Autism Spectrum Disorders: Intervention
for Non-Speakers
Rhea Paul, Ph.D., CCC-SLP
Southern Connecticut State University
Yale Child Study Center
Feb. 11-15, 2008
rhea.paul@yale.edu
Treatment Approaches
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No single approach is best for all individuals, or for the same
individual over time (NRC, 2001)

Select strategies based on the child’s needs at a given stage
Strategies depend on whether:
 New skills are to be taught (call for more structured, direct
teaching)
 Newly acquired skills need to be generalized (call for more
naturalistic context and incidental teaching)
 Whether the focus is on the child initiating or responding
Effective treatment:
 Intensive, long-term, delivered directly to children, mostly
one-to-one
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Goals of Treatment for Prelinguistic
Children with ASD
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Social Interaction skills
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Communication skills
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Gestures
Vocalizations
Speech, alternative mode
Listening
Adaptive skills
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Imitation; Reciprocity
Joint attention
Play; peer relations
Learning to learn
Self-help
Self-regulation, emotional regulation
Preacademic skills appropriate to developmental level
Developing Social Interaction Skills
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Imitation
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Begin with motor imitation: using ABA techniques
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Fundamental to learning
Serious deficit in ASD
Karin video
Progress to
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Small motor imitation
Imitation with objects
Imitating vocalizations
Imitating words
Contingent Imitation
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Adult imitates child actions and vocalizations.
Led to increases in gaze toward adult.
One of the few demonstrations of way to
increase gaze behavior.
Joint Attention
(Kasari, Sigman, Mundy, & Yirmiya, 1990)
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Thought to be a fundamental deficit in ASD
Supported joint attention (Yoder & McDuffie, 2006):
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Adult manipulates object to get child attention
Adult comments on object child is focused on
Provides linguistic mapping for
objects and activities child shows
interest in
Found to support the
development of vocabulary
(Siller & Sigman, 2002)
Associated with language
development (Paul et al., in press;
Wetherby et al., 2007)
Symbolic Play
(Toth, K., Munson, Meltzoff, & Dawson, 2006)
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Symbolic play is thought to be highly related to the
development of language
Play behaviors taught by:
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Discrete trial imitation
Physical guidance
Modeling and practice in
 using objects representationally,
 Referring to absent objects
 Attributing properties
to objects (hot!)
Evidence shows these can be taught
Evidence also shows children with more play skills do better in
other interventions for communication
Fostering Peer Relations
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Peer Group Entry
Buddy Time
Peer and Target Training
Peer Group Entry
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Child is assigned a role to establish group
membership
Child is prompted to initiate interactions
Child is given highly valued prop
Child is taught five-step sequence for
entering group, using Visual Schedule
Peer Group Entry
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Walk over to your friend.
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Watch your friend.
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Get a toy like your friend is using.
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Do the same thing as your friend.
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Tell an idea.
Buddy Time
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20 min. period during school day
Each child assigned a buddy
Buddies rotate
Class is taught ‘buddy’ rules sequentially
Both buddies receive reward if follow rules for entire
buddy period:
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STAY
PLAY
TALK: say name, talk about the play, respond to partner,
repeat then say more about it, ask a Q
Peer and Target Training
Peer Training:
 Learn to play new game
(e.g., Ring around the Rosy,
Hide and Seek)
 Learn initiation strategies:
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Tap T on shoulder
Say T’s name
Say, “Would you like to
play..” name once choice
while pointing to
appropriate card
Target (T) Child Training:
 Learn new game
 Learn response strategies:
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Say “yes” to peer
Look at card
Look at peer
Play game
8 sessions prompted
8 sessions w/out prompts
Communication
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Speech-focused: aimed at getting child to use
oral language
Communication-focused: aimed at getting
child to engage in reciprocal social interactions;
e.g., expressing communicative intent through
gestures, gaze, vocalization, etc.
