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|Posted: Tue Apr 03, 2007 9:56 am Post subject: Developing Expressive Communication Skills for Non-verbal Ch
|Developing Expressive Communication Skills for Non-verbal Children With Autism
by Susan Stokes Autism Consultant
"Written by Susan Stokes under a contract with CESA 7 and funded by a discretionary grant from the Wisconsin Department of Public Instruction.?
What is Communication?
Communication is a range of purposeful behavior which is used with intent within the structure of social exchanges, to transmit information, observations, or internal states, or to bring about changes in the immediate environment. Verbal as well as nonverbal behaviors are included, as long as some intent, evidenced by anticipation of outcome can be inferred. Therefore not all vocalization, or even speech, can qualify as intentional communicative behavior (7). This definition emphasizes that communication takes place within a social context. Speech/verbalization becomes communication when there is a desire or intent, to convey a message to someone else. Because social relations are a primary area of difficulty for children with autism, it is not surprising that effective communication is significantly impaired for these children. These two areas, communication and social skills, are tightly interwoven and interdependent. Therefore the development of communication skills cannot be the sole responsibility of the speech/language pathologist. While she may provide the "guide posts" and strategies, communication must be addressed continually by everyone who comes in contact with the child.
The two-fold purpose of this article is to provide:
? Key questions to consider in order to determine the child's current communication abilities;
? Information regarding the development of a communication intervention program based on the child's communication needs.
Key questions to consider in order to determine the child's current communication abilities.
In order to develop an appropriate communication intervention program for the non-verbal child with autism, it is essential to determine the child's current communication abilities. The following are important questions to consider in order making this determination:
Does the child exhibit intentional communication?
It is important to determine if the child is exhibiting communicative intent. Intent to convey a message distinguishes communication from non-communicative speech, verbalizations and gestures. When the child anticipates an outcome from his communication, regardless of the form (i.e.: speech, gesture, etc.), he demonstrates intent.
Example: A parent responds to a crying child. At this point, the child has not exhibited communicative intent. However if the child continues crying, looks at the parent, and then looks at a desired object, intent to communicate has been demonstrated. Through crying, looking at the adult and looking at the object, the child is anticipating that she will obtain the wanted item.
Communicative intent is indicative of the child's desire to communicate. In turn, the desire to communicate is inextricably tied to the development of social relationships, an area of significant difficulty for children with autism. Because these children are often unaware of, or may be uninterested in, others, communicative desire or intent is often absent. They do not understand that they can use communication to get something, or to get someone to do something for them. They attempt to get their needs and wants met by themselves in any way possible, and may exhibit distress when unsuccessful. When interacting with a child with autism, it is important to be able to distinguish this distress from a desire to communicate, in order to determine if the child is exhibiting communicative intent.
In what way does the child communicate?
A child with autism, who demonstrates intentional communication, can do so using various forms or modes. It is important to consider which of the following communication forms are used by the child:
Motoric: Direct physical manipulation of a person or object (e.g., taking a person's hand and pushing it towards a desired item; giving a cup to a caregiver to indicate, "Want milk").
Gestural: Pointing, showing, gaze shift (e.g., a child looks or points to a desired object and then shifts his gaze to another person, thereby requesting that object. [i.e. the communicative act of requesting).
Vocalization: Use of sounds, including crying, to communicate (e.g., a child says "ah-ah-ah", to draw another person's attention to him).
Sign language: Communication with a conventional sign language system.
Using objects: The child hands an object to another person to communicate (e.g., the child hands a cup to his parent to indicate "drink").
Using photo: Use of two-dimensional photographs to communicate (e.g., the child points to, or hands photographs of various objects, actions or events to communicate his desires).
Pictorial: Use of two-dimensional drawings which represent objects, actions or events (e.g., a child hands a line drawing of a "swing" to his parent to indicate that he wants to swing).
Written: Use of printed words or phrases to communicate (e.g., the child writes, "too loud" to indicate that the noise level in the environment is bothering him).
In addition it is important to determine if the form of communication used by the child varies, depending upon the context and situation or the type of communication desired. For example, the child may use a motoric mode of communication (taking a person's hand and pushing it towards a desired item) to request an object. However the same child may use a vocalization (crying) to reject an item, or to protest.
How does the child use his language to communicate?
Research has shown that the child with autism uses his language to communicate for a narrow or restricted range of purposes or functions (7). There are three primary functions or purposes of language: behavioral regulation, social interaction and joint attention (7). It is important to note that all three communicative functions are developed by approximately age 12 months in typically developing children, and are listed in hiearchical order from least social to most social (6):
Behavioral Regulation: This is the easiest and earliest emerging communicative function (6). The child uses communication to request / protest, or satisfy his immediate physical needs. Behavioral regulations include:
? Requesting objects
? Requesting actions
? Requesting assistance
? Protest/reject object
? Protest/reject action
Social Interaction: Types of communicative behaviors that are used to initiate, respond to, maintain, or terminate social interactions. These social communicative interactions include:
Requesting social routines (e.g., requesting to play "peek-a-boo" and "patty-cake" games);
Requesting comfort (e.g., requesting to be held when distressed);
Greetings (e.g., "Hi" /"Bye");
Calling attention: (e.g., child calls attention to self through calling others);
Showing off (e.g., child exhibits "show off" behaviors during games, such as peek-a-boo, dress up, etc.).
This is the most difficult communicative function for children with autism spectrum disorder to develop (6). These communicative acts are used to direct another's attention to an object, event, or topic of a communicative act. Joint attention communication acts include:
Commenting (e.g., a baby looking at his parent and pointing to the sky at an airplane overhead. The child is not requesting the airplane but commenting about it, drawing another person's attention to this object);
Requesting information from others (e.g., the child asks another "Where did you go?").
Giving information to others (e.g., the child gives information about something that is not obvious or known to another person: "I went to the fair last night");
Is there a reason for the child to communicate?
It is important to determine what motivates the child before developing a language intervention plan. As in typical child language development, children with autism will generally not engage in communicative interactions unless they are motivated to do so. Therefore, if the child loves swinging, or jumping or playing with string or particular foods, then these are the actions/objects that should be part of an intervention plan. Incorporating motivating activities and objects is vital when helping children develop communicative intent / desire. Teaching a core of early developing vocabulary words is merely teaching the child with autism to label and does not constitute teaching him to communicate. By initially using motivating actions and objects, the child will truly learn the purposes or functions of communication. Once the child has learned this, vocabulary can then be expanded through a variety of teaching strategies.
Does the child initiate and/or respond to communicative interactions?
Communication implies being both an initiator of, and a responder to information while engaged in a social situation (4). Therefore it is important to determine if the child with autism is able to understand, as well as participate in, both roles in communicative interactions.
Example: A non-verbal child might initiate a communicative interaction with his parent by vocalizing to call attention, and then pointing to request a desired item. The same child might respond by pointing to a picture of a desired food item when his parent asks, "What do you want to eat?"
Children with autism typically have difficulty initiating communicative interactions with others, and tend to be better at learning to respond (4). When determining if the child initiates or responds to any communicative interactions, it is important to ascertain the particular contexts/settings, the manner or form of communication and the communicative purpose or function.
Example: A child finds his mother in another room, takes her hand and leads her into the kitchen, where he places her hand on the refrigerator handle. The mother opens the refrigerator and begins taking items out one by one until the child indicates by facial and body expression which item he wants. In this example the child initiated communication in the kitchen (context) to request desired food (purpose), by using a motoric and gestural form of communication.
Is the child able to use "repair" strategies when communication breakdowns occur?
Due to their significant difficulties in successfully communicating, children with autism may experience frequent occurrences of communication breakdowns as both speakers (expressively communicating) and listeners (when asked to respond). Therefore it is important to determine if the child has developed, or is able to use, any communication repair strategies for both receiving and expressing communicative messages.
Communication breakdowns as a listener (receiving information): Because children with autism have significant language comprehension difficulties, many communication breakdowns as listeners may occur. These breakdowns transpire when the child does not understand, or responds inappropriately to verbal information. A communication repair strategy that can be used in these situations is to present the misunderstood information visually (children with autism generally process visual information more easily than verbal information. In this way one can determine if the child is not responding appropriately (communication breakdown), either because the information is given verbally, or he doesn't understand the information, whether verbally or visually presented. Many children with autism can easily be mislabeled as being non compliant when they do not respond to verbal information. Careful consideration should always be given to the child's ability to comprehend and respond to verbal information (as opposed to visual information) in determining the reason for the breakdown in the communication.
Repair strategies for communication breakdowns as a speaker (expressing information): When breakdowns in expressive communication occur, it is important to understand whether the child exhibits any of the following repair strategies:
Repeating the same communicative attempt: Being persistent. For example the child repeatedly points to a shelf out of reach, as the adult takes each item off of the shelf and shows it to the child to see if it is the desired item.
Showing the person what they are trying to communicate: a child might take an adult to the refrigerator, for example, open the door and reach towards a shelf where the milk is located, demonstrating that he wants milk.
Use of an alternative way to communicate the same message: In the above example, if the child points to the shelf several times, but the adult still does not understand (a breakdown in communication), the child might then choose a picture from his communication book to clarify his communicative request, thus repairing the breakdown in communication.
Developing an Intervention Program for the Non-Verbal Child with Autism:
After considering the previous questions, an intervention program can then be developed to address the child's communicative needs at this preverbal level. It should include the following essential communication elements:
Developing communicative intent:
Following the establishment of such pre-linguistic skills as attending and maintaining eye contact, a non-verbal child with autism can be taught communicative intent in several ways:
Cause/effect reasoning: Cause/effect reasoning helps develop communicative intent, because it teaches the child that doing one action can cause another to happen. It is important for the child to develop an understanding of cause/effect reasoning through a variety of experiences, such as playing with pop-up/musical toys that are activated by the push of a button, climbing up on a chair to get a cookie off of the counter, being rewarded for specific desired behaviors, etc.
Joint activity routines: Highly predictable routines including movement routines, such as blowing bubbles, blowing up a balloon and letting it go, "Here Comes the Spider" tickle game, food making routines, such as making Kool-Aid or chocolate milk, play routines with simple toys, can establish anticipatory behaviors in the child. The child's ability to anticipate the outcome of these highly predictable joint activity routines ensures an understanding of cause/effect. Joint activity routines are a highly effective teaching strategy for children with autism, as they provide learning through a strength feature of autism, a preference for routines. Joint activity routines allow for the child and adult to engage in meaningful, natural social communicative interactions within the routine of an activity. Another positive outcome in using joint activity routines is that they teach the child that he can share experiences with others through the communication embedded in these routines (2).
Delay responses to anticipated wants/needs: At times it may be easy to anticipate and respond to the wants and needs of the non-verbal child, even though the child may not exhibit intentional communication. However, because the goal of the intervention program is to develop meaningful communication skills (i.e. purpose, intent, and desire), it is important to remember to expect the child to communicate. Even though the adult may know what the child wants, it is important to delay meeting the child's wants and needs so that he is placed in situations which require him to interact with others to get his wants and needs met.
Establishing an efficient and appropriate way (form) to communicate:
After determining the child's form of communication, (i.e. motoric, gestural, etc.) it is important to consider if a more efficient form can be used to express the same functions (uses) of language. For example: if the child jumps up and down excitedly in the general area of a desired item, a more efficient way to "request" desired items should be considered. This piece of the intervention process is two-fold: a) determining which visual representation system is best understood by the child (i.e.: objects, photographs, realistic drawing, line drawings, written words); and b) using this information to determine an appropriate alternative communication system for the child. The following visual representation systems are listed in hierarchical order, from concrete to more abstract.
Visual Representation Systems:
Real objects: The child uses various real objects to communicate (e.g., gives his parent shoes to indicate that he wants to go outside).
Miniature real objects: The child understands that a miniature object represents the full-sized object (e.g., a miniature cup is representative of a real cup).
True Object Based Icons (T.O.B.I.s): A T.O.B.I. can be a line drawing, scanned photograph, etc., which is cut out in the actual shape or outline of the item it represents. Symbol shape, which the child can both see and feel, appears to assist the child in more readily understanding a 2-dimensional representation system (1). T.O.B.I.s tend to be somewhat larger than typical 2-dimensional visual representation systems and when initially introduced, may be 3 inches in size or larger (1).
Photos: The child understands that a photograph of an action or object is representative of the real object, action or event.
Real drawings: The child understands that a real drawing of an action or object is representative of the real object, action or event.
Line drawings: The child understands that a simple line drawing of an action or object is representative of the real object, action or event.
Written word: The child understands that the written word is representative of the real object, action or event. The written word should accompany all visual representation systems, as many children with autism, even at the non-verbal level, exhibit emerging literacy skills.
Alternative Communication System:The following are various alternative communication systems that may be tried with the non-verbal child with autism. (list does not represent any type of hierarchy):
Gestural: This is an alternative communication system that is important to establish in the non-verbal child with autism. It does not require any type of visual representation system. A gestural system can include pointing and/or looking to desired items: the child shaking his head "no"; pushing something away to protest or reject; and hand-waving for greetings.
Object exchange: An object exchange system is based on the child giving an object to another person to indicate that he wants something. That is, the child exchanges objects to request, one of the functions of communication. For example if the child wants more milk, he gives his cup to someone to indicate this request.
Picture point system: This system requires the child to point to various visual representation systems to communicate. Visual representation systems that can be used: photos, real drawings, line drawings, written words.
Picture Exchange Communication System (PECS): PECS allow the child to spontaneously initiate a communicative interaction by actually exchanging, or giving a visual representation system to another person (3). In this alternative communication system, the child quickly learns the cause and effect of communication. In addition, by physically exchanging a visual representation system with another person, the child develops a concrete understanding that communication is an actual exchange of information between two or more people (e.g., the child hands a picture of a swing to an adult to indicate that he would like to swing). The PECS program is composed of various phases or levels, starting with simple, concrete communicative exchanges and moving to more abstract communication. For example, the beginning child starts very concretely exchanging one item to make a request. As he advances, his exchanges become more communicatively complex, developing higher level social communication functions, such as commenting. Visual representation systems which can be used: miniature objects, T.O.B.I.s, photos, real drawings, line drawings, written words.
Electronic/alternative keyboards or computers: Some non-verbal children with autism exhibit reading and writing skills to effectively communicate as both speaker (expressively) and listener (receptively). They can use various electronic or alternative keyboards for communication (e.g., a child can type out a communicative request to "listen to music" on an AlphaSmart, an electronic keyboard). Visual representation system which can be used: written words.
Voice Output Communication Aids (VOCAs): Using VOCAs, non-verbal children with autism can express themselves by pushing a button, which plays a pre- recorded message on a communication device . A visual representation system, which the child understands, should be positioned on the "button(s)" of the voice output communication aid/device. Many children with autism spectrum disorder are motivated to communicate by use of these devices, particularly by the auditory feedback immediately given as their communicative message. Use of VOCAs have proven effective in teaching children the cause/effect of language through activities which are stimulating to them (e.g., Use of the Big Mack for a child to request highly desired sensory activities such as "chase me"; "tickle me"; "hug me"; "listen to music").
While VOCAs have many positive qualities, caution should be taken when using them to initially teach communication functions / purposes. VOCAs can be overly motivating and stimulating for some children. In these cases, the VOCAs tend to function as repetitive and stimulating high interest item rather than as communication devices. The child will repeatedly push down the button(s) on the device for the self-motivation that he receives from the auditory feedback, rather than for the cause/effect of the communicative message. When this occurs, a different alternative communication system is suggested to initially teach the child the purpose of communication. After the child learns the purpose of communication, use of a VOCA might then be explored. Visual representation system which can be used: real objects, miniature real objects, T.O.B.I.s, photos, real drawings, line drawings, written words. Expanding the range of communicative functions or purposes:
It is important to teach the child to communicate for a variety of purposes. After determining how the child is using his language to communicate, intervention activities can be developed to expand the child's communicative purposes. Joint activity routines, as well as play activities, provide natural language-learning opportunities to expand how a child uses his language to communicate. These activities should be developed, based on the individualized motivations, needs, and learning strengths of the child (7). The following list describes communication opportunities that should be made available for the child with autism to develop and expand in relation to the three primary language functions: behavioral regulation, social interaction and joint attention(7):
Behavioral Regulation: This is the earliest emerging language function where the child uses communication to regulate his physical needs. To develop communicative behavioral regulations, the intervention program includes:
? Opportunities to request food or objects;
? Opportunities to make choices among alternatives;
? Opportunities to protest actions or to reject objects;
? Opportunities to request cessation of an activity;
? Opportunities or needs to request assistance.
Social Interaction: These are communicative behaviors used to initiate, respond to, maintain or terminate social interactions. To develop this communicative function, intervention should include:
? Opportunities to request social games or routines, or continuation of games or routines;
? Opportunities to practice greeting behaviors verbally or non-verbally;
? Opportunities (or needs) to bring attention to self, either verbally or non-verbally, through calling others or requesting comfort;
? Opportunities to "show off" during games (e.g., hide-and- seek, peekaboo, dressing up, etc.).
Joint Attention:This is the most difficult communicative function for children with autism to develop. It refers to the child's ability to direct the attention of another person to the object, event or topic of communication acts, including commenting, requesting information and giving information. Intervention programs should include:
? Opportunities (or needs) to give or transfer objects, or to follow another person's focus of attention;
? Opportunities (or needs) to use gestures or vocalizations to bring attention to objects or events (e.g., looking at books, going to the zoo, looking out a window, etc.);
? Opportunities to comment on events introducing novelty and change (e.g., taking new toys out of a cloth bag, performing interesting actions on objects);
? Opportunities or needs to request information or clarification (for children with high-level abilities).
Motivation to communicate:
Children with autism are not always motivated by the elements that motivate typically developing children, such as intrinsic satisfaction or social praise. Therefore, we need to assess on a regular basis what is motivating to the child through "reinforcement assessments". Parents can provide much of this critical information. Motivating activities, objects, etc. can serve as a starting point in teaching the child the functions of communication.
Example: It is determined that a child is highly motivated by being bounced on a therapy ball. The therapy ball is then used to establish a familiar joint activity routine, the purpose of which is to teach the child communicative intent, using any form of communication - gestures, physical manipulations, pictures/line drawings, etc.
Developing the ability to both respond to and initiate communication:
Responding to information: How the child processes information must be considered prior to teaching him to respond to communication. If the child's ability to process auditory information is poor, he will have significant difficulty learning to respond to verbal communication. In turn, if the child's ability to process visual information is strong, this processing mode should be used in teaching him to respond appropriately to communicative interactions. The child should be taught to respond in natural occurring situations through a processing channel which he easily understands.
Example: During free play, a communication partner presents a visual choice card to the child that shows two pictures. The partner then verbally prompts with "What do you want to do?". The child can appropriately respond to the question by pointing to or selecting his visual choice).
Initiating communication: Communicative situations should be created, using things which are motivating to the child in an established familiar joint activity routine (6). Once the child anticipates a predictable pattern of response in the familiar joint activity routine, the routine is disrupted to create an incentive for the child to initiate a communicative interaction, in order to re-establish the routine.
Example: A familiar joint activity routine of blowing bubbles has been established. The communication partner disrupts the routine by closing the bubble lid very tightly and placing the bubbles in front of the child. An incentive is created for the child to initiate a communicative interaction for "more bubbles".
The Picture Exchange Communication System (PECS), which was developed to teach the child to initiate spontaneous communicative interactions with others, is another method for teaching the child this communication skill.
Developing strategies to repair breakdowns in communication:
Communication breakdowns can occur for the non-verbal child with autism in both receiving and expressing communicative messages.
Breakdowns in receiving communication: The following strategies can be used to prevent breakdowns, or assist the child in repairing breakdowns in communication when receiving information (6):
Secure the child's attention prior to communicating by calling his name, or by physically prompting (for example, touching his shoulder);
Monitor signs of comprehension (child performs appropriate action or attempts to respond expressively);
Use simple, short sentences;
Reduce the amount of auditory information given;
Give the child time to respond before repeating, due to the possibility of delayed auditory processing;
Use of various visual support strategies to ensure that the child understands the message given.
Breakdowns in expressive communication: The child with autism can be taught "repair strategies", which will assist him in successfully repairing breakdowns in expressive communication. The child must first demonstrate intentional communication prior to teaching repair strategies (6). Strategies for repairing breakdowns in expressive communication include:
Persistence: teaching the child to repeat his communicative attempt, if the communicative partner does not initially understand. This skill must be taught through the use of highly motivating activities, which will keep the child's interest in pursuing the communicative interaction, even though a breakdown has occurred. (For example, if the child is not overly motivated to communicate that he wants to go to the bathroom, he will not be motivated to persist in repeating this message once a breakdown in communication occurs). After the child communicates an unclear message, the communicative partner can respond with, "I don't understand", or, "Tell me again" accompanied by an appropriate gesture (shoulder shrug). The child should be encouraged to repeat the message, given minimal prompting if necessary.
"Show me": after the child learns to be persistent, he should then learn to respond to "show me" and then be given an appropriate language model if this is successful.
Example: A child approaches an adult, jumps up an down, vocalizes loudly and looks at a specific area of the classroom. The adult verbalizes "Show me", points to the area of the classroom indicated by the child, and then leads the child over to that area to encourage them to "show".
Alternative communication systems: the child should be encouraged to use alternative communication systems if appropriate
Example: A child approaches an adult, vocalizes loudly and points to a shelf out of reach. The adult encourages the child to "use your words" which is a verbal prompt for the child to use his PECS communication book to communicate.
Having a good understanding of a child's current level of communicative competence is the first step in developing an appropriate communication intervention program for the non-verbal child with autism. Alternative communication systems for these children must also be considered. At this preverbal level of communicative competence, it is critical for the child to have some way to effectively communicate, rather than focusing solely on the development of verbal skills. These skills (i.e. learning to speak) may develop in conjunction with the use of alternative communication systems.