for one-word requests and for automatic routines such as counting or "ready, set, go." He shared excitement and joy in several joint activity routines with various people and referred to their facial expressions for approval and reassurance.

Sylvia Diehl, PhD, CCC-SLP, is an assistant professor in the Communication Sciences and Disorders Department of the University of South Florida, where she teaches courses in augmentative and alternative communication, language disorders, autism, and developmental disabilities. Contact her at diehl@cas.usf.edu.

Tait: Communicating Emotions

by Jane Wegner

Tait is a 12-year-old boy who was diagnosed with ASD at age 2. Tait is generally healthy although he has recently been diagnosed with rheumatoid arthritis and is sensitive to pain. He has difficulty with small spaces and "bottlenecks" where many people are congregated. Tait participates in special education at a local elementary school. His strengths include being curious, social, and visually astute. His challenges include communication, impulsivity, and behavior that may include tantrums, aggression, and property destruction. These challenges have made it difficult for Tait to participate in activities with peers.

Communication Profile

Tait has a positive-behavior support team and receives speech-language intervention at the Schiefelbusch Speech-Language-Hearing Clinic. He is a multimodal communicator whose verbal communication is not understood by most people. He uses a Palm 3 (Dynavox Technologies), pictures, idiosyncratic signs, gestures, and some words to communicate.

Assessment

Tait's communication was assessed with the SCERTS® Assessment Process (SAP; Prizant, Wetherby, Rubin, Laurent, & Rydell, 2006) in spring 2007. As a criterion-referenced, curriculum-based tool, the SAP determines a child's profile of strengths and needs based on his or her developmental stage in the domains of social communication and emotional regulation. Tait was in the Language Partner stage of communication. We collected data in three contexts: school, home, and an intervention session in the Schiefelbusch clinic.

Social Communication

Tait's strengths in the area of social communication included engaging in reciprocal interactions, sharing attention to regulate the behavior of others, and using several modes of communication. His needs in social communication included sharing a range of emotions with symbols and sharing intentions for joint attention by commenting on objects, actions, events, or requesting information across partners and contexts.

Emotional Regulation

Tait's emotional regulation strengths included responding to assistance from a familiar partner that he trusted, recovering from extreme dysregulation with support from a familiar partner, and using a behavior strategy (holding a block of wood) to remain focused and calm in some familiar environments. His needs in the area of emotional regulation were seeking assistance with emotional regulation from others, responding to assistance across contexts, and responding to the use of language strategies across environments.

Transactional Support

Transactional support was strong in some areas. For example, all of Tait's partners wanted him to learn and communicate more conventionally and he had consistent, responsive communication partners at home. Tait needed the same responsive style across all partners and the consistent use of visual and organizational supports as well as his AAC system to enhance learning and comprehension of language and behavior.

Intervention

Goals included:

  • Increased use of emotion words on the AAC device.
  • Commenting on objects, actions, or events.
  • Choosing what he needs to calm himself from choices offered (from an adaptation of the 5-point scale by Buron and Curtis, 2003).

Transactional goals included:

  • Using augmented input (Romski & Sevcik, 2003) with redirection, expansion, and modeling by Tait's partners.
  • Providing a binder with a schedule and social stories (Gray, 1995) for preparation for activities.
  • Making an AAC device always available and using an interactive diary developed by his mother.

These supports were implemented in activities of interest to Tait such as holidays, his life in photo albums, tools, and events at home.

Outcomes

In the past two years, Tait has made many communication gains. His AAC device has more than 200 pages of icons, which he accesses independently to express feelings. He has told us when he is angry, happy, sad, frustrated, and sick, and he engages in reciprocal exchanges, commenting on the shared object or event of interest. He has started to mark tense when he comments by using the "later" and "past" icons on his device to clarify his message. He is able to indicate to his partner what he needs to calm himself when choices are offered. In addition, he has more communication partners who are responsive and able to provide him with the learning supports he needs.

Find Out More

View an article and video about Tait

Jane Wegner, PhD, CCC-SLP, is a clinical professor and director of the Schiefelbusch Speech-Language-Hearing Clinic at the University of Kansas. She teaches courses in AAC and autism spectrum disorders and directs the "Communication, Autism, and Technology" and "Augmentative and Alternative Communication in the Schools: Access and Leadership" projects. Contact her at jwegner@ku.edu.

