Autism Spectrum Disorder: Autism Spectrum Disorder (ASD) is a neurodevelopmental disorder characterized by impairments in social reciprocity and communication, as well as patterns of repetitive, ritualistic behaviours or intense interests.” (Bennett et al., 2014). Autism affects; language and communication, social interaction, sensory processing and behavior and thinking. Persistent deficits in social communication and social interaction across multiple contexts, manifested by the following: DSM-V Diagnostic Criteria of ASD: 1. Deficits in social-emotional reciprocity E.g. Abnormal social approach Inability to have back and forth conversation Reduced sharing of interests and emotions/affect Failure to initiate or respond to social interactions 2. Deficits in nonverbal communicative behaviours used for social interaction E.g. Poorly integrated verbal and non-verbal communication Abnormalities in eye contact and body language Deficits in understanding and use of gestures Lack of facial expressions and non-verbal communication 3. Deficits in developing, maintaining and understanding relationships E.g. Difficulties adjusting behaviour to suit various social contexts Difficulties in sharing imaginative play or in making friends Absence of interest in peers Restricted, repetitive patterns of behaviour, interests, or activities, as manifested by at least TWO of the following: 1. Stereotyped or repetitive motor movements, use of objects, or speech E.g. Simple motor stereotypies Lining up of toys Flipping objects Echolalia Idiosyncratic phrases 2. Insistence on sameness, inflexible adherence to routines, or ritualised patterns of verbal or nonverbal behavior E.g. Extreme distress at small changes Difficulties with transitions Rigid thinking patterns Greeting rituals Need to take same route or eat same food everyday 3. Highly restricted, fixated interests that are abnormal in intensity or focus E.g. Strong attachment to or pre-occupation with unusual objects Extremely restricted or persistent interests 4. Hyper-or hypoactivity to sensory input, or unusual interests in sensory aspects of the environment E.g. Apparent indifference to pain/temperature Adverse response to specific sounds or textures Excessive smelling or touching of objects Visual fascination with lights or movement ASSESSMENT OF CHILDREN WITH ASD o o o o Visual schedule will so that the child can visualize what they are expected to complete, according too Goldstein and Shneider (2010) children with autism benefit from a structured environment. Breaks will be taken and assessment will be conducted over many sessions. Assessment will be made a team effort to ensure a comprehensive assessment. From clinical experience it was found that Children have difficulty concentrating for ling period of time and therefore breaks will be taken when required. *Before conducting the assessment the student therapist will take into consideration pre-task considerations according to Casey and Alant, (2005): o Emotional state attitude and motivation o Physical state level of fatigue of health status o Factory in the environment light, temperature, acoustics, familiarity with the examiner. o Time of day and medication 1. CASE HISTORY INFORMATION: Obtained from medical file or interview with parent It is important to obtain case history information to ensure the assessment process is comprehensive. Important to get Case history information as it provides a holistic understanding of the patient and more detailed overview. Helps in determining the direction of assessment and management as well as helps to identify any red flags that may be contributing factors to speech, language and communication difficulties. Case history information: o Reason for referral o Parental concerns o Medical history o Developmental history According to Bauman (2010) children with autism typically have delayed or disordered language. o Educational history o History of assessment and intervention o Family history 2. ORAL MOTOR EXAMINATION It is important to do an OME with the patient to observe any structural or functional factors that may be influencing his speech. o According to (Cheryl et al., 2015) it is specifically important to do an OME with an autistic child as autism and apraxia commonly coincide. Therefore it is important to monitor and assess a child with autism to help identify children as early as possible and allow them access to services appropriate to their needs. In order to gain a better picture of the patients oral motor functioning the student therapist will encourage him to imitate the following movements: o Observe for facial symmetry at rest, muscle tone, throat clear, vocal quality o Oral cavity dentition, hygiene, excessive secretions o Jaw o Position at rest o Presence of involuntary movement o DDK- provide an indication of the child’s ability to produce sounds at speed as well as an ability to sequence sounds rapidly (ptk) o Open wide and close, lateralize to left and right (ROM) o Open and close with resistance (strength) o Lips position at rest, (ROM)- smile, frown, say ‘o’, say ‘o’ ‘e’, lip seal- puff lips and hold. Childhood apraxia of speech- an inability to preform voluntary movements required for speech in the absence of muscle weakness or paralysis. o It is persistent and affects the development and production of intelligible speech. 