Early Communica.ve Acts in Young Children with Au.sm Noa Hannah Ph.D., CCC-­‐SLP, BCBA-­‐D Seattle Children’s Autism Center Communica.on and Prerequisites for Communica.on to Occur:   Today’s definition: Communication is the process that communication partners use to exchange information ideas, needs, and desires.   Prerequisites:   1. A sender of a message   2. A receiver of the message   3. A shared intent to communicate   4. A shared means of communication Communica.on – What is it?   The exchange of ideas from one person to another   Receptive language – what we understand others saying   Expressive language – what we say to others   Typically developing children (and us!) have higher receptive language than expressive language Communica.ve Func.ons Emerging in the First 2 Years   Behavioral Regulation   Social Interaction   Joint Attention Where’s the breakdown for children with ASD and related disabili.es?   Joint attention – the ability to attend to the same object with another; the ability to request with eye-­‐gaze, pointing, showing, etc.   Difficulty understanding spoken language and common gestures (shrugs, facial expressions, verbal directions, etc.)   Difficulty with functional language skills such as speech and common gestures Core deficits cont’d.   Lack of initiations, especially to peers   Sustaining interactions whether in the initiator or responder role   Receptive may or may not be higher than expressive (e.g. echolalia) Suppor.ng children with ASD visually   Why not American Sign Language?   Difficulty with motor imitation   Often have idiosyncratic signs only known to family members   Symbols are transitory, not stable, no easy reference Func.onal Communica.on This takes into account what the child brings: 1. Their own repertoire of intentionality. 2. Their motoric skills, cognitive level, and sensory needs. 3. Their family/cultural situation and preferences.   In reality, it is teaching children skills that are important to them, that can actually be used and reinforced by normally occurring life-­‐events. Inten.onality   Communicative Intent: The child is aware that communication serves a purpose   Baby cries…is fed   Toddler brings cup to parent…cup leads to milk or juice from the refrigerator   Toddler brings the parent to the refrigerator to request an item or puts their hand on the item   Preschooler tantrums when denied a desired item or activity Con.nuum of Skills   Language is built on a continuum from basic to complicated.   It begins with an awareness of a goal, to sending a message, to repairing/changing the message if the need is not met.   For students with severe disabilities, expecting development along the typical continuum may lead to disappointment. Communica.ve Func.ons   Use of language regardless of form serves a purpose or purposes including (but not limited to) :   1. requesting   2. protesting   3. commenting   4. clarifying   5. showing/pointing/telling/sharing   6. greeting Idiosyncra.c and Unconven.onal Communica.on   Idiosyncratic:   Odd prosody, vocal abuse, mannerism, tone.   Immediate, delayed, and mitigated echolalia.   Unconventional: Resorting to unwanted behaviors that work for the child to obtain what they want, e.g., hitting to obtain a cookie Communica.ve Repertoire   Consider the student’s current behavioral repertoire:   1. Is he understandable to others?   2. Are the behaviors socially acceptable?   3. Do they get his needs met?   4. Are the behaviors efficient?   5. Are they part of a negative behavior sequence/repertoire that should be replaced? Modes   What does the child currently do to communicate, i.e.   1. Does she use gestures such as pointing, eye gaze, shaking head, etc.   2. Does she use single words/
phrases?   3. Does he take you to a desired item or push an undesired item away? Augmenta.ve and Alterna.ve Communica.on Systems (AAC)   Consider their use when language is impaired or absent for whatever reason.   Augmentative: supplements any existing speech.   Alternative: replaces natural (verbal) speech. Symbol Systems   Symbols can take a variety of forms   Real Objects/Tangible Objects   Photographs   Color Symbols   Black & White Symbols   Word Pre-­‐Symbolic to Symbolic Example:   From: do2learn.com: Division TEACCH   Systems can use the real object or a part of the object, such as the bubble wand, moving to an outline of the wand, to the symbol picture, to a picture + word, and finally to just a word. Crea.ng Communica.ve Environments   Communication opportunities can be greatly increased by making changes in the way the home or therapeutic environment is arranged   We want to create a communicative environment to encourage more structured opportunities for the child to initiate or respond to a communicative bid Environmental Strategies   Specific strategies for creating opportunities:   1. Put away items that students naturally gravitate towards such as toys, preferred games, etc. In sight but out of reach   During snack times consider making each eating time a communicative instructional time. Keep food in one place first with an adult and have the children request   It can be difficult if your child has had free access to items he likes and then there is a communication demand instead. Ques.ons?   I want to go back to a specific pre-­‐linguistic skill, joint attention Where Do I Look? Joint a1en2on deficits in young children with au2sm   This study was a follow-­‐
up to answer the question are joint attention skills related to PECS acquisition? What is joint aUen.on?   Joint attention is the ability to communicate non-­‐verbally through gestures or eye-­‐gaze to show or to request objects, actions or social engagement   Acquisition begins around 4 months and develops until about 18 months (Berko Gleason, 2005)   Joint attention skills have been directly linked as the primary predictor of later verbal language production (Anderson, et al. 2007) P.E.C.S.   Bondy and Frost, 1994, 2001   Specifically for children with autism   Built in joint attention   Built in initiations   Built in communication partner necessity   Built in discrimination Pros and Cons of PECS   While not intended to induce speech output, it seems to increase it, and definitely does not inhibit it   Teaches basic skills in a meaningful, functional way that takes the child’s interests into account   Generally a basic request system What is P.E.C.S.?   Picture Exchange Communication System   Developed by Bondy & Frost (1994, 2001)   Child initiated   Symbol based   Built on successful exchanges   Uses a child’s interests to promote positive communication exchanges Advantages to P.E.C.S.   Does not require complex materials   Does not require intensive staff training   Can be used in a variety of settings   Children become competent very quickly   Avoids teaching prompt dependency PECS is a highly used alterna.ve communica.on system   PECS is a highly used communication system seen across early childhood educational settings.   Emerging research that it promotes verbal productions   (Charlop-­‐Christy, 2007; Ganz & Sampson, 2006) Phases of PECS   Phase I – exchange of one picture for desired item   Phase II – traveling to communication book and to communication partner to complete exchange   Phase III – discriminating between icons of preferred items   Phase IV – incorporating an “I want…” strip   Phase V -­‐ answering the question, “What do you want?”   Phase VI -­‐ commenting Phase I of the PECS protocol   Phase I of PECS protocol teaches a child to exchange a picture for a desired item   A symbol (2-­‐inch size) is placed between the child and the desired item (only 1 symbol at a time) What Does Phase I Look Like?   A highly preferred item is in view but slightly out of reach of the child   This protocol requires that two adults be used during this phase. One adult is the communicative partner and one adult is the prompter to help the child physically make the exchange Phase II: Distance and Persistence   The second phase of the PECS protocol Child
teaches the child to travel between his communication book and the communicative partner   A second adult is also required during this phase to facilitate successful exchanges PECS
book
Adult
Purpose of Study   The purpose of this study was to evaluate the effectiveness of the Picture Exchange Communication System on the acquisition of joint attention skills in young children with autism. Joint AUen.on Framework Adult
Initiation
(receptive)
Child
Initiation
(expressive)
Protoimperative
(request)
1
2
Protodeclarative
(show)
3
4
Par.cipants   This study was conducted with 4 preschool children with a diagnosis of ASD   Participants were children who presented as functionally non-­‐verbal   Did not have a functional communication system in place   Had not been taught to use PECS Par.cipants   Jade 4;4 Vietnamese is spoken in the home   Isaiah 3;7 English is spoken in the home   Sara 4;7 English and Urdu is spoken in the home   Morgan 3;3 Urdu is spoken in the home Interven.on   Children received 30-­‐minute treatment sessions three times per week following PECS protocol (Bondy and Frost, 2001)   The treatment period continued until a child met criteria for Phase III acquisition (picture discrimination)   One month after intervention period a post-­‐
treatment assessment of joint attention skills, PECS phase acquisition, general language skills and receptive vocabulary skills was conducted. Standardized measures   All of these measures were used in the pre-­‐treatment, post-­‐treatment, and one month follow-­‐up treatment format   Early Social Communication Scales (ESCS; Mundy, Delgado, Hogan, & Doehring, 2003)   Preschool Language Scale (PLS-­‐4; Zimmerman, Steiner, and Evatt Pond, 2002)   Peabody Picture Vocabulary Test-­‐IV (PPVT-­‐IV; Dunn and Dunn, 2007, Forms A & B) Probe for Joint AUen.on at Phase Change Protoimperat
ive
(request)
Adult initiation
(receptive)
Child initiation
(expressive)
1. 
Does the child follow a
proximal point as a request to
follow a direction (give that, sit
here, etc.)?
Does the child follow a distal
point as a request to follow a
direction?
Does the child follow eye gaze
from adult as a request to
follow a direction?
1. 
Does the child share enjoyment
when adult has activity?
Does the child look for novel
things when adult uses a
proximal point to show?
Does the child look for novel
things in his environment when
adult uses a distal point?
1. 
2. 
3. 
Protodeclarative
(show)
1. 
2. 
3. 
2. 
3. 
2. 
3. 
Does the child use a proximal point to
request?
Does the child use a distal point to request?
Does the child use eye gaze to request?
Does the child bring an object to show simply
for the sake of enjoyment with the adult (not
when toy is broken, or he needs to activate
it)?
Does the child use proximal or distal pointing
to show or share enjoyment with the adult
(pointing to airplanes, fire trucks, etc.).
Does the child use eye gaze to direct attention
to a shared object or activity?
Results   All four children began to gainJA skills at the Phase II level   Percentage increase in JA ranged from 17 -­‐25% at the Phase II level   Children in the study acquired joint attention skills in the same scope and sequence of typically developing children; however, much later.   Three of the four children continued to gain skills after study was completed at one month follow up Ques.ons?