Sam: From Gestures to Symbols

by Emily Rubin

Sam is a 16-year-old young man with ASD and significant cognitive delays. As part of professional development training for his educational team, this speech-language pathology consultant followed him for 12 months. Sam now attends a public school special day class that offers frequent instruction in varied settings to foster independence in the community.

History

Birth and Development

Sam was born six weeks premature following his mother's hospitalization for pre-term labor. His birth history was significant for low birth weight (2 lbs., 10 oz), respiratory distress, intraventricular hemorrhage, and a neonatal hospital stay of six weeks. He began receiving intervention services at 12 months of age to address speech, language, social-emotional, and cognitive delays. To date, evaluations yield developmental age equivalents up to the 24-month level. Since birth, Sam's history is unremarkable for significant medical concerns and he is in good health. He has passed hearing screenings and wears corrective glasses.

Communication Profile at Baseline

At 14 years, 8 months of age, Sam spontaneously shared his intentions through nonverbal means, which included facial expressions (e.g., looking toward staff to request a snack), physical gestures (e.g., pulling his teacher's hands to his head to request a head massage), and more conventional gestures (e.g., pointing to request and a head shake to reject). He also used unconventional nonverbal signals that included biting his hand to share positive and negative emotions and pinching to protest. Sam occasionally used a few verbal word approximations (e.g., "no," "yes," "more," and "balloon"), the sign for "help," and picture symbols on a voice output device. However, he typically used these symbols passively, most often in response to a direct verbal prompt from his social partner (e.g., "Do you want more?").

Assessment

At baseline, the SAP was administered to gather information about functional abilities in daily activities through observation and a comprehensive caregiver questionnaire. Given his baseline presentation, the SAP placed him at the Social Partner Stage, a stage that is relevant for individuals using pre-symbolic communication. With this profile, functional educational goals based upon parent priorities and evidence-based supports were determined.

Research

The SAP was derived from longitudinal descriptive group research. It enables providers to select educational objectives that are predictive of gains in language acquisition and social adaptive functioning (Prizant et al., 2005). Sam's educational team selected objectives shown to predict an individual's symbolic growth, such as increasing his rate of spontaneous communication and his range of communicative functions. The team worked to move him beyond requesting objects to requesting specific people and actions. The SAP also facilitated the selection of evidence-based supports such as AAC when developing educational accommodations to address these objectives.

Intervention

Sam's Individualized Education Program objectives shifted from those for passive responses (e.g., responding to questions such as "Where did you go?") to initiating communication using AAC (e.g., requesting help or other actions, expressing emotions, and making choices of coping strategies). Throughout the day, Sam accessed an emotion necklace of laminated cards. On the front of each card was a graphic symbol representing an emotional state (e.g., happy, angry, and sad). On the back were symbols representing words Sam could use to request actions from others (e.g., "high five" for happy). This support fostered symbolic requests for communicative functions that Sam already exhibited spontaneously using nonverbal means at baseline (e.g., expressing emotion by biting his hand and looking toward staff).

During language art centers, Sam engaged in activities designed to elicit more sophisticated requests for preferred actions. Rather than identifying pictures, he could choose a preferred sensory activity, such as a head massage, a back rub, or tickling. Color-coded symbols paired with sentence templates allowed Sam to create his own sentences for functions already exhibited spontaneously using nonverbal means at baseline (e.g., requesting comfort by pulling his teacher's hands toward his head).

Outcomes

Sam's first quarterly review occurred around his 15th birthday. Observations and videos revealed a higher rate of spontaneous bids for communication and the emergence of symbols to express emotion (e.g., "happy" and "mad"), request coping strategies (e.g., "head squeezes" and "high fives"), and form simple sentence structures (e.g., "Jim squeeze head" and "Karen rub back"). By six months post-intervention, Sam began to take turns, requesting interaction using subject + verb sentences and then responding to interaction. His teacher might request that "Sam rub back" and Sam would oblige. At 12 months post-intervention, Sam continues to expand his symbolic language skills and recently began to generalize his sentences to include names of his peers.  

Emily Rubin, MS, CCC-SLP, is director of Communication Crossroads, a private practice in Carmel, Calif. She is an adjunct faculty member at Yale University, where she has served as a member of its Autism and Developmental Disabilities Clinic. She is a co-author of the clinical manual for the SCERTS Model, a comprehensive educational approach for children with autism spectrum disorders. Contact her at Emily@CommXRoads.com. 


Interagency Autism Coordinating Committee

ASHA Provides Input to Interagency Autism Coordinating Committee

by Ann-Mari Pierotti

The Interagency Autism Coordinating Committee (IACC) was established in accordance with the Combating Autism Act of 2006 (P.L. 109-416.) The committee coordinates all efforts within the Department of Health and Human Services (HHS) concerning autism spectrum disorder (ASD). The IACC includes both members representing federal agencies and the public to ensure that perspectives and ideas are represented and discussed in a public forum.

The IACC mission is to:

  • Advise the Secretary of Health and Human Services regarding federal activities related to ASD.
  • Facilitate the exchange of information and coordination of activities related to ASD among the member agencies and organizations.
  • Increase public understanding of the member agencies' activities, programs, policies, and research by providing a public forum for discussions related to ASD research and services.

ASHA staff has been attending the IACC's meetings, which include presentations and discussions on a variety of topics such as activities and projects of the IACC, recent advances in science, and autism policy issues. Catherine Gottfred, 2008 ASHA president, submitted comments to the IACC on Dec. 12, 2008 emphasizing the critical role of the speech-language pathologists with respect to assessment and treatment of ASD. During this comment period, ASHA informed the committee of ASHA's policy documents related to the role of the SLP with respect to autism. These documents include a position statement, technical report, guidelines, and a knowIedge and skills statement and are available online.

Additionally, ASHA staff provided input to the IACC as the agency developed its 2010 Strategic Plan for Autism Spectrum Disorder Research. ASHA's comments focused on the need for:

  • Screeners with high sensitivity and specificity that identify early signs of behavioral, cognitive, and communication impairments that are critical to accurate and early diagnosis.
  • Evidence-based comparative effectiveness research that identifies effective treatments.
  • Research that will provide clear indications regarding which services and support strategies or combinations are most effective.
  • Research to assess the efficacy of behavioral treatment approaches to determine which intervention(s) yield clinically significant improvements in speech, language, and social communication.
  • Emphasis on sub-groups within the ASD population and their responsiveness to various treatment approaches.
  • Research regarding the development of outcome measurement instruments for the ASD population, especially for preschool and school-aged children.
  • Comprehensive intervention programs that include a strong family component to achieve the best outcomes.
  • Behavioral research related to the effectiveness of speech and language treatment.

ASHA's comments were considered by panelists at the 2009 IACC Scientific Workshop in Bethesda, Md.

Ann-Mari Pierotti, MS, CCC-SLP, associate director for clinical issues in speech-language pathology, can be reached at apierotti@asha.org.



References

Article by Sylvia Diehl

Bondy, A. S., & Frost, L. A. (1994) PECS: The Picture Exchange Communication System. Training manual. N.J.: Cherry Hill.

Bryan, L. & Gast, D. L. (2000). Teaching on-task and on-schedule behaviors to high-functioning children with autism via picture activity schedules. Journal of Autism and Developmental Disorders, 30, 553–567. 

Carr D., & Felce J. (2007). The effects of PECS teaching to phase III on the communicative interactions between children with autism and their teachers. Journal of Autism and Developmental Disorders, 37(4), 724–737

Cowan, R., & Allen, K. (2007) Using naturalistic procedures to enhance learning in individuals with autism: A focus on generalized teaching within the school setting Psychology in the Schools, 44(7), 701–715.

Ganz J. B., & Simpson R. L. (2004). Effects on communicative requesting and speech development of the Picture Exchange Communication System in children with characteristics of autismJournal of Autism and Developmental Disorders. 34(4), 395–409.

Krantz, P. J., MacDuff, M. T., & McClannahan, L. E. (1993). Programming participation in family activities for children with autism: Parents' use of photographic activity schedules. Journal of Applied Behavior Analysis, 26(1), 137–138.

Miranda-Linné, F., & Melin, L. (1992). Acquisition, generalization, and spontaneous use of color adjectives: A comparison of incidental teaching and traditional discrete-trial procedures for children with autism. Research in Developmental Disabilities, 13, 191–210.

Morrison, R. S., Sainato, D. M., Benchaaban, D., & Endo, S. (2002). Increasing play skills of children with autism using activity schedules and correspondence training. Journal of Early Intervention, 25(1), 58–72.

Mundy, P. & Neal, R. (2001). Neural plasticity, joint attention and autistic developmental pathology. In L. M. Glidden (Ed.), International Review of Research in Mental Retardation, 23, 139–168. New York: Academic Press.

Temple, K. (2007). A randomized comparison of the effect of two prelinguistic communication interventions on the acquisition of spoken communication in preschoolers with ASD. Child Care Health and Development, 33(3), 348–349.

Wetherby, A., & Prizant, B. (1993). Communication and symbolic behavior scales. Chicago, IL: Riverside.

Article by Jane Wegner

Beukelman, D., & Reichle, J. (Vol. Eds.), Augmentative and alternative communication series. Communicative competence for individuals whouse AAC: From research to effective practice (pp.147–162). Baltimore: Brookes.

Britt, K. (2009, June 21). Autistic children might find their 'voice' with KU project. LJWorld.com. Retrieved from http://www2.ljworld.com/news/2009/jul/21/autistic-children-might-find-their-voice-ku-projec/.

Buron, K., & Curtis, M. (2003). The incredible 5-point scale. Shawnee Mission, KS: Autism Asperger.

Prizant, B. M., Wetherby, A.M., Rubin, E., Laurent, A. C., & Rydell, P. J. (2006). The SCERTS® Model: A comprehensive educational approach for children with autism spectrum disorders. Vol. I: Assessment. Baltimore: Brookes.

Romski, M. A. & Sevcik, R. A. (2003). Augmented input: Enhancing communication development.  In J. Light, D. Beukelman, & J. Reichle (Eds.) Communicative Competence for Individuals Who Use AAC (pp. 147–162)Baltimore, MD: Paul H. Brookes. 

Article by Emily Rubin

National Research Council. (2001). Educating children with autism. Washington, DC: National Academy Press, Committee on Educational Interventions for Children with Autism, Division of Behavioral and Social Sciences and Education.

Prizant, B. M., Wetherby, A. M., Rubin, E., Laurent, A. C., & Rydell, P. J. (2005). The SCERTS Model: A comprehensive educational approach for children with autism spectrum disorders. Baltimore, MD: Brookes.



Earn CEUs While Preparing to Serve Clients with Autism

ASHA's policy documents on the roles and responsibilities of speech-language pathologists in autism spectrum disorder are now being offered as a continuing education program. To earn CEUs, complete the following steps.

1. Read the following four policy documents (search "autism" at ASHA's Web site):

  • Roles and Responsibilities of Speech-Language Pathologists in Diagnosis, Assessment, and Treatment of Autism Spectrum Disorders Across the Life Span: Position Statement
  • Principles for Speech-Language Pathologists in Diagnosis, Assessment, and Treatment of Autism Spectrum Disorders Across the Life Span: Technical Report
  • Guidelines for Speech-Language Pathologists in Diagnosis, Assessment, and Treatment of Autism Spectrum Disorders Across the Life Span
  • Knowledge and Skills Needed by Speech-Language Pathologists for Diagnosis, Assessment, and Treatment of Autism Spectrum Disorders Across the Life Span

2. Visit ASHA's Online store for product information.

These documents on the role of SLPs with respect to ASD, published in 2006, were developed by ASHA's Ad Hoc Committee on Autism Spectrum Disorders. Members of the committee were Amy Wetherby (chair), Sylvia Diehl, Emily Rubin, Adriana Schuler, Linda Watson, Jane Wegner, and Ann-Mari Pierotti (ex officio). Celia Hooper, 2003–2005 vice president for professional practices in speech-language pathology, served as the monitoring officer.



  

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