3. COSMIC- Classroom Observational Schedule to Measure Intentional Communication developed by Pascoe, Gordon, Howlin, Charman, (2008). Rational all from (Pascoe, Gordon, Howlin, Charman, (2008): o The COSMIC was developed to be used with children with autism as and impairment in communication is a core feature. o The COSMIC will look at the child’s early social communication skills in various contexts, as they are important prognostic indicators for later language and social development. o Formally assessing a child with severe language and communication can be a challenge, and in some cases the use of standardized assessments may not be suitable. o The formal context of an assessment may not be suitable for the child with autism spectrum disorder and their language and communication skills may be highly situation specific and best observed in more natural settings. o It is therefore important to observe patient’s language and communication in a natural setting and various contexts to gain a holistic picture of the child’s communication functions and forms (Pascoe, Gordon , Howlin, Charman, 2008) Parent/Educator Interviews can also be conducted to gain an idea of how and why the child communicates, in which environment and with whom. During observation of child, it is important to take note of the following for further assessments: a) Will the child be able to follow directions in a testing situation? b) Will they be able to respond in a manner called for by assessment tools selected? c) Does the child need visual and gestural cues to understand and respond appropriately? d) Are there any potential triggers to avoid? e) What sensory issues need to be considered (i.e. bright lights, noise, etc)- in order to make accommodations to assessment f) What is the best time of the day to see the child? 6. CONDUCT A SYMBOL ASSESSMENT SCREENER (Beukelman & Mirenda, 2013) Will be conducted with patient that is either non-verbal or preverbal and does not have an ability to express him/her self. It is important to do a symbol assessment screener to gain information on the symbol level the child is at. This will aid in how to conduct the rest of the assessment and management.` o Have object of 10 items, photographs of 10 items, clipart of the 10 items and then line drawing of the 10 items. Note: Need to ensure that the items used within the symbol assessment are those the individual knows or understands o o o o Identify about 10 functional items with which the person is familiar (could be based on observation or report of family members, teachers, etc.) Begin symbol assessment by starting with functional use format (most basic level) (Do they use the item appropriately or know the use of the item?) Present child with two or more items/ symbols and ask them to ‘show me the cup’. Repeat using a more complex symbol each time. EXPRESSIVE AND RECEPTIVE LANGUAGE 7. RECEPTIVE LANGUAGE- Receptive language refers to child’s ability to understand language. LOWER END OF THE SPECTRUM Functional Communication profile will be used The functional assessment is appropriate to use as it addresses all communication possibilities and is designed for use with children who have mild to profound deficits (Kleiman, 2003). Clients are assessed and rated in the major skills categories of communication through direct observation, teacher and caregiver reports and one on one testing (Kleiman, 2003). o The therapist needs to establish a base level performance and this is another reason why the FCP will be used According too Skwerer, Jordan, Brukilacchio & Tager-Flusberg (2016) standardized tests may be challenging for minimally verbal children with Autistic Spectrum disorder (ASD) for a variety of reasons such as; o Social unresponsive to the examiner o Distractions in the environment o Behavioral challenges o Poor attention span o Unfamiliarity with the testing environment and frustration with performance as test items get harder. Therefore the function communication profile has also been chosen as many formal tools have not been standardized on the South African Population nor have they been standardized on individuals with ASD. Looks at a child’s Comprehension of: (the student therapist will plan activities for subtests being conducted using pictures and adaptions to response mode will be using gesture/or eye gaze to indicate answer): o Verbal and nonverbal language o Oral comprehension: does a child understand at a: o sentence Interest