Resource Manual for
Commissioning and
Planning Services for
SLCN
Professor Pam Enderby
Dr Caroline Pickstone
Dr Alex John
Kate Fryer
Anna Cantrell
Diana Papaioannou
© RCSLT 2009
Resource Manual for Commissioning and Planning Services for SLCN
Acknowledgements
The RCSLT and the Project Team would like to thank all those who assisted in drafting this
guidance. We have received valuable advice from many reviewers from within the speech and
language therapy profession who have given up their time generously. Experts on particular topic
areas from related professions have also been consulted and assisted with detail. Service
Commissioners and senior managers have commented on drafts showing patience and fortitude!
We would particularly like to thank the many who contributed to the focus groups which helped to
shape this document.
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Resource Manual for Commissioning and Planning Services for SLCN
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Resource Manual for Commissioning and Planning Services for SLCN
CONTEXT
The aim of this section is to set out the context for this resource. This work forms part of a
range of tools which can support leaders with service planning and delivery, in line with
both government and local priorities.
It is essential for service providers to demonstrate quality and productivity and to:
ƒ show value for money
ƒ be able to provide a strong financial argument for the need to invest in services for
people with speech, language, communication and swallowing needs
ƒ demonstrate improvements in outcomes for individuals, families and society
Value for money is not about being the cheapest option but about delivering the most
return (impact, best outcomes) for a given investment over time.
The key drivers for change to services include:
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The broad context, which can be divided according to the following factors:
Political and Legislative factors
Economic factors
Social factors
Technological factors
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The near or local context, including:
Localised policies
Addressing local needs
Service provision
Workforce
The evidence base
THE BROAD CONTEXT (MACRO-ENVIRONMENTAL ANALYSIS): FACTORS FROM
THE WIDER WORLD
The Macro-environmental analysis commonly takes the form of a PEST analysis:
Political and legislative factors
Economic factors
Social factors
Technological factors
Political and legislative drivers
Devolution has resulted in changes to the powers of the different institutions across the
UK.
The government in power at Westminster maintains responsibility for policy and legislation
in relation to key areas including: tax, benefits, foreign affairs, international development,
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trade and defence for the four countries of the UK. Government in Westminster is also
responsible for health, social care and education in England, but these areas are devolved
for Northern Ireland, Scotland and Wales.
As a result of devolution, each country of the UK may have different parties in power, with
the possibility of increasing powers in the future. The impact of this is the diversification of
policy and direction of travel.
Legislative drivers
The main areas of UK-wide legislation that are relevant include the following themes:
ƒ Human Rights
ƒ Disability Discrimination
ƒ Equality
Though there is different local interpretation, these far-reaching legal instruments define
the rights and responsibilities of people and those commissioning and providing services
for them.
Public protection has also been strengthened through the introduction of registration of
professionals, for example, through the Health Professions Council.
There is separate legislation relating to health, education and social services in each of the
devolved administrations in England, Northern Ireland, Scotland and Wales.
Economic
The current challenging economic backdrop will have a significant impact on the financing
of public services, with local planners and commissioners prioritising services which are
value for money, evidence based and releasing cash through innovation.
Social
In order to plan and deliver services, it is essential to identify the demographic factors
relevant to speech and language therapy (SLT) and the challenges that these bring.
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The population is aging: people are living longer.
The birth rate is falling: most families are having fewer children
The infant mortality rate is also falling, with more children surviving premature birth or
health problems or injury in infancy.
The urban population is growing.
The proportion of the population in employment is falling.
The proportion of the population with English as an additional language is increasing,
particularly in urban areas.
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THE NEAR OR LOCAL CONTEXT
Localised policies
Central to the new reforms is the emphasis on local decision-making within a national
framework. Across the four countries of the UK there are requirements to provide services
to accord with local need and influence. In England there is a particular focus on
increasing the range of potential providers (plurality of provision) with commissioners
having a role to stimulate the market.
For each country, arrangements have been established to assess whether commissioners
are achieving better health outcomes for the local population. Part of this process will be
an assessment of how well commissioners are performing against specified
competencies/indicators/targets. For example, in Northern Ireland these targets are based
upon high-level outcomes linked to local strategies.
With the devolution of power to local levels, there is a focus on developing more robust
accountability. There is an emphasis on joint working to support integrated commissioning,
service planning and provision across health, social care and education.
There are different approaches to this development with different structures and
commissioning and performance management arrangements being established across the
UK. The dominant theme in strengthening accountability is “putting service users at the
centre” with respect to:
ƒ Access and self–referral
ƒ User voice at strategic to operational to individual case management
ƒ Population/local engagement
ƒ Information and advice for users, parents/ carers
ƒ Patient Rights
ƒ Self management of conditions
Some localities will be commissioning or planning speech and language therapy services
as a single service whilst others will be commissioning integrated services, cutting across
traditional boundaries, with health services integrated with education or social services. In
many areas, this has already happened for children's services.
It is recognised that, often, no single agency can deliver best outcomes for their service
users by working in isolation. Joint commissioning is advocated wherever the meeting the
needs of individuals requires contributions from a number of agencies.
Similarly, some service planners or commissioners will be organising services around
disease groups, such as services for persons who have survived a stroke. In either case, it
will be important for speech and language therapy managers to liaise with other services
to ensure that SLT provision is incorporated in their service plans.
Special arrangements are in place for commissioning services for unusual, low incidence
or costly interventions. Speech and language therapy managers should identify the
specialist commissioning procedures that may be required for individuals requiring
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particular interventions such as costly augmentative communication aids, protracted or
intensive interventions.
Addressing local needs
In general terms, the UK is experiencing a number of long-term demographic changes
(some of which are identified above).
There is significant local variation within these general trends. It is important to understand
what these changes and variations imply in relation to the provision of local SLT services.
Other local factors to be taken into consideration include: employment, cost of living,
housing, transport and, particularly, levels of deprivation.
There are information resources available online from which planners, commissioners and
providers can find out more about local and regional demographic factors. Some of these
can be found signposted on the RCSLT website www.rcslt.org .
Local public health teams will also be able to sign-post local services to relevant data and
information for their area.
There will also be learning from data collected by services. The RCSLT has developed an
online tool called Q-SET, the Quality Self- Evaluation Tool to help you collate local SLT
service derived information http://www.rcslt.org/resources/qset . Q-SET should be used
alongside national and local data to support service planning and evaluation of service
delivery.
Through completing Q-SET, provider services can:
ƒ use the resource every 9-12 months to review progress in meeting action plans and to
demonstrate service enhancement
ƒ compare their service with other similar service types e.g. urban, rural, acute,
community, adult, paediatric, education, 3rd sector
ƒ demonstrate that their service meets the needs of the service users
ƒ identify areas of strength and generate action plans relating to areas of development.
ƒ submit the results as part of the evidence for a clinical audit
ƒ retain ownership of the monitoring and development of services ensuring that strong
professional standards are maintained in the context of multi-agency teams
Service providers completing Q-SET will support commissioners to:
ƒ reduce the ‘postcode lottery’ of service availability and quality
ƒ have high quality information that is relevant and accessible
ƒ have an overview of developments, trends and initiatives within the service
ƒ have accurate and timely statistics to support performance management and
monitoring
ƒ collect data to contribute to the debates on benchmarking. Where benchmarks do not
yet exist Q-SET will enable Commissioners to contribute to this in the future
ƒ collect examples of good practice to inform other pieces of work and the development
of services as a whole.
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Locally derived information will help SLT services to illustrate:
ƒ the numbers of patients/clients seen
ƒ sources of referral
ƒ amount of resource used in providing a service to the client e.g. number of sessions
and skill mix
ƒ nature and severity of the disorder, disability, psychosocial impact at the onset of
intervention
ƒ nature and severity of the disorder, disability, psychosocial impact at the completion of
intervention.
ƒ level of satisfaction with the service.
Service provision
Speech and language therapists have a role in delivering specialist and targeted support
to clients, carers and their families. Speech and language therapists can also reduce longterm demands on services by addressing immediate needs that arise from circumstance
rather than underlying impairment. Providing training for the wider workforce is integral to
the speech and language therapists core role, as outcomes for people with speech,
language and communication needs SLCN are improved when the whole workforce is
able to contribute appropriately to care pathways.
SLTs also work with the wider workforce contributing to the public health agenda,
promoting health and well-being in respect of communication and swallowing. There is
little awareness outside the profession of the role of speech and language therapists in
preventing the development of speech and language impairments and the further impact
and consequences of different speech, language and communication disorders upon
health, education, social integration and employment.
The challenges of meeting the speech, language and communication needs (SLCN) of a
given population are best understood through a social (participative) model. Key elements
of a total service specification will start with:
ƒ identifying the needs of the service user, parent or carer for support and information
ƒ identifying/assessing and diagnosing specific SLCN and providing appropriate
intervention.
ƒ considering needs of service users within the environments they encounter
ƒ training the wider workforce that interfaces with them to maximise opportunities for
positive outcomes.
The balanced system (diagram 1) below illustrates the wider context for how SLTs
contribute to this range of activities. The needs of service users should be considered in
service specifications. The role of SLTs in supporting the active participation of service
users in service planning, adapting the environment and enskilling the workforce is as
relevant as the SLT role in identification and intervention.
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Workforce
Careful planning of services, including joint commissioning, will help to shape the
workforce and inform the skill mix required to deliver high quality services, improve
outcomes and support value for money. Because the commissioning and planning of
services relies on the evidence base for a given type of SLCN or model of practice, it is
essential that clinical and managerial expertise from speech and language therapists is
available to support innovation and quality of service design.
Speech and Language Therapists, as part of the wider workforce, may be employed by a
range of organisations, including the third sector, social care and education or be working
as private practitioners.
Equal Access to services is of importance to local decision makers. Local demographic
profiling will inform workforce requirements. For example, bilingual staff and support
workers are required in most areas to meet the needs of diverse communities. The
appropriate skill mix should enable services to be family-centred and be culturally and
linguistically appropriate and responsive. It may be necessary to consider increasing home
delivered services or providing services in unusual locations.
The RCSLT also acknowledges the important role that Assistants and Support Workers
have in the delivery of effective speech and language therapy services. Assistants and
Support Workers are integral members of both speech and language therapy and multidisciplinary teams, engaged in a wide range of clinical settings with diverse client groups,
duties and responsibilities. http://www.rcslt.org/aboutslts/rcslt_statement_v3.pdf
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In order to support more effective use of skill mix, SLT services also need to provide
education and training of the wider workforce and not be focussed solely on direct patient /
client care. For all services, this is critical to secure the appropriate balance of costeffective universal, targeted and specialist services.
PRACTICAL CONSIDERATIONS
Many people involved in strategic planning, commissioning or reviewing services will not
be familiar with speech and language therapy, its objectives, the needs of clients requiring
speech and language therapy, the principles driving the profession, or the evidence base
and the following points may support people.
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Where possible, draw on the evidence base.
Communicate clearly and succinctly.
Avoid using acronyms and provide a glossary of terms.
Do not assume knowledge of local arrangements or the requirement to interface with
other agencies
Set your service in the context of local priorities.
The RCSLT’s Communicating Quality 3 (CQ3) provides clear guidance on care pathways,
clinical standards and issues related to quality assurance. This information should be used
in submissions to support commissioning quality services.
The following guiding principles have been adopted and apply to all client groups. Services
are to:
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Resource Manual for Commissioning and Planning Services for SLCN
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be family centred and culturally and linguistically appropriate and responsive
be comprehensive, coordinated and team based
work with and communicate effectively with other services meeting the needs of the
client
be evidence based
ensure equal access
involve the family and carers
include training and education of co-workers
ensure practitioners continuing professional development and appropriate support.
Evidence of the impact of the service will be important to commissioners and providers.
Providers will need to demonstrate the impact of their service, particularly when services
are being reviewed. Determining the objectives of the service will support the process of
outcome measurement. SLT services will need to provide information on outcomes
achieved and levels of client satisfaction. Some of this information can be gathered
through use of the RCSLT’s Q-SET tool, as detailed above.
Managers of speech and language therapy services will need to equip themselves to
engage effectively and positively with those who are commissioning or monitoring
services. They will need to:
ƒ identify who is commissioning or responsible for overseeing different services. For
example, health commissioners may be working with commissioners for
education/head teachers. It is important to identify who is taking the lead for each
aspect of the service delivery in the locality.
ƒ establish good working relationships and effective communication with those
commissioners and planners for their area of responsibility.
ƒ be aware of local priorities and commissioning plans and strategies.
ƒ have a good understanding of the commissioning/planning/monitoring framework for
the locality
ƒ be equipped with local data, knowledge and evidence to the tendering process
ƒ be clear of the unique contribution of the service to improving health, employment,
education and social outcomes
ƒ be able to clarify and demonstrate local working partnerships and collaborations
ƒ provide data describing the service provided, (numbers and types of patients, numbers
of attendances, health and social outcomes etc).
The RCSLT has developed a range of resources to support its members with Continuing
Professional Development. CPD is a regulatory requirement for all SLTs and this requires
all HPC Registrants to demonstrate how the CPD they have undertaken has sought to
enhance service delivery and to be of benefit to service users. The RCSLT has endorsed
this requirement through its own CPD standards. http://www.rcslt.org/cpd/resources
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Resource Manual for Commissioning and Planning Services for SLCN
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THE EVIDENCE BASE
The commissioning and planning of services must be informed by the evidence base of
effective practices.
This Resource Manual SLCN is based on a synthesis of existing published research. The
threshold for inclusion in the syntheses has favoured the most scientifically robust
research methodologies which have often reflected medical (impairment) rather than
social (participative) models of care.
In the section summaries, emerging practices that have not been included in the evidence
synthesis, are referred to and should be considered alongside the syntheses. This tension
between empirical evidence resulting from robust research, which by definition is
retrospective, and the needs to encourage innovation and service re-design to support
improvements in outcomes for people with speech, language, communication and
swallowing difficulties is natural and unavoidable. Emerging practice will not have the
same evidence base and therefore less empirically stringent measures of evidence need
to be taken into account for these areas including professional consensus and measures
of service user, parent or carer experience. However, because of the value of some
emerging innovative practice, they have been included in this resource.
An overview of the methodologies employed in identifying practices that are included in
this resource accompanies this document.
Using these resources
Speech and language therapy managers can assist commissioners by understanding their
agenda and the objectives that they are to be assessed on.
The Royal College of Speech and Language Therapists is providing these resources to
assist speech and language therapists in gathering the core data required to support
service tendering agreements, service planning, monitoring arrangements and/or where
services require specification.
Each part of these resources is focused on a specific area.
The resources provide:
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The Contextual Synthesis. This includes definitions, information on the incidence and
prevalence of the disorder, key contribution of speech and language therapists,
consideration of the implications and broader consequences of the disorder.
The Synthesis of Key Literature. This summarises the evidence of the impact of
speech and language therapy.
Each section within these resources gives succinct information to inform the factual
content for any service planning activity. These include:
ƒ Key points
ƒ Topic –What is [the condition]?
ƒ How many people have [the condition]?
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What causes [the condition]?
How does this condition affect individuals?
What are the aims/objectives of speech and Language therapy interventions for [this
condition]?
What is the management for people with [this condition]?
What is the evidence for Speech and language therapy interventions in [this
condition]?
Studies
Assessment methods
Speech and language therapy interventions
Summary
References
This information will need to be put into context, using local information.
Other guidance and resource materials
It is recognised that service managers may wish to amplify or clarify, an aspect of their
service by providing reference to other national or local research of relevance.
The RCSLT has a range of resources which can be used to further support and inform the
commissioning, planning and provision of services for people with speech, language,
communication and swallowing needs. These can be found on the RCSLT website:
www.rcslt.org
The RCSLT is grateful to the experts from within the SLT community who
contributed to the evidence published in this document.
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Resource Manual for Commissioning and Planning Services for SLCN
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METHODOLOGY FOR SYNTHESIS OF LITERATURE
Introduction
The focus of the interventional synthesis within these briefings is to provide a synopsis on
the effectiveness of speech and language therapy interventions for each specific condition.
The interventional syntheses are produced by reviewers within the Information Resources
Section (within the Health Economic and Decision Science Section) at the School of
Health and Related Research (ScHARR). Information specialists/reviewers for this bulletin
were Diana Papaioannou and Anna Cantrell.
Methodology
The interventional syntheses are not intended to be a full systematic review within each
topic area. However, they draw upon systematic review techniques to ensure that the
syntheses are developed according to systematic, explicit and transparent methods. The
intention of the syntheses is to consolidate twenty articles which represent some of the
best research for each topic area.
Literature searching
Systematic literature searches were undertaken to identify a range of evidence for each
interventional synthesis. The interventional syntheses do not attempt to consolidate all
research within a particular topic area; rather they aim to present a careful selection of the
most current research within that field. Therefore, the approach adopted for the literature
search aims to be comprehensive reflecting this systematic and explicit approach.
Firstly, search terms were selected within the project team drawing on the expertise of four
speech language professionals. This involved listing all possible synonyms describing the
condition or population (for e.g. children/infant, stuttering/stammering) and combining
those with terms to describe speech and language therapy. Terms were used in both free
text and thesaurus searching. The following databases were used:
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ASSIA
CINAHL
The Cochrane Library (which includes the Cochrane Database of Systematic Reviews,
Cochrane Central Register of Controlled trials, Database of Abstracts of Reviews of
Effects, Health Technology Assessment Database and NHS Economic Evaluations
Database).
Linguistics and Language Behaviour Abstracts
MEDLINE
PsycInfo
All references retrieved from the literature searches were entered onto a Reference
Manager Version 11 database using appropriate keywords.
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Selecting and obtaining relevant articles
Articles for inclusion were selected to illustrate the range of good quality evidence within
each topic area. An initial screening of articles was undertaken by the Information
specialists/reviewers who adopted the following principles:
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Articles must be empirical research evaluating the effectiveness of a particular speech
and language therapy intervention
Only articles published in English language are included.
In general, only the most current (1998-present) literature is included. However,
exceptions were made to this if a particular article was felt to be important to include.
Where possible higher level evidence was included (systematic reviews, randomised
controlled trials). However, this research did not always exist in every topic area.
Efforts were also made to seek out literature that provided a range of perspectives on
interventions for each topic area, i.e. both quantitative and qualitative research.
Following initial screening, the remaining articles were examined by two members of the
team; each having considerable speech and language therapy knowledge and experience.
Approximately, twenty articles were selected by the two reviewers with disagreements
being resolved by a third reviewer.
Assessing the quality of relevant articles
Formal quality assessment of the articles was not undertaken. Instead, quality assessment
involved using checklists as a guide to give an indication of the overall quality of studies
and highlight the main good and bad aspects of each study. For each interventional
synthesis, the included study designs are listed and the problems with each study design
noted. General observations on study quality are made and common errors within the
studies, where appropriate, are specifically noted. The checklists used are one for
quantitative and one for qualitative studies from the Alberta Heritage Foundation for
Medical Research.1 Additionally, when an identifiable study design was used, the
appropriate Critical Appraisal Skills Programme (CASP) checklist was selected.2
Syntheses of the twenty articles
Each article was read in turn by one of the Information Specialists/reviewers. The key
points were summarised including the objective of the study, the participants’
characteristics, the methodology, the intervention, results and limitations. From this,
articles were grouped into themes according to the factor being investigated (for e.g.,
length of intervention, personnel carrying out intervention, family involvement in treatment,
nature of disorder). Results were summarised and drawn together within each particular
theme and a summary paragraph provided at the end.
These syntheses first went out for review by selected individuals, identified by the
research team, with particular expertise in the delivery or management of services to the
1
LM Kmet, RC Lee, LS Cook (2004) Standard Quality Assessment Criteria for Evaluating Primary Research
Papers from a Variety of Fields. Accessed at http://www.ihe.ca/documents/hta/HTA-FR13.pdf (Accessed on
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25 September 2008, now no longer available)
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Critical Appraisal Skills Programme (2007) Appraisal Tools. Accessed at
http://www.phru.nhs.uk/Pages/PHD/resources.htm on 9th January 2009.
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Resource Manual for Commissioning and Planning Services for SLCN
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specific client group. Comments were included in the second draft, which was then
dispatched to those selected by the Royal College Speech and Language Therapists who
were invited to attend a focus group day. These therapists gave detailed consideration to
their specialist area and contributed to the more general discussion of one further area.
Issues to be captured in the key points were also identified within the focus groups. These
comments contributed to the third draft of the syntheses, which again went out to
reviewers. In some cases, further work was required in order to modify the wording and
reflect discussion.
Checklist for service managers involved in commissioning services
Have you presented incidence and prevalence figures and local demographic trends for the
conditions in your area?
Have you provided information on local access and use of services in the context of the number
expected and highlighted your approaches to inequalities?
Have you consulted systematically with users to inform development of this commissioning
proposal?
Does your proposal fit/link with local cross agency priorities?
Have you outlined the range of services provided including training?
Have you made clear how this fits with future planning for your service over the next 3-5 years?
Have you stated the assumptions which underpin your thinking in the plan and for future
developments?
Have you offered predictions about the likely impact of investment in the proposal?
Have you made clear where the risks are and what contingency plans you have put in place?
Professor Pam Enderby
Dr Caroline Pickstone
Dr Alex John
Kate Fryer
Anna Cantrell
Diana Papaioannou
© RCSLT 2009
RCSLT RESOURCE
MANUAL FOR
COMMISSIONING AND
PLANNING SERVICES FOR
SLCN
Autistic Spectrum Disorders
© RCSLT 2009
RCSLT RESOURCE MANUAL FOR COMMISSIONING AND PLANNING SERVICES FOR SLCN
Autistic Spectrum Disorders
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Autistic Spectrum Disorders
1. Key points-Autistic Spectrum Disorders
1.
Speech and language therapists have a unique role in identifying the social communication
characteristics of importance to diagnosis, contributing to differential diagnosis and
facilitating identification of retained abilities and co-morbidities e.g. hearing loss.
2.
Difficulties with social communication are a predominant feature in reducing access to
education, recreation, employment, and social integration, including forming relationships
and expressing personality.
3.
Communication difficulties are associated with increased prevalence of challenging
behaviours.
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Improved communication has an impact on behaviour, social skills, peer relationships, and
self-confidence.
5.
Improved communication has an impact on literacy, numeracy and skills for learning.
6.
Speech and language therapists should be integral members of services and multi agency
teams supporting children and adults with ASD, their families and carers.
7.
Because children and adults with ASD may present in different ways and have varying
profiles of skills and needs, services should provide a range of interventions.
8.
There is evidence of the effectiveness of different targeted approaches to the treatment and
management of social communication impairments and functioning of children with ASD.
9.
Speech and language therapists have a key role in educating/training others involved in the
care of those with ASD, including the family, health, education and social care staff. Parents
usually have a requirement for information or wish to be trained to a level whereby they can
support their child’s skills actively.
10. There is evidence that interventions with preschool children are appreciated, acceptable and
effective, improving communication and having a positive impact on learning.
11. Whilst most research has been conducted on preschool and school aged children with ASD,
adults with this condition remain at risk and still require intervention and support particularly
when life circumstances change, e.g. transition from school to college.
12. Persons with autistic spectrum disorders remain at risk as defined by the Incapacity Act and
speech and language therapists are integral to assessing competence for consenting, etc.
13. Pathways of care for children and adults with ASD should take account of multiple needs and
the changing focus of intervention at different points in their care.
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Autistic Spectrum Disorders
3
2. What is Autistic Spectrum Disorder?
Autism/Autistic Spectrum Disorder (ASD) and Asperger’s Syndrome are neurodevelopmental
conditions qualitatively identified by the presence of behavioural impairments: impaired social
interaction, communication and social imagination. In this synthesis the WHOICD-10 term
Autism Spectrum Disorder (ASD) is used to cover the condition Autism, Atypical Autism and
Asperger’s Syndrome.
ASD is a pervasive developmental disorder (PDD) with severe and persistent impairments which
together comprise different sub-groups. These are characterised by abnormalities in reciprocal
social interactions and in patterns of communication, and by restricted, stereotyped, repetitive
repertoire of interests and activities (WHO ICH-10).
In the ASD continuum, Autism has all 3 features and is evident before 3 years of age. Atypical
Autism differs in the age of onset and frequently in not fulfilling all three sets of diagnostic criteria.
Autism is a continuum with individuals described as being either high or low level functioning.
The descriptions of behaviours and the term can include those individuals who do or do not fulfil
all the criteria. Autism is categorised according to the presence of behaviour defined by DSM IV
Classifications and WHO ICH-10.
It is recognised that defining ASD is problematic and that boundaries are blurred between the
different identified groups [PDSNOS, Asperger Syndrome, high functioning autism (HFA), ASD],
and other developmental conditions, such as severe Developmental Attention Mental Perception
(DAMP) (Gillberg 1993). ASD and Asperger Syndrome do not show the same patterns of early
language delay and disorder and are linked to differing degrees to other cognitive and social
impairments. In individuals with ASD, HFA, and Asperger Syndrome, similar levels of
performance on the ‘Strange Stories Test’ have been observed. This has led to a general
agreement that Autistic Spectrum Disorder and Asperger’s Syndrome to be part of a continuum
rather than discrete conditions (Jolliffe & Baron-Cohen, 1999).
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Autistic Spectrum Disorders
Table 1: WHO ICH-10 – Autism
WHO ICH-10 – Autism
Autism Spectrum Disorder (ASD):
Individual needs to exhibit 8/16 features
Qualitative impairments in reciprocal social interaction (3/5 needed):
1. Failure adequately to use eye-to-eye gaze, facial expression, body posture and gesture
to regulate social interaction
2. Failure to develop peer relationships
3. Rarely seeking and using other people for comfort and affection at times of stress or
distress and/or offering comfort and affection to others when they are showing distress
or unhappiness
4. Lack of shared enjoyment in terms of vicarious pleasure in other peoples’ happiness
and/or spontaneous seeking to share their own enjoyment through joint involvement
with others
5. Lack of socio-emotional reciprocity
Qualitative impairments in communication:
1. Lack of social usage of whatever language skills are present
2. Impairment in make-believe and social imitative play
3. Poor synchrony and lack of reciprocity in conversational interchange
4. Poor flexibility in language expression and a relative lack of creativity and fantasy in
thought processes
5. Lack of emotional response to other peoples’ verbal and non-verbal overtures
6. Impaired use of variations in cadence or emphasis to reflect communicative modulation
7. Lack of accompanying gesture to provide emphasis or aid meaning in spoken
communication
Restricted, repetitive and stereotyped patterns of behaviour, interests and activities:
1. Encompassing preoccupation with stereotyped and restricted patterns of interest
2. Specific attachments to unusual objects
3. Apparently compulsive adherence to specific, non-functional routines or rituals
4. Stereotyped and repetitive motor mannerisms
5. Preoccupations with part-objects or non-functional elements of play material
6. Distress over changes in small, non-functional details of the environment
Autistic Savant:
Individual has exceptional abilities in one area of
performance e.g. mathematics, drawing, music
High-Functioning Autism (HFA):
Term given to those individuals who have normal
intelligence (IQ 70 or above) and who develop
language
Asperger’s Syndrome:
Qualitative deficiencies in reciprocal social
interaction and restricted, repetitive, stereotyped
patterns of behaviour, interests, and activities.
No general delay in language or cognitive
development, pedantic speech is common, may be
markedly clumsy
Pervasive developmental disorder Criteria for ASD or Asperger syndrome has not
not otherwise specified (PDDNOS):
been met but the child’s difficulties are
characteristic of those found within the spectrum of
autistic disorder
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3. How many people have Autistic Spectrum Disorder?
The heterogeneous nature of ASD has resulted in different sub-groups. As a consequence the
figures on incidence and prevalence show great variation relating to sub-group, age group and to
the size of the sample used, with small sample sizes generating higher numbers of incidence and
prevalence (Fomfonne, 2005). A study by Baird et al (2003) quoted that children with some form
of ASD constituted 1% of the child population in the UK. Increased screening and provision of
diagnostic centres have resulted in more individuals obtaining a diagnosis of ASD. Current
figures indicate a growth in incidence and prevalence figures which may be more related to
improved identification.
Table 2: incidence and prevalence of ASD
Incidence
Prevalence
7.1/10,000 Autism
20/10,000 All ASD (Williams et
al 2006)
Autism and learning disability –
296,872
HFA – 242,894
539,766 individuals with ASD
(Knapp and Romeo 2001,
2007)
1/100 in children (Autism
Society UK)
7,714/100,000 under 19yrs
ASD (SIGN 2007)
Autistic Savant: 10%
prevalence in ASD (1% in the
rest of the population) (WHO
ICD-10).
2.6/1000 live
births (Lingam
et al 2003)
8.3/10,000
children with
ASD Powell et
al (2007)
Country
Systematic
review of all
countries
UK
Gender
UK
Scotland
Autism male 3-4/1 female
Asperger’s male 8/1
female (WHO ICD-10)
UK
UK
24·8/10,000 ASD (Baird et al
2006)
1:160 between 6-12 yrs (Wray
& Williams 2007)
21.1/10,000 at 5 years (Honda
et al 1996, 2005)
1/165 (Fombonne 2003)
16.2/10,000 median
UK
Australia
Japan
Canada
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Incidence
Prevalence
36.4/10,000 all PDD
13/10,000 for autistic spectrum
disorder,
21/10,000 for PDDNOS,
2.6/10,000 for Asperger
Syndrome (Fombonne 2005)
Autism and learning disability –
296,872
HFA – 242,894 (Knapp and
Romeo 2007)
Country
6
Gender
UK
As shown, ASD can co-occur with other conditions, learning difficulty being the most common;
70% of individuals with ASD are estimated to have a learning difficulty.
The rate of ASD among siblings in a family, where one child already has ASD, is about 1 in 20.
Sometimes siblings may have language-related difficulties or delays, but not ASD (Ronald et al
2006, 2005; Dale et al 2003).
4. What causes Autistic Spectrum Disorder?
Research suggests that there is a combination of factors both genetic and environmental which
may account for changes in brain development. In some cases the disorders are associated
with, and presumably due to, some medical condition, of which infantile spasms, congenital
rubella, tuberous sclerosis, cerebral lipidosis, and the fragile X chromosome anomaly are among
the most common ( WHO ICH-10).
Recent studies using Magnetic Resonance Imagery (MRI), positron emission tomography scans
and magnetoencephalography have identified underconnectivity in the brain as a factor, with
thinning of the corpus callosum reducing connectivity mainly in the frontal areas and the fusiform
face area (Hughes, 2007). While a study by Melke et al (2008) indicated that a low melatonin
level resulted from ‘a primary deficit in ASMT activity’, it is considered to be a ‘risk factor’ for ASD.
Melatonin is considered to be an important factor in both cognition and behaviour.
There is evidence that complex genetic factors play a major role in aetiology (Wing & Porter
2003, Robinson 1999, Gillberg 2003, Baird et al 2003). However, Happe et al (2006) suggest
that, while each part of the ‘triad of impairment’ is heritable, each part makes its own individual
contribution.
.
There is an increased risk of related language, speech and developmental problems in families
with an autistic child (Ronald et al 2006, 2005; Dale et al 2003).
5. How does Autistic Spectrum Disorder affect individuals?
ASD affects the way an individual understands their world, communicates with, and relates to
people around them. Wing (1989a, 1989b) described the ‘triad of impairment’ as encompassing
difficulties in social interaction, communication and imagination.
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Whilst individuals with ASD can have all levels of cognitive and intellectual ability, there is a
significant learning disability in some three-quarters of cases (WHO ICH 10). A study by Rapin
(1997) reported that a third of those diagnosed with ASD do not develop any useful language
while those with High Functioning Autism (HFA) or Asperger’s Syndrome acquire language but
have social communication difficulties.
Usually language skills (both verbal and non-verbal) are affected in infancy and have been
consistently reported to be the best predictor of later outcomes, including the ability to adapt,
school achievement, and independence as an adult (Dworzynski et al. 2007, Howlin 2002,
Szatmari 2003). A study by Dworzynski et al (2003) found that lower language performance,
seen in poor expressive vocabulary, at two years was a predictor of later development of higher
autistic type traits by eight years in communication, social interaction and life skills.
Semantic and pragmatic difficulties affect the individual’s ability to interpret subtle messages and
emotions which are communicated by facial expression and body language and are key factors in
the individual’s ability to effectively engage in social interactions. Gillberg (1993) observed that
putting emotions into a cognitive perspective was problematic for individuals on the autistic
spectrum and, while they had the ability to recognise strong emotions (happy, sad, fear, anger),
comprehending the emotions of others was difficult, as were subtle emotional concepts e.g.
compassion and empathy. Prosodic difficulties in both expression and reception can result in
lifelong additional social and communication barriers (McCann et al 2007).
Social interaction is affected by the individual’s desire to interact with others. In ASD this can
vary from no interaction, through extreme remoteness, passivity, to interaction with others which
can lack understanding of appropriate social participation and awareness, and inappropriate
social interaction (RCSLT Clinical Guidelines 2005). In particular, individuals with Asperger
Syndrome may be highly motivated to interact with others and be socially accepted by their peer
groups but lack the appropriate social communication skills and awareness to successfully
integrate.
Other conditions are sometimes associated with ASD. These may include attention deficit
hyperactivity disorder (ADHD), attention, motor control and perception (DAMP), epilepsy, learning
difficulties such as dyslexia (reading/writing problems) and dyspraxia (speech motor planning),
and feeding difficulties. Individuals may also present with semantic-pragmatic (understanding
meaning) difficulties affecting their ability to process information, especially verbal information,
and delays with responding.
Heightened sensitivity to sounds, textures, foods, and light affects the ability to interact in social
settings and impacts on all aspects of everyday life and ability to work in certain environments.
As ASD and atypical autism are lifelong conditions, an individual’s behaviours need to be
continually assessed throughout their life, especially at transition points between pre-school,
primary and secondary school transitions and out into life (Scottish Intercollegiate Guidelines
Network (SIGN) 2007, National Service Framework for Children, Every Child Matters 2003,
Children Act 2004, National Service Framework for Children 2005). The transition phase from
child to adult life necessitates good communications between different agencies which includes
school, local authority, local Connexions service and social services. Consideration needs to be
given to effect of HFA and Asperger’s Syndrome in adulthood in relation to further and higher
education, employment and personal relationships (e.g. marriage breakdown). There can be
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difficulties in accessing help or services because of not meeting the criteria for help from adult
learning disabilities or mental health teams (All-Party Parliamentary Group on Autism Survey
2003).
The care required throughout the life of the individual has funding implications. It has been
estimated that the direct and indirect lifetime costs for individuals with ASD are £28 billion per
annum as an aggregate cost for children and adults across
the spectrum in the UK, the majority of this funding being focused on intervention, child and day
care (Knapp and Romeo, 2007). At present, clients with ASD do not ‘fit’ into a clear care pathway
so they do not always access the services they need until a crisis has arisen.
Table 3: International Classification of Functioning: Dimensions and impact of ASD
ICF
Dimension
Impairment
Impact
Impaired communication and cognition affecting:
Receptive and expressive language including pragmatic abilities, verbal
and non-verbal language, prosody, relevance, selecting salient points and
a literal understanding of language
ˆ Cognitive difficulties in developing theory of mind, putting emotions into a
cognitive perspective in understanding or interpreting other peoples
thoughts, feelings or actions, imagining alternative outcomes to situations,
predicting what will happen next, in recognising or understanding other
people's emotions and feelings
ˆ Working Memory
ˆ Visuospatial abilities
ˆ Coordination for motor skills
ˆ Sensory sensitivity senses, hypersensitive/ hyposensitive (e.g. sensitivity
to sound, textures, foods)
Performance ability and behaviours are on a continuum of difficulty involving:
ˆ
Limited social use of language to communicate with others
ˆ
Use or understanding of facial expressions or tone of voice, jokes and
sarcasm, common phrases and sayings, subtle messages put across by
facial expression and body language
ˆ
Use of appropriate social behaviour in social situations
ˆ
Use of imagination to make inferences or be creative, activities can be
rigid and repetitive finding change hard to cope with
ˆ
Use of others as a tool to get wants or needs, hand leading or using
another's body to communicate rather than point
ˆ
Excessive mouthing of objects, fixation or obsessions on objects or how
things work
ˆ
Reacting physically to change, sensory overload, or upset by rocking,
hitting self or others
ˆ
Aversions to social touch, poor non-social visual orientation/ attention
ˆ
Unusual mannerisms involving the hands and/or fingers
ˆ
Difficulty in coping with unstructured spaces
ˆ
Difficulty in coping with unstructured situations
ˆ
Feeding, eating certain foods, coping with textures and consistencies
Social communication, interaction and imagination difficulties impacts on
ˆ
Activity
Participation
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ICF
Dimension
Well-being
9
Impact
ability to:
ˆ Function appropriately in social settings
ˆ Form friendships because of difficulties in interacting with other people
and ability to work with others cooperatively
ˆ Be autonomous in life, may need life-long support
ˆ May need to withdraw from social situations to cope with emotions.
ˆ Behaviour appropriately to the situation
ˆ Cope with changing environments
ˆ Anger, anxiety, frustration and mental anguish may result from coping
with, and understanding, other people and their environment
ˆ Depression, low self-esteem, low self-confidence
6. What are the aims/objectives of SLT interventions for Autistic Spectrum Disorder?
The SLT forms part of the diagnostic team. The SLT will aim to work closely with individuals,
their family and caregivers to assess (RCSLT Clinical Guidelines, 2005):
‰
‰
‰
‰
‰
Behaviours
Identify comorbidities
Areas of need related to the triad of social impairments
Executive functioning deficits, motivation, memory and central coherence
Sensory sensitivity and integration, intersubjectivity
SLTs work to develop communication, social interaction and life skills (Bartlett et al, 2005). Any
intervention will take into account age, specific ASD difficulties, learning ability/disability and the
individual’s own personality, strengths and weaknesses (Jones, 2002). Management of
communication needs is considered in the context of a social model of disability. Due to the
social and emotional nature of presenting difficulties and the effect of ASD on all aspects of the
individual’s and family’s life, input is often best undertaken in a multi-disciplinary setting and with
particular support from a psychological service.
There are issues around control of the environment in individuals with ASD. There is a need to
consider their need for routine with a dislike of change, hypersensitivity to noise or textures,
dislike of close proximity to others, need for rituals and other behaviours that impact on their
everyday life. These needs have implications for learning and learning environments and later on
the working environment for adults.
As required by the needs of the individual, the SLT will identify and aim to facilitate the
development of communication in both children and adults.
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Table 4: International Classification of Functioning: Dimensions and aims and objectives for ASD
ICF Dimension
Impairment
‰
‰
‰
‰
‰
‰
‰
Activity
‰
‰
‰
‰
‰
‰
‰
‰
‰
‰
Participation
‰
‰
‰
‰
‰
Well-being
‰
‰
‰
‰
Develop
speech and language abilities
semantic and pragmatic skills
shared attention
understanding of emotions
understanding of relevance
theory of mind
executive functioning – organisational factors for handling and
processing information
communication skills
turn taking
shift in attention
strategies to cope with change
strategies to reduce inappropriate behaviours
use of assistive and augmentative communication
strategies to assist understanding of environment
strategies to cope with work and work environment
strategies to develop life skills
social interactional skills
ability to integrate socially with others
ability to behave appropriately in social settings
self-esteem as a communicator
autonomy
ability to work and interact appropriately with others
strategies for coping with emotions arising from different interactions
strategies to cope with mood changes
strategies to reduce anxiety
strategies to promote emotional well-being
Approaches to intervention encapsulate different theories of underlying difficulties (Heflin &
Simpson 1998, The National Autistic Society webpage 06022009).
1. Relationship-based - facilitating attachment, affect, or relatedness
2. Skill-based - facilitating development of specific skills through differing strategies, such as
Picture Exchange Communication System (PECS), social stories, discreet trial learning,
Treatment and Education of Autistic and Related Communication Handicapped Children
(TEACCH www.teacch.com)
3. Physiologically oriented - facilitating changes in brain processes through sensory and auditory
integration, psychopharmacological treatments and dietary alterations
The SLT will have a clear role in educating/training broadly across a wide range of settings in
mainstream arenas so that ‘reasonable adjustments’ are made to enable people with HFA/AS to
function and integrate.
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7. What is the management for Autistic Spectrum Disorder?
The management of ASD involves multidisciplinary and multi-agency teams (SIGN 2007, NRC
2001). Provision of care is across health, social services, education and the voluntary and
independent sectors for both children and adults with ASD. Speech and language therapists
work as an enabler at each life stage in identifying areas of need and supporting individuals, their
families and carers. This includes assessing and supporting changes in environments to
accommodate the needs of the adult and the child.
Table 5: SLT as a member of different teams may include the following:
Age Group
0 - 2 years
3 – 4 years
5 and 18 years
19 years upwards
Teams
Family/carers, Health Visitor and Health Team and the specialist Child
and Adolescent Mental Health Services (CAMHs) team who include child
psychology, child psychiatry, clinical psychology, paediatrician,
occupational & physical therapy, audiology, Social Services team,
voluntary and independent sectors
Family/carers, Nursery Staff, Health Team and Child and Adolescent
Mental Health Services and the Education Team (includes teachers,
educational psychologist, specialist teachers), Social Services team,
voluntary and independent sectors
Family/carers, Education Team, Health Team and specialist Child and
Adolescent Mental Health Services, Social Services team, local authority,
voluntary and independent sectors
Family & carers
Holistic care involves a wide range of statutory organisations, specialist
support services within organisations and social groups such as:
‰
Parenting supports
‰
Higher Education providers
‰
Joint Learning Disability/Mental Health Teams
‰
Specialist dedicated services
‰
Social Services teams
‰
Local Authority – e.g. specialist residential, education
‰
Specialist employment services
‰
Voluntary and independent sectors
‰
Police and probation services
‰
Criminal justice system
‰
Forensic and secure services
‰
Employers and business/commerce
‰
Ethnic and faith groups
‰
Relationship guidance
Parents and caregivers are involved from the beginning and are key to the management so they
can be supported and have the opportunity to acquire skills and strategies for managing children
and adults with ASD. Specialist programmes may be devised targeting areas of need. Social
Stories have been shown to be an effective approach for improving social skills and
understanding appropriate behaviour (Quirmbach et al, 2008). SLTs can provide support for the
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National Autistic Society ‘Early Bird Help’ project and the Hanen project ‘More than Words’.
These provide group training and individual home visits to educate, train and support the primary
care givers. (RCSLT Clinical Guidelines 2005, Division TEACCH, www.teacch.com,)
As part of a multidisciplinary team, SLTs are part of the diagnostic team and contribute to
comprehensive programmes for children and adults through direct or indirect methods to
ameliorate and affect changes in the behaviours of individuals with ASD. Individuals with
Asperger’s Syndrome may not be diagnosed early in life and may not get a diagnosis until
adulthood. Adults, particularly those with higher functioning autism and Asperger’s syndrome,
can find it hard to access speech and language therapy services. These individuals have specific
needs at times and need support at different periods so open access to SLT and other support
services is important (Ignored or Ineligible- National Autistic Society, 2002).
The policy of inclusion of children with ASD in mainstream schools has had an impact for
individuals with ASD, teachers and fellow pupils. While some children cope with good support,
studies have found that social isolation, loneliness and bullying are commonplace for pupils with
ASD who attend mainstream schools (Connors, 2000). A recent survey reported 40% complained
of bullying (Corbett & Perepa, 2007). In addition, there is a high incidence of exclusion; 20% was
reported in Corbett & Perepa’s survey (2007). SLTs work with the individual and those in their
communicative environment to facilitate social communication, interaction, learning and
emotional coping strategies. The main interventions reported for education in the UK are
‘Treatment and Education of Autistic and Related Communication Handicapped Children’
(Division TEACCH, www.teacch.com ), ‘Early Intensive Behavioural Intervention’ (EIBI) and
‘Applied Behavioural Analysis’ (Humphrey & Parkinson, 2006).
The communication difficulties and problems of social interaction encountered in childhood can
continue into adulthood and vulnerable individuals need care and support to cope in society.
There is recognition that a holistic approach to care is needed by all involved in care and a move
to Person Centred Planning (PCP) is being adopted in the UK with the aim of bringing choice and
control for the individual in their daily life. Through tools such as Planning Alternative Tomorrows
and Hope (PATH), Magil Action Planning (MAP) and Circle of Friends (CoF), the individual’s
aspirations are identified and action taken to best meet their needs by working across all health,
education and social boundaries. A Total Communication (TC) model has been used in child and
adult services to promote effective communication in a social setting (Goldstein, 2002).
The speech and language therapist will be working as part of multidisciplinary team, including
people from health, social, education and voluntary organisations. They will also be including
within the management process the individual’s family members and others in their
communication environment. There are time implications for the education and training that
SLT’s provide to other professionals and family members. Working as part of a multidisciplinary
team necessitates taking on team roles and attending meetings which also have time
implications.
Augmentative and Alternative Communication
Augmentative and Alternative Communication (AAC) refers to any system of communication that
is used to supplement or replace speech, to help people with communication impairments to
communicate. It covers a range of high technology and low technology systems, including those
involving no equipment, such as eye pointing, to high tech voice output communication aids. In
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ASD, a number of different AAC approaches are used. One system is the Picture Exchange
Communication Card System (PECS), which has been used in facilitating communication with
some effect when the approach is supported by ongoing SLT training (Howlin et al, 2007). Sign
language, interactive communication boards, communication cue cards, conversation books, and
voice output communication aids have all been used with people with ASD.
Cultural diversity
Individuals with ASD who have English as a second language may need help to access services
and, once seen, it will be important to ascertain a full speech and language profile. An interpreter
may be required to conduct the SLT assessment to ensure it is both accurate and reliable and to
facilitate understanding of therapy and implementation of treatment strategies. There are time
and cost implications when working with interpreters/co-workers; for example, in taking a case
history and completing a full assessment in all languages spoken by the child and family.
Timings of services need to be culturally sensitive; for example, not offering appointment times
which coincide with religious observations (Communicating Quality 3).
Those who come from black and minority ethnic (BME) communities may experience
discrimination in terms of their ethnicity (Corbett & Perepa, 2007). Ability to function can be
exacerbated by second language issues along with the communication difficulties arising from
ASD.
8. What is the evidence for SLT interventions for Autistic Spectrum Disorder?
All of these studies consider speech and language interventions to develop or improve language
and communication skills in individuals with autism. The studies investigate different speech and
language interventions for predominantly young children with autism. One study investigates
older children aged 7-12 years and another investigates teenagers and young adults aged 17-25
years.
Details of the studies
All of the studies were published in English from 1988-2008. Ten of the studies were conducted
in the USA, two in the UK, one in Australia, one in Singapore and one in Netherlands. Two
studies were systematic reviews and synthesised results from studies worldwide. The number of
children who took part in the studies ranged from 4 to 61. The studies cover a range of
interventions and associated factors including timing of the intervention, computer-based
interventions, acceptability of treatment, and delivery of intervention.
Study quality
The quality of the 20 studies was mainly good. The two systematic reviews were of good quality.
The three randomised controlled trials (RCTs) of the studies were of good/excellent quality. The
controlled clinical trial was of good quality. The case series, comparison, retrospective, and
longitudinal studies were of fair quality. The results from these studies should be interpreted with
caution due to the limitations of all clinical trials, i.e. lack of randomisation introducing bias.
Additionally, many of these studies only investigated small samples, which limits their
generalisability.
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It is worth noting that the findings from the non-UK papers need to be interpreted cautiously due
to generalisability of findings to the UK population.
It is also worth noting that the findings from the older papers need to be interpreted cautiously as
these findings may not be applicable to the current situation.
Consideration of Speech Language Therapy interventions
The studies examined a range of components of speech and language therapy intervention and
their effect on language and communication outcomes. These included early interventions,
behavioural interventions, who to deliver interventions and computer-based interventions.
Early interventions
Eight of the studies can be classed as early interventions aimed at preschool children. All of the
interventions aimed to increase and improve children’s language. The studies investigated a
variety of different speech and language interventions to improve communication and language
skills in autistic preschool children. Additionally, one longitudinal study considers the
developmental outcomes of children diagnosed with autism at age 2-3 years, at age 9.
One good RCT conducted in the USA compared the impact of joint attention (JA) and symbolic
play (SP) interventions on 58 preschool autistic children (Earlier Kasari study). The longer-term
impact 12 months after the intervention was presented in a further paper (Kasari et al, 2008).
Expressive language gains were greater in the JA and SP groups than in the comparison group.
For the children that started the intervention with the lowest language levels, the joint attention
intervention improved their language outcomes significantly more than the symbolic play
intervention. The findings from this study suggest that joint attention and symbolic play
intervention can produce expressive language gains in autistic children. The study further
suggests that implementing intervention based on a child’s initial language skills could be
beneficial.
The other early intervention RCT was also set in the USA and compared the effect of two
communication interventions aimed at 36 preschoolers with ASD (Yoder & Stone 2006a;Yoder &
Stone 2006b). The two interventions were responsive education and prelinguistic milieu training
[RPMT] and the picture exchange communication systems [PECS]. Both treatments were
delivered in 20-minutes sessions, three times a week for six months. The RPMT intervention
facilitated the children’s frequency of generalised turn taking and generalised initiating joint
attention more than the PECS intervention. Increases in joint attention only occurred for children
who had at least some initiating joint attention before the study. Contrastingly, the PECS
facilitated children’s generalised requests more than the RPMT for children with very little
initiating joint attention before the treatment. Additionally, PECS was more successful than RPMT
in increasing the number of different non-imitative spoken communication acts and the number of
different non-imitative words used at the post-treatment period. The study findings suggest that
both of the interventions can have a beneficial effect on the communication of autistic children.
The findings further suggest that the intervention effect could be dependent on a child’s initial
skills.
One good controlled clinical trial in the USA compared the effects of three treatments for 61
preschool children with ASD (Howard et al, 2005). The children were assigned to treatments
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groups according to their parents’ preference. Twenty-nine children in the intensive behaviour
analytic intervention group received 25-40 hours per week of treatment on a 1:1 adult:child ratio.
Sixteen children received an intensive ‘eclectic’ intervention which used a combination of
methods for 30 hours per week in 1:1 or 1:2 adult::child ratio. Another group of 16 children
attended a non-intensive early intervention programme which consisted of a combination of
methods for 15 hours per week in small groups. At follow-up the behaviour group had higher
mean standard scores in all skills than the other two groups. The differences for all skills were
statistically significant apart from for motor skills. At follow-up learning rates were also
considerably higher in the behaviour group than the other groups. There were no significant
differences between the mean scores of the eclectic and small groups group.
A UK study compared two early intervention programmes: the LUFAP and the ABA (Farrell,
Trigonaki, & Webster, 2005). LUFAP was developed by Lancashire LEA and used a combination
of delivery styles in particular Applied Behavioural Techniques and the TEACCH. The
intervention was delivered to eight children in a mainstream school environment by Special
Support Assistants supported by teachers and educational psychologists. The ABA programme
was an intensive home-based programme based on the work of Oliver Lovaas. Nine children
received a minimum of 30 hours of 1-to-1 support per week from as many as 5 therapists. Both
groups made considerable progress on all measures indicating that both programmes were
successful in helping the children to develop. All of the children though were still well below their
chronological age and would require support throughout school. It was not possible to make any
definite judgement about which programme was more successful as the ABA programme had
started before the LUFAP and data for each child was collected at different times. When an
average month’s progress on socialisation, daily living skills and communication were calculated
the averages were all higher for the LUFAP group. Interestingly, the ABA children had lower
scores on socialisation which was a possible consequence of the home-based nature of the
approach. Although the findings from this comparison study should be treated with caution they
do demonstrate that autistic children who receive early intervention can make progress.
Another UK intervention for 10 preschool children aged 2-3 years focused on developing the
pragmatics of language (Chandler et al. 2002). The intervention consisted of an individualised
programme of home visits, modelling workshops and written information and lasted 18 months.
Parents delivered the intervention in partnership with the therapist. After just six months parents
noticed improvements in their children’s expressive communication, and within 18 months all of
the children had made substantial progress in social interaction and expressive communication.
The findings from the small study suggest the possible benefits for autistic children of an
individualised programme.
A small case series conducted in the USA investigated the effects of facilitating parents to use
teaching strategies within their child’s daily routines (Kashinath et al, 2006). Parents were taught
to include two teaching strategies to target routines to address their child’s communication aims.
All of the parents were able to learn and use the teaching strategies competently and were able
to generalise the strategies across their child’s routines. The intervention had positive effects on
the communication outcomes of each child and the parents perceived the introduction of the
teaching strategies as beneficial to their children’s communication.
Another case series based in the USA investigated the effects of a voice output communication
aid (VOCA) and naturalistic teaching strategies on four children age 3-5 years with severe autism
(Schepis et al, 1998). Teaching strategies provided opportunities for VOCA use within normal
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classroom routines. All children showed increases in communicative interaction using VOCA’s as
the strategies were implemented. This small case series indicates that VOCA’s could potentially
be useful for children with autism.
One retrospective study considered the results from a larger RCT for a population subset of
autistic children (Hancock & Kaiser 2002). The RCT investigated whether the enhanced milieu
training (EMT) caused changes in children’s language and, secondly and more importantly, if the
changes were then generalised to interaction with their parents. The population subset was four
autistic children and their mothers. During the intervention, which lasted 24 weeks, parents
brought their children to the clinic twice each week, and then once each month during the six
month follow-up period. All children showed positive increases for specific target language use at
the end of 24 intervention sessions, and results were maintained through the six month follow-up
observations. Generalisation to home setting was observed for three of the four children, with the
greatest changes occurring immediately after the intervention than at the six month follow up.
A longitudinal study based in the USA investigated the development outcomes of children with
autism from age 2 to age 9 to assess the impact of early identification of autism (Turner et al.
2006). At age 9, 88% of the sample still obtained a diagnosis of ASD. The majority of the
children’s cognitive scores improved significantly with more than 50% having scores in the
average range at follow-up. Language outcomes were also encouraging at follow-up, with 88% of
the sample demonstrating some functional language and 32% being able to engage in
conversation. Predicted outcome status was from the following early characteristics: age of
diagnosis, age 2 cognitive and language scores, and total hours of speech and language therapy
between ages 2 and 3. The findings from this longitudinal study investigating 25 children
demonstrate the importance of both early identification and early intervention for autistic children
for their long-term developmental outcomes.
These studies together demonstrate that early interventions can be beneficial for autistic children.
Behavioural language interventions
Six of the studies considered behavioural language interventions. The most common
interventions considered were discrete trial/structured, sign language and normalised/milieu
behavioural language interventions.
A systematic review reviewed the comparative effects of structured training with normalised
methods for improving language and communication skills in children with autism (Delprato,
2001). The review included 10 experimental studies investigating 63 young children aged 3-8
years. In the eight studies that investigated a language outcome, all found that normalised
language training was more effective than discrete-trial training. The studies reviewed were small
case series or comparison studies but the combined results suggest that further research into
normalised interventions is justified.
Another systematic review considered the benefits of speech and language interventions for
individuals with autism (Goldstein 2002). The review considered any communication treatment for
autistic children aimed at improving their language; particularly interventions that involved sign
language, discrete-trial training and milieu training. The review concluded that there is substantial
evidence available to assert that effective interventions do exist that can teach communication
skills to autistic children. Most of the studies in the review investigated only a small number of
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children, but still nearly all interventions did improve the communication skills of the autistic
children. The studies reviewed suggest that autistic children with some language and
communication skills could benefit quickly from many of the approaches. Non-verbal children
need more precise programming and will generally progress more slowly.
A good quality RCT in the USA, from 1988, investigated whether comprehension, production, and
spontaneous use of language were greater, in 60 children with moderate to severe autism,
following language training by sign-alone, speech-alone, simultaneous communication or
alternating between speech and sign (Layton 1988; Yoder & Layton 1988). Children received 90
individual 40-minute daily sessions. When analysing the results the children were divided into
high- and low-verbal imitators based on their initial verbal imitation performances. The high-verbal
imitators did equally well in all four conditions and, as expected, performed better than the lowverbal imitators in all of the conditions. The low-verbal imitators performed equally well in all
conditions apart from speech-alone condition on which they did the poorest. Children retained the
word or signs that they learnt for three months after the treatment, regardless of their treatment
group and their initial verbal imitation performance. The findings from this study indicate that a
child’s initial communication assessment could be beneficially used to select the most appropriate
intervention for them.
One retrospective study considered the results from a larger RCT for a population subset of
autistic children (Hancock & Kaiser 2002). The RCT was investigating whether enhanced milieu
training (EMT) caused changes in children’s language and, secondly, if the changes were then
generalised to interaction with their parents. EMT is a hybrid approach to naturalistic early
language interventions and incorporates aspects of both behavioural and social interactionist
approaches to language interventions. During the intervention, which lasted 24 weeks, parents
brought their children to the clinic twice each week, and then once each month during the six
month follow-up period. Observational data indicated that all children showed positive increases
for specific target language use at the end of 24 intervention sessions, and results were
maintained through the six month follow-up observations. Generalisation to home setting was
observed for three of the four children, with the greatest changes occurring immediately after the
intervention than at the six month follow up.
One case series set in the Netherlands considered the impact of small-group training on
question-asking skills in adolescents with ASD (Palmen, Didden & Arts, 2008). Nine students
received weekly sessions from a trainer of verbal feedback, role-play during short conversations,
a table game, and a self-management strategy, for six weeks. The amount of correct questions
during tutorials with their personal coaches increased following the training. The students and
their personal coaches found the training effective and acceptable.
Another case series based in the USA investigated the effects of a voice output communication
aid (VOCA) and naturalistic teaching strategies on four children age 3-5 years with severe
autism. Teaching strategies provided opportunities for VOCA use within normal classroom
routines. All children showed increases in communicative interaction using VOCA’s.
The findings from these studies suggest the behaviour interventions can be useful in developing
the communication skills of autistic children. Naturalistic training is generally more effective than
discrete-trial training.
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Computer Interventions
Two case series studies investigated computer interventions for children with autism (BernardOpitz, Sriram & Sapuan 1999; Bosseler & Massaro 2003). One investigated children aged 3-7
years in Singapore and the other investigated children aged 7-years in the USA.
The first case series (Bernard-Opitz, Sriram & Sapuan, 1999) investigated the comparative
effects of computer assisted interaction with traditional play interaction on the vocal imitation of
10 autistic children aged 3-7 years in Singapore. The children’s parents delivered the intervention
with the trainer. Each child received 10 sessions, twice a week. In the computer and personal
instruction,s the trainers and parents modelled the sounds while the child then tried to imitate.
The Speech Viewer used in the computer instruction provided interesting visual reinforcement
when children produced the correct sounds. Participants demonstrated significantly greater vocal
imitations in the computer assisted instruction condition, compared with the personal instruction
condition. This trend was present in 9 out of 10 children and the effects were consistent across
both parent and trainer. Overall, the enhancement of sound through visual feedback using the
SpeechViewer seems promising for the non-verbal autistic population.
The other case series investigated computer assisted instruction for children aged 7-12 years in
the USA (Bosseler & Massaro, 2003). The study consisted of two experiments involving eight and
then six children. The first experiment tested whether autistic children could learn vocabulary and
language from Baldi, a computer-animated tutor in a Language Wizard/Player and their reactions
to Baldi. All children learned a significant number of new words and grammar and seven of the
children appeared to enjoy working with Baldi. One child disliked working with Baldi and at his
parents request was withdrawn from the experiment. The computer intervention in this study was
generally acceptable to autistic children aged 7-12 years. The second experiment investigated
just six of the eight children and investigated whether Baldi was responsible for the learning and if
the learning could be generalised to interaction with a tutor. All students showed an increase in
identification accuracy once training was implemented and demonstrated generalisation of
learned vocabulary to new instances of vocabulary item, either immediately or after a few
treatment sessions. This study demonstrates that the children could learn language and
vocabulary from a computer-animated tutor and then generalise their knowledge from the
computer program to an independent assessment by an instructor. The study did not consider
whether the children could use the new vocabulary in spontaneous speech though. Findings from
this small case series suggest that autistic children can learn new language and vocabulary from
a computer-animated tutor and that this method of instruction is generally acceptable to autistic
children.
Both of these studies demonstrate that computer instruction could be useful for autistic children
and that this method of instruction is generally acceptable to the population.
Teacher implemented intervention
Three of the studies were delivered by teachers solely or as part of a larger team.
One case series based in Australia investigated a teacher implemented intervention for four
children (Keen, Sigafoos & Woodyatt, 2001). The intervention was individualised for each child
and teachers sought to replace communication behaviours that were unclear or inappropriate;
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opportunities occurred naturally as part of the classroom routine. The results suggest that the
intervention package delivered by teachers was effective in replacing prelinguistic behaviour with
alternative forms of functional communication.
Another case series based in the USA investigated the effects of a voice output communication
aid (VOCA) and naturalistic teaching strategies on 4 children age 3-5 years with severe autism
(Schepis et al, 1998). The intervention was delivered by a teacher and three assistants who were
taught to use the teaching strategies to provide opportunities for VOCA use within normal
classroom routines. All children showed increases in communicative interaction using VOCA’s as
the strategies were implemented. The results from this study suggest that teachers with the help
of assistants can implement interventions in the classroom with autistic children.
A UK case series compared two early intervention programmes delivered by teams, one involving
teachers (Farrell, Trigonaki & Webster, 2005). The staff responsible for the day-to-day running of
LUFAP were the project teacher, Special Support Assistants (SSAs) and a speech and language
therapist. Each child had a full-time Special Support Assistants who undertook most of the work
with the children. The programme was delivered under the direction of the project teacher and in
collaboration with parents. The ABA team consisted of the children’s parents, lead therapist, team
of therapists, trained ABA supervisors from the UK and ABA consultants from the USA. Both
groups made considerable progress on all measures. When an average month’s progress on
socialisation, daily living skills and communication were calculated, the averages were all higher
for the LUFAP group. The rate of progress in communication for children receiving LUFAP was
considerably higher than for the children who received ABA. Interestingly, the ABA children had
lower scores on socialisation which was a possible consequence of the home-based nature of the
approach.
The three small case series studies demonstrate that teachers could be effective in delivering
interventions to autistic children solely or as part of a wider team.
Involving parents as therapists
Five of the studies involved the autistic child’s parents as therapists.
A UK study compared two early intervention programmes delivered by teams, both involving
parents (Farrell, Trigonaki & Webster, 2005). LUFAP was delivered under the direction of the
project teacher and in collaboration with parents. The ABA team consisted of children’s parents,
team of therapists, trained ABA supervisors and consultants. Both groups made considerable
progress on all measures indicating that both programmes were successful in helping the
children to develop.
One UK intervention for 10 preschool children, aged 2-3 years, consisted of an individualised
programme of home visits, modelling workshops and written information delivered by parents and
therapists in partnership (Chandler et al, 2002). After just six months of the intervention, parents
noticed improvements in their children’s expressive communication and within 18 months all of
the children made substantial progress in social interaction and expressive communication.
Importantly, during the intervention parents also developed their confidence in dealing with their
children.
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An intervention comparing computer-assisted and personal instruction was delivered by parents
and trainers (Bernard-Opitz, Sriram & Sapuan, 1999). Participants showed significantly greater
vocal imitations in the computer-assisted instruction condition, compared with the personal
instruction condition, and the effects were consistent across both parent and trainer.
A small case series set in the USA investigated the effects of facilitating parents to use teaching
strategies within their children’s daily routines (Kashinath et al. 2006). All of the parents were able
to learn and use the teaching strategies competently and were able to generalise the strategies
across their child’s routines. The intervention had positive effects on the communication
outcomes of each child and the parents perceived the introduction of the teaching strategies as
beneficial to their children’s communication.
One retrospective analysis in the USA investigated the impact on children’s verbal
communication following training from their fathers at home (Seung et al, 2006). After the training
there was a decrease in the ratio of parent to child utterances and an increase in the use of
imitation by the parents and the number of single words and different words produced by the
children.
Together these small studies suggest that parents can work effectively with therapists or by
themselves to improve the language and communication outcomes of their autistic children.
Acceptability of treatment
A number of the studies considered the acceptability of the intervention to the autistic individual
and, for younger children, the child’s parents.
Children aged 7 -12 years in the computer instruction intervention generally enjoyed working with
Baldi, a computer animated tutor (Bosseler & Massaro, 2003). Another case series considered
the acceptability of small-group training to adolescents with ASD (Palmen, Didden & Arts, 2008).
The students found the training effective and acceptable.
Studies considering the acceptability of the treatment to parents of children with autism generally
found parents to very positive. A case series computer intervention found that mothers found the
sessions helpful and would recommend them to other parents with autistic children (BernardOpitz, Sriram & Sapuan,1999). A retrospective study on EMT found that parents’ rating of their
satisfaction with the training were very positive. The only aspect that parents were not completely
satisfied with was the time requirement involved in the training, with parents wanting more
sessions for longer time periods. A small case series facilitated parents to use teaching strategies
within their children’s daily routines (Kashinath et al, 2006). This intervention had positive effects
on the communication outcomes of each child and the parents perceived the introduction of the
teaching strategies as beneficial to their children’s communication.
Summary
The studies demonstrate that there are a variety of different approaches that can improve
language and communication skills in individuals with ASD. A number of the studies provide
evidence that interventions for preschool children can achieve good results. Consideration needs
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to be given to who delivers the intervention. A number of studies suggest that parents can
usefully be involved in delivering interventions. Interventions that involve teachers in the delivery
also seemed promising. Interventions delivered by teachers in a school environment could
possibly help to develop children’s socialisation more than interventions delivered in the child’s
home. Additionally, there is some evidence to indicate that introducing interventions as part of a
child’s daily routine can be effective. Computer-based interventions appeared promising for
children with autism especially as they provide the predictability and patience autistic individuals
require. Many of the programmes were individualised for each child, indicating the differences
between children with a diagnosis of autism. A few of the studies found that interventions were
more effective for children that start the study with some speech than for non-verbal children.
Further research is required to identify which interventions are most effective for autistic children
with different abilities.
References
Bernard-Opitz, V., Sriram, N., & Sapuan, S. 1999. Enhancing Vocal Imitations in Children with
Autism using the IBM SpeechViewer, Autism, 3, 2, 131-147.
Bosseler, A. & Massaro, D. W. 2003. Development and Evaluation of a Computer-Animated Tutor
for Vocabulary and Language Learning in Children with Autism, Journal of Autism and
Developmental Disorders, 33, 6, 653-672.
Chandler, S., Christie, P., Newson, E., & Prevezer, W. 2002. "Developing a Diagnostic and
Intervention Package for 2- to 3-Year-Olds with Autism: Outcomes of the Frameworks for
Communication Approach", Autism, 6, 1, 47-69.
Delprato, D. 2001. Comparisons of discrete-trial and normalized behavioral language intervention
for young children with autism, Journal of Autism & Developmental Disorders, 31, 3, 315-325.
Farrell, P., Trigonaki, N., & Webster, D. 2005. An exploratory evaluation of two early intervention
programmes for young children with autism, Educational and Child Psychology, 22, 4, 29-40.
Goldstein, H. 2002. "Communication Intervention for Children with Autism: A Review of
Treatment Efficacy", Journal of Autism and Developmental Disorders, 32, 5, 373-396.
Hancock, T. B. & Kaiser, A. P. 2002. The Effects of Trainer-Implemented Enhanced Milieu
Teaching on the Social Communication of Children with Autism, Topics in Early Childhood
Special Education, 22, 1, 39-54.
Howard, J. S., Sparkman, C. R., Cohen, H. G., Green, G., Stanislaw, H., Howard, J. S.,
Sparkman, C. R., Cohen, H. G., Green, G., & Stanislaw, H. 2005. A comparison of intensive
behavior analytic and eclectic treatments for young children with autism, Research in
Developmental Disabilities, 26, 4, 359-383.
Kasari, C., Freeman, S., & Paparella, T. 2006. Joint attention and symbolic play in young children
with autism: a randomized controlled intervention study, Journal of Child Psychology and
Psychiatry, 47, 6, 611-620.
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Kasari, C., Paparella, T., Freeman, S., & Jahromi, L. 2008. Language outcome in autism:
randomized comparison of joint attention and play interventions, Journal of Consulting & Clinical
Psychology, 76, 1, 125-137.
Kashinath, S., Woods, J., Goldstein, H., Kashinath, S., Woods, J., & Goldstein, H. 2006.
Enhancing generalized teaching strategy use in daily routines by parents of children with autism,
Journal of Speech Language & Hearing Research, 49, 3, 466-485.
Keen, D., Sigafoos, J., & Woodyatt, G. 2001. Replacing prelinguistic behaviors with functional
communication, Journal of Autism & Developmental Disorders, 31,4, 385-398.
Layton, T. L. 1988. Language training with autistic children using four different modes of
presentation, Journal of Communication Disorders, 21, 4, 333-350.
Palmen, A., Didden, R., & Arts, M. 2008. Improving question asking in high-functioning
adolescents with autism spectrum disorders: effectiveness of small-group training, Autism, 12, 1,
83-98.
Schepis, M. M., Reid, D. H., Behrmann, M. M., Sutton, K. A., Schepis, M. M., Reid, D. H.,
Behrmann, M. M., & Sutton, K. A. 1998. Increasing communicative interactions of young children
with autism using a voice output communication aid and naturalistic teaching, Journal of Applied
Behavior Analysis, 31, 4, 561-578.
Seung, H. K., Ashwell, S., Elder, J. H., Valcante, G., Seung, H. K., Ashwell, S., Elder, J. H., &
Valcante, G. 2006. Verbal communication outcomes in children with autism after in-home father
training, Journal of Intellectual Disability Research, 50, 2, 139-150.
Turner, L. M., Stone, W. L., Pozdol, S. L., & Coonrod, E. E. 2006, Follow-up of children with
autism spectrum disorders from age 2 to age 9, Autism, 10, 3, 243-265.
Yoder, P. & Stone, W. L. 2006a, A randomized comparison of the effect of two prelinguistic
communication interventions on the acquisition of spoken communication in preschoolers with
ASD, Journal of Speech, Language & Hearing Research, 49, 4, 698-711.
Yoder, P. & Stone, W. L. 2006b, Randomized comparison of two communication interventions for
preschoolers with autism spectrum disorders, Journal of Consulting and Clinical Psychology, 74,
3, 426-435.
Yoder, P. J. & Layton, T. L. 1988, Speech following sign language training in autistic children with
minimal verbal language, Journal of Autism and Developmental Disorders, 18, 2, 217-229.
Literature synthesis-Autism
Study
(BernardOpitz,
Sriram, &
Sapuan
1999)
Country
Singapore
Study design
Comparison
study
Subjects
10 non-verbal
children. 9 male, 1
female. Age range
3-7 years
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Intervention
Computer assisted instruction
using IBM speech viewer was
compared with traditional play
interaction. Participants
attended sessions twice
RCSLT RESOURCE MANUAL FOR COMMISSIONING AND PLANNING SERVICES FOR SLCN
Autistic Spectrum Disorders
Study
Country
Study design
Subjects
(Bosseler &
Massaro
2003)
USA
Case series
8 children aged 712 years old. 7 boys
and 1 girl
(Chandler
et al. 2002)
UK
Case series
10 children, 9 boys,
1 female. Aged 2 to
3 years
(Delprato
2001)
International
Systematic
review
(Farrell,
Trigonaki, &
Webster
2005)
UK
Comparison
study
10 controlled
studies with 63
children with autism.
Range – 3-8 years
with an overall
median of 5 years
9 preschool children
in ABA/Louvaas,
Two girls and 7
boys.
8 preschool children
in the LUFAP, Two
girls and six boys
(Goldstein
2002)
International
Systematic
Review
Children with autism
(Hancock &
Kaiser
2002)
USA
Case
series/longitu
dinal study -
4 Pre-school
children
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23
Intervention
weekly and received a total 10
sessions.
Vocabulary lessons using
Baldi-Language Wizard
player. Students were trained
in roughly 10-to 30 minutes
sessions twice to five times a
week.
Intervention focusing on
pragmatics of language based
on home visits, modelling,
workshops, and written
information, with parents
acting as ‘therapists’.
Studies compared traditional
operant behavioural
procedures with normalised
interventions for teaching
language to young children
with autism.
Study compares impact of two
early intervention
programmes. For the
ABA/Louvaas, based on
applied behavioural analysis
technique, pupils received 30
hours per week of one to one
support mainly at home. The
Lancashire Under Fives
Autism Project (LUFAP)
amount of one to one support
time was more flexible and
integrated into classroom
activities in a mainstream
preschool. LUFAP used
combination of delivery styles,
in particular Applied
Behavioural Techniques and
TEACCH.
Compared communication
interventions, in particular sign
language, discrete-trial
training, and milieu teaching
procedures.
Twenty-four 15 minute
sessions twice weekly of
Enhanced Milieu Teaching by
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Autistic Spectrum Disorders
Study
Country
Study design
? see notes
below
Controlled
clinical trial
(Howard et
al. 2005)
USA
(Kasari et
al.
2008;Kasari
, Freeman,
& Paparella
2006)
USA
RCT
58 children, 46 boys
and 12 girls aged 34 years
(Kashinath
et al. 2006)
USA
Case series
5 Preschool children
(Keen,
Sigafoos, &
Woodyatt
2001)
Australia
Case series
4 children. 3 boys
and 1 girl aged 4-7
years
(Layton
1988;Yoder
& Layton
1988)
USA
RCT
60 moderate to
severe autistic
children aged 3-9
years
24
Subjects
Intervention
skilled therapists.
61 preschool age
children
29 children received
behaviour analytic intervention
for 25-40 hours per week.
Adult to child ratio 1:1. 16
children received intensive
“eclectic” intervention. This
involved a combination of
methods for 30 hours per
week. Adult to child ratio 1:1
or 1:2. 16 children attended
non-intensive public early
intervention programmes
which involved a combination
of methods for 15 hours per
week provided in small
groups.
Compared joint attention and
symbolic play interventions.
Both papers report the same
study. The 2006 paper
describes in detail the study
methodology and initial
outcomes. The 2008 paper
details the longer term (12
months after the intervention)
language outcomes.
Parents taught to include
teaching strategies within
children’s daily routine to
address communication
strategies.
Teacher implemented
intervention package to
replace prelinguistic
behaviours with functional
communication.
Language training by signalone or speech-alone,
simultaneous communication
or alternating between speech
& sign. Treatment included 90
individual 40-minute daily
sessions. Both of these
papers report the same study
and outcomes but are
published in different journals.
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Autistic Spectrum Disorders
Study
(Palmen,
Didden, &
Arts 2008)
Country
Netherlands
Study design
Case series
Subjects
9 high-functioning
adolescents with
ASD. Aged 17-25
years. 7 male, 2
female
(Seung et
al. 2006)
USA
Retrospectiv
e study
(Schepis et
al. 1998)
USA
Case series
(Turner et
al. 2006)
USA
Longitudinal
study
(Yoder &
Stone
2006a;Yode
r & Stone
2006b)
USA
RCT
8 children and their
fathers. Age range
4-7 years. Six boys
and 2 girls
4 children. 3 boys
and 1 girl. Age
range 3-5 years
25 children aged
approximately 9
who had received a
clinical diagnosis of
autism (n=18) or
PDD-NOS (n=7)
under the age of 3.
21 male, 4 female
36 preschoolers
with ASD. Aged 1860 months. 31 boys
and 5 girls
25
Intervention
Weekly small group training
consisting of feedback and
self-management lasting
about an hour for 6 weeks.
Adolescents in groups of 3 for
training.
In-home father training
consisting of expectant
waiting and imitation with
animation.
Use of voice output
communication aid and
naturalistic teaching.
Follow-up evaluation of
developmental outcomes.
Child received either
Responsive Education and
Prelinguistic Milieu Teaching
or Picture Exchange
Communication System.
Treatment was for 6 months
and delivered in 20-minute
sessions 3 times a week.
Both of these papers report on
the same study with each
focusing on slightly different
outcomes.
9. References Cited
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2. Powell, J., Edwards, A., Edwards, M., Pandit, B., Sungum-Paliwal, S., Whitehouse, W., 2007
Changes in the incidence of childhood autism and other autistic spectrum disorders in
preschool children from two areas of the West Midlands, UK, Developmental Medicine &
Child Neurology, 42, 9, 624-628.
3. All-Party Parliamentary Group on Autism Survey 2003.
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4. Bartlett, S., Armstrong, E., Roberts, J. (2005) Linguistic resources of individuals with Asperger
syndrome. Clinical Linguistics & Phonetics, 19, 3, 203-213.
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childhood: a twin study. International Journal of Language Communication Disorders, 42, 3,
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12. Every Child Matters: Change for Children 2003 www.everychildmatters.gov.uk
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Applied Research in Intellectual Disabilities, 18, 281–294
14. Fombonne, E., 2003a Epidemiological surveys of autism and other pervasive developmental
disorders: an update. Journal of Autism and Developmental Disorders 33, 365–382.
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Association, 289, 1–3.
16. Frith, U. 1991 Autism and Asperger syndrome. Cambridge: Cambridge University Press.
17. Gillberg, C. 1992 Autism and Autistic-like Conditions: Subclasses among Disorders of
Empathy, The Journal of Child Psychology and Psychiatry and Allied Disciplines, 33, 5, 813842.
18. Goldstein H 2002 Communication Intervention for Children with Autism: A Review of
Treatment Efficacy Journal of Autism and Developmental Disorders, 32, 5, 373-396.
19. Gray, C. (2002) My Social Stories Book. London: Jessica Kingsley Publishers.
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