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Relationship-based methods
Skills-based methods
Developmental/Pragmatic methods
Speech-Focused Methods
Active Ingredients: Speech-Focused
Methods
 Clinician
control
 Use of imitative response
 Tangible reinforcement
 Stimulus-response-reinforcement
sequence
Lovaas Young Autism
Project (Lovaas, 1987)
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19 preschoolers treated between 1970 1n 1984
Individual discrete trial training 40 hrs./week
Average IQ=84
Results reported ONLY for 9 BEST outcomes
Later study applying same technique to children
with low IQs failed to show significant effect of
the treatment
Sheinkopf & Siegel showed similar results
obtained w/ 20 and 40 hours/week
Verbal behavior: Partington &
Sundberg (1998)
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Traditional Skinnerian approach; increase verbal
imitation through use of reinforcement
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Highly effective for many children with ASD
(Ross & Greer; Yoder & Layton)
Has difficulties always associated with
behavioral approaches re: generalization
Many children with ASD do not imitate
vocalizations
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Teach Me Language
(Freeman& Dakes, 1996)
Mands
Echoes
Tacts
Receptive
Intraverbal
With single
word
Imitate
speech
sounds
Imitates
words
Names
reinforcers
Follows
instruction to do
a fun activity
Fill in words in
songs
Names
common
objects
Fill in blanks in
game activities
Imitates
phrases
Names
people
Imitates with
prosody
Names
pictures
Imitates with
appropriate
volume
Names
ongoing
actions
Follows
instruction to
look at a
reinforcer
Follows
instruction to
look at a
common item
Follows
instruction to
touch a
reinforcer
Follows
instruction to
touch a common
item
With
reinforcer
present
With
reinforcer
not present
Without
prompts
Mands for
action
Say animal
sounds
Fill in words in
common
activities
Fill in items by
feature,
function, class
Rapid Motor Imitation Training (Tsouris &
Greer, 2003)
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Child imitates rapid motor imitation sequences of actions
the child can already do, then a simple word for a
preferred item is added to the end of the sequence to be
used as a request
Later, a new word for a
nonpreferred item is required
as a label, then the preferred
item is given as a reward
Results show both requests
and labels are produced without prompts
RMIA Video
Scripts and Script Fading
(McClannahan & Krantz, 2005)
Use
a ‘prompter adult’
Teach names for preferred objects and activities
Record names on card reader
Teach child to use cards to produce requests
Eventually, require the child both to run the card AND
repeat the word for a request function
Gradually fade scripts
Some evidence published for efficacy in
small number of Ss.
PROMPT (Hayden, 1984)
Prompts for Restructuring Oral Muscular Phonetic
Targets (PROMPT)
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Derived from program for adult apraxia
Based on assumption that a major limiting factor in speech
development for children with ASD is apraxia
Structured tactile stimulation of articulators to induce
appropriate articulatory postures and movements for speech.
Little empirical support in either apraxia or autism
Rogers et al (in press): PROMPT did not result in greater gains
than more communication-focused approaches (single subject).
Hayden et al. (nd): Both PROMPT and general language
stimulation yield similar results
Communication-focused
Interventions: Relationship-based
Methods
Floortime
(Greenspan & Weider, 1999)
 Goal is to foster intimacy and
interaction
 Follow child’s lead, open circle of
communication (child flips light, adult covers switch)
 Efficacy supported through testimonials, case studies and
vignettes
 Goal is not to teach skills, but to develop pleasure in
relating to others
 Parents encouraged to be primary intervention agents;
exclusive
 Only support is anecdotal case review
 Recent study raises Qs
Relationship Development
Intervention
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Goal is to engage the child in a social relationship,
not achieve a specific behavioral objective
Speech is NOT a focus
Provides sequenced curriculum of
activities to achieve this first in
dyadic relations, then groups
No published evidence of
effectiveness
Website claims decrease in
symptomotology on ADOS
Communication-focused
Interventions: Skills-based
Sign Language
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Several studies show nonverbal
children fail to use any signs
functionally (Layton & Watson, 1995)
Grove & Dockrell (2000) showed that children
with MR taught signs did not progress past Brown’s
stage I.
Yoder & Layton (1988) in only direct comparison of
speech and sign instruction in ASD found no
advantage for Sign
Mirenda reports no advantage for Sign vs. graphic
symbols
Aided Language Modeling
(Drager et al., 2006)
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Procedure:
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Multiple-baseline design across sets of symbol vocabulary used
with 2 children who had autism.
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point to a referent in the environment
point (within 2 s) to a graphic symbol of the referent
simultaneously say the name of the referent
Four vocabulary items were taught in each of 3 legs of the
design, for each child.
Both participants demonstrated increased symbol
comprehension and elicited symbol production.
Symbol comprehension production was maintained by both.
For both children, symbol comprehension > symbol production.
Other AAC Approaches
(Millar, Light, & Schlosser, 2006)
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Research review of use of a variety of AAC
devices shows most are associated w/
modest improvements in speech production
No evidence AAC training inhibits speech
No direct comparison to speech treatment
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Most efficient method is not yet clear
Picture Exchange Communication
System
(Bondi & Frost, 1998)
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Several studies (e.g., Charlop-Christy et al., 2002; Ganz & Simpson, 2004)
show children with ASD taught PECS increase communication and
speech,
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but Magiati & Howlin (2003) found that although there were increases in PECS
use, speech was much slower to show improvement
Tincani (2004) showed PECS and Sign were equally effective in
eliciting requests for different children, but Sign elicited more
vocalizations
Yoder & McDuffie (2002) showed PECS was better for children who
communicated infrequently at intake; but not for those who
communicated frequently
Yoder & Stone (2006) found growth was faster in the PECS group for
children who began treatment with relatively high object exploration,
but slower in the PECS group for children who began treatment with
relatively low object exploration.
No direct comparison available between PECS and explicit speech
training
Picture Exchange Communication
System Video
Graphic symbols
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Several studies have looked at use of non-PECS
communication boards (e.g., Garrison-Harrell
et al., 1997), BUT
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Millar et al., (2000) meta-analysis: Looked for
evidence that speech development resulted from
AAC training.
No evidence that Sign or other AAC is more likely to
lead to speech development. Both led to modest
gains.
Voice Output Communication Aids
(Brady, 2000)
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Improve PA and spelling in nonspeaking
children with ASD
Using these to request functional activities in
preschool resulted in spontaneous use with
teachers, but not peers
Anecdotal analysis of 58 children using VOCAs
showed 53% used them successfully.
Prelinguistic Milieu Teaching
(Yoder & Warren, 2001)
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In sight but out of reach
Uses expectant waiting, focusing
on objects of child interest
Associated with increased ability to initiate
communication, increases in the frequency,
spontaneity and elaboration of language,
Some nonverbal children have developed speech
w/ PMT (Yoder & Stone, 2006);
Works best for children w/ little play, but more
communicative acts and gaze to face
Prelinguistic Milieu Techniques
 Withhold
materials of interest
 Give inadequate materials, portions
 Sabotage familiar routines
 Violate expectations
 Protest child actions
 Create silly, unexpected situations
 Misuse, misname, misplace objects
Prelinguistic Milieu Video
Parent-delivered PMT: Techniques
(Kashinath et al., 2006)
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Arranging the environment: Put preferred toys out of reach
but in sight, requiring children to request assistance.
Natural reinforcement: Verbally acknowledges
communication attempts and provide access to objects only in
response to child's requests.
Time delay: Present object of interest to the child (e.g., an
unopened toy) and waits briefly (3–5 s) before giving the child
a verbal prompt to respond.
Imitating contingently: Imitate child actions immediately
Modeling: Provide verbal models describing activity or
labeling objects that the child is interested in, but do not ask
child to imitate.
Gestural/visual cuing: Use gestures and visual prompts to
prompt child participation in a routine.
Parent-delivered PMT
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METHOD
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Five preschool children with autism participated in
intervention with a parent within daily routines in the
family's home. Parents learned to include 2 teaching
strategies in target routines to address their child's
communication objectives. Generalization data were
collected by measuring strategy use in untrained routines.
A multiple baseline design across teaching strategies was
used to assess experimental effects.
RESULTS
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All parents demonstrated proficient use of teaching
strategies and generalized their use across routines. The
intervention had some positive effects on child
communication outcomes.
BUT…
(Keen et al., 2007)
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Pilot study investigated the effects of a parentdelivered social-pragmatic intervention on the
communication and symbolic abilities of 16
children, 2-4 years, with autism.
Standardized measures of communication and
symbolic behavior conducted by independent
observers pre- and post-intervention
Changes in some communication and symbolic
behaviors occurred, according to parent report.
BUT improvements based on ratings by
independent observers were not significant.
Developmental and Pragmatic
Methods
Active Ingredients: Developmental
Approaches
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Target prelinguistic foundations for speech
Focus on teaching communication, not
speech specifically
Provide intervention in “natural
environments”
Follow the child’s lead
Communication-focused Interventions:
Developmental/Pragmatic
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Use the normal sequence of development to provide goals.
Provide intensified opportunities engage in activities that
similar to those of peers, in the belief that these are the most
effective contexts for learning social and communication skills.
Use learning opportunities that naturally arise, rather than
relying on a predetermined curriculum.
‘Facilitate’ interactions, including symbolic play, rather than
addressing teacher-chosen goals, by
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focus on what a child is already interested in
model ways to communicate about activities child chooses
expand on what the child produces spontaneously
Target functional goals
Communication-focused interventions
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Use environmental arrangement
Use natural reinforcers
Respond to ALL child communicative attempts
Treat behavior as if it were communicative
Emphasize appropriate affect model language
w/out requiring imitation
Imitate the child
Train parents to deliver intervention
Communication-focused
interventions: Evidence
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These techniques can lead to increases in
communication, joint attention, and play
skills
Parents can implement the interventions
successfully
Center-based intensive programs using these
approaches are also successful
SCERTS
(Prizant et al., 2006)
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Social Communication,
Emotional Regulation, Transactional Support
Combines both child-centered, relationship-based components
with naturalistic hybrid components (PMT)
SC goals include prelinguistic communication such as joint
attention
ER goals include arousing through physical activities, calming
through swinging, etc.
TS goals include peer support, environmental arrangement
and support to families
Argues for doing all interventions within the context of every
day routines
Argues against using discrete trial approaches
No empirical support
Treatment and Education of Autistic and
Communicatively Handicapped Children: TEACCH
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State-wide program for children with ASD
Combines relationship-based and skills-based
approaches
Focuses on improving adaptive functioning and
modifying the environment to accommodate ASD
characteristics (TS)
Uses structured teaching and curriculum, modified
environment and visual schedules
Some limited empirical support (Mesibov, 1997)
Eclectic Programs
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Denver
Douglass DD Center,
Princeton Child Development Institute,
Learning Experiences Alternative Program
Pivotal Response Training
New Findings: Howard et al., 2005
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Compared intensive ABA/hybrid program(25-30
hours/week <3, 35-40 hr./wk >3; 1:1 ratio) to
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Eclectic program of similar intensity (25-30 hrs./wk.)
General preschool SpecEd program (15 hours/week; 1:6
ratio)
Found significantly greater growth in IBA program in
all areas
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IBA group achieved near-normal learning rates; other
groups showed below-normal learning rate
IBA group showed greater gains in all domains than either
contrast group
G group showed least gain
Quotes from Howard et al., 2005:
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“Young children with ASD who received IBA
for 14 mo. Outperformed comparable
children who received eclectic intervention
services”
Intensive eclectic treatment “did not prove
effective”
“At least 30 hours/ week of competently
delivered, intensive behavior analytic
intervention produced large improvement.”
ABA vs. DIR
(Hilton & Seal, 2007)
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Two yr. old MZ twins; one treated w/ DIR, one
w/ discrete trial for receptive labels
CSBS scores pre/post
Child in DT showed greater gains, but had
more crying
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Parents opted to continue both in DIR, despite data
Summary
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Both ABA and more naturalistic speech-focused approaches (PMT)
have established efficacy in eliciting first words
Developmental-pragmatic approaches aimed more broadly at
social communication and interaction have a less well-established
empirical track record for eliciting first words, although they have
been shown to increase preverbal behaviors such as imitation and
joint attention.
AAC methods have been shown to be compatible with the
development of speech, although efficiency relative to
straightforward speech treatment has not yet been established.
There are few direct comparisons, so it is not possible to say that one
method is more effective than another.
Pre-Rx child characteristics are
related to outcomes.
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Initial frequency of intentional communication and
object play predict lexical density growth (Yoder, 2006)
Words said, verbal imitation, pretend play, and the
number of gestures to initiate joint attention predict
children with most rapid expressive vocabulary growth
(Smith et al., 2007).
Relation between amount of intervention and gain in
language age depended on ability to respond to bids
for joint attention and initial language skills. (Bono et
al., 2004).
THEREFORE: Characteristics of children effect relations
between interventions and outcomes
What is to be done?
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Speech is
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Most viable form of communication
Most closely related to outcome in ASD
Make every effort to elicit speech as primary
mode of communication
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Use or support use of discrete trial approaches for
emerging speech; for many kids, they work
Augment structured direct speech training with other
communication-focused activities
BUT hybrid activities (e.g., PMT) so far appear to be
the most effective supplements in early stages
The Bottom Line
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Match child characteristics to therapeutic
approach, based on what is known
Intensive Rx is necessary to effect significant
change.
Supplement ABA/DT for speech w/ more
naturalistic and AAC methods for
communication, BUT
Mixed approaches are not effective unless
therapists are highly trained in whatever
approach they use;
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THEREFORE, it may be necessary to have different
highly trained therapists for each approach used
Adaptive, Preacademic Skills
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Use task analysis
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Identify the task to be analysed.
Break this down into between 4 and 8 subtasks. These subtasks
should be specified in terms of objectives and, between them,
should cover the whole area of interest.
Draw the subtasks as a layered diagram ensuring that it is
complete.
Decide upon the level of detail.
Produce a written account as well as diagram.
Present the analysis to someone else who has not been involved in
the decomposition but who knows the tasks well enough to check.
Sample Task Analysis
Brushing Teeth
Pick up the tooth brush
Wet the brush
Take the cap off the tube
Put paste on the brush
Brush the outside of the bottom row of teeth
Brush the outside of the top row of teeth
Brush the biting surface of the top row of teeth
Brush the biting surface of the bottom row of teeth
Try to make yourself understood while answering the question
of someone outside the door
Brush the inside surface of the bottom row of teeth
Brush the inside surface of the top row of teeth
Spit
Rinse the brush
Replace the brush in the holder
Grasp cup
Fill cup with water
Rinse teeth with water
Spit
Replace cup in holder
Wipe mouth on sleeve
Screw cap back on tube
Practicing Task Analysis
Activity:
Task analysis for
teaching shoe tying
Emotional Regulation
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Avoid triggers
Use distraction
Use soothing techniques (voice, touch, rocking)
NEVER reward