level. in pictures and objects o Word, phrase or o Following commands: o Simple conversation o Complex conversation o Attention commands e.g. no, o Direct and indirect requests look, stop o Accepting and giving objects o Use of sign language/makaton/PECS/AAC e.g. when asked does child require gesture, o Following instructions Basic concept o Colors o Body parts o Shapes o Object function o Prepositions o Quality o Same/different o Emotions children with ASD have difficulty identifying emotions and controlling emotions (Howard et al. 2000) o Categories o Understanding of nonverbal communication: Gestures Intonation changes Facial expressions Body language Throughout the assessment of visual (e.g. pictures), verbal, physical (hand-over-hand, tapping child) cues and prompting will be used if the patient is having difficulty and requires them. Positive reinforcement will also be used to keep the child motivated and interested. The student therapist will ensure the instructions are short throughout the assessment and will always model what she requires the patient to do. The patient will be provided with motivation throughout the assessment to ensure motivation. The student will note in the assessment report if they are used. RECEPTIVE LANGUAGE TEST FOR HIGHER END OF THE ASD SPECTRUM: The TACL (the Test of Auditory Comprehension of Language) (3-12 yrs.) o The standardized assessment will be used even though it is not age appropriate for the patient as according too According to Bauman (2010) children with autism typically have delayed or disordered language and therefore we expect to find the patient has a delay in their language. As well as the reason for referral indicates the child has delayed language. o The above assessment has not been standardized on the South African population or individuals with autism and therefore results will be taken as a guideline only. The TACL will be supplemented with the FUNCTIONAL COMMUNICATION PROFILE because according too, (Charman 2004) standardized tests are sometimes inappropriate for children with ASD because they often tap skills that are too advanced for the child being assessed (Charman 2004) or because of complications arising from a lack of attention or motivation (Koegel et al. 1997). This is why the TACL will be supplemented with use of the functional communication profile to get a more holistic view of the patient and observe their understanding of: Verbal and nonverbal language o Oral comprehension: does a child understand at a: o Word, phrase or sentence level. o Simple conversation o Complex conversation o Direct and indirect requests o Use of sign language/makaton/PECS/AAC o o Interest in pictures and objects Following commands: o Attention commands e.g. no, look, stop o Accepting and giving objects e.g. when asked does child require gesture, o Following instructions Understanding of nonverbal communication: Gestures Intonation changes Facial expressions Body language o Basic concept o Colors o Body parts o Shapes o Object function o Prepositions o Quality o Same/different o Emotions children with ASD have difficulty identifying emotions and controlling emotions (Howard et al. 2000) o Categories The TACL requires the patient to complete 3 subtests: o The vocabulary subtest looked at Reanetse’s understanding of word classes (nouns, verbs, adjectives and adverbs). o The grammatical morphemes subtest assessed Reanetse’s understanding of grammatical morphemes such as prepositions, pronoun, verbs and tenses o Elaborate phrases and sentences looks at child’s ability to understand the arrangement of words and ohrass to create a well-formed sentence. Understanding of active (e.g. “the boy and the man ate popcorn”), passive (e.g. “the dog is chased by the boy”), negative (e.g. “The man isn’t drinking”), interrogative (e.g.” the man said, “can you reach it”) and embedded sentences (e.g.” Mary, her student, drank some milk”) was assessed. NB if the child is bilingual and the language of learning and teaching (LoLT) is English and their home language is isiXhosa the functional communication test will also be conducted in isiXhosa so that therapist has a more holistic understanding of the child and is able to observe what the child understands in their home language and if it is consistent with findings in their second language. From clinical experience this was done to gain an accurate understanding of the child’s difficulties and whether they are present in one or both languages. It is essential for the healthcare professional to take into consideration the patient’s cultural and linguistic background (Fielding & Normand, 2003). The FCP will be translation as the translation of a standardized assessment such as the TACL may result in targeted information being lost in translation. Echolalia repetition, with similar intonation, of words or phrases that someone else has said (Tager-Flusberg, Paul, and Lord, 2005). o o Most frequent in children with autism who had minimal expressive language Echo immediately questions and commands that they did not understand or for which they did not know the appropriate response. Lord, Shulman, and DiLavore (2004) found that this kind of “language regression” after a pattern of normal language onset was unique to autism and not found among children with other developmental delays. o Generally, the regression is a gradual process in which the children do not learn new words and fail to engage in communicative routines in which they may have participated before. 6. EXPRESSIVE LANGUAGE EXPRESSIVE LANGUAGE LOWER END OF SPECTRUM Functional Communication profile will be used Will look at: o Verbal status and method of communication- e.g. non verbal communicator, verbal communicator, limited verbal communicator. o Expressive level (e.g. one unit, single words, phrases, sentences, conversation, etc) – average phrase length o Methods of communication e.g. signing, vocalization, writing, eye gaze, head nodding, PECS o Self expression e.g. name, basic needs, ideas, emotions, Echolalia o Uses common gestures e.g. spontaneously, with gestural pompt o o o Basic communication expression: a. Expresses choice b. Expressing discomfort/pleasure c. Expressing name d. Expressing object labels Ability Naming objects and pictures: o Body parts o Colours o Shapes o Days of week o Prepositions o Quality Spontaneous speech- days of week and counting. E.g. attempts speech, speaks, imitates speech, sign language, finger spelling, writing, PECS, eye gaze, head nodding. EXPRESSIVE LANGUAGE TEST FOR HIGHER END OF THE ASD SPECTRUM: The Renfrew Action Picture Vocabulary Test will be used to assess expressive language: o This test requires the patient to construct a sentence using information given in the picture. This test looks at the length and complexity of spoken utterances. It assessed the amount of information included in the sentence and the grammar of the sentence. Supplement by looking at the Functional communication Profile: o Use of basic concepts e.g colours, body parts, prepositions, shapes o Use of gestures o Automatic/spontaneous speech e.g. days of week o Narrative speech (picture description/picture sequencing) 7. PRAGMATICS Pragmatic language checklist by Prutting and Kirchner will be used to assess child’s pragmatic skills. Pragmatic skills refer to a child’s social use of language. The child will be observed in class, on the playground, in on-on-one sessions (different contexts). Pragmatics is important to assess as children with ASD usually display difficulties in this area according to Flusberg, Paul, and Lord (2005). Basic pragmatic skills that will be observed and noted: Nonverbal communication skills (e.g. appropriate eye contact, understands body language, uses appropriate space boundaries, understands changes in facial expression ect.) General conversational skills (e.g. topic initiation, sufficient information, asks for repetition or clarification, provides relevant answers, maintains topic, gets to point). Basic social language (e.g. greets, goodbye, polite, wants and needs, protests, requests, requests more, asks for help, demonstrates affection appropriately, appropriate explanations for actions). Turn taking Joint attention We could expect to find the patient has difficulty with the following pragmatic skills as according too Owens (2004): Joint attention Difficulty initiating and maintaining a conversation, resulting in much shorter conversational episodes Poor topic maintenance. Limited range of communication functions. Few gestures used, misinterpretation of complex gestures Limited eye contact Over use of questions, some may be inappropriate. Unable to express feelings or recognize the viewpoints or interests of others. From my own clinical experience I observed a child that displayed difficulty initiating and maintaining conversation as well as difficulty in being able to ask for help. 8. LITERACY AND PHONOLOGICAL AWEARNESS -if age appropriate 1. Phonological awareness skills The phonological awareness test will be used to assess the patients phonological awareness skills, it must be taken into consideration that that this test is not normed on individuals with ASD or individuals of the South African population. If nonverbal SLT will have to make accommodations by getting the child’s response though pointing at cards. That PAT will observe: o Rhyming o Isolated phoneme awareness (initial, medial and final position) o Segmentation (beginning at a sentence, then syllable and then sound level) o Deletion (syllable and phoneme) o Substitution (substituting sounds and making new words) o Blending o Phoneme –Grapheme awareness o Decoding of nonsense words Literacy If the child is age appropriate 6 years. Kottymeyer spelling test can be used to assess reading skills An informal passage can be used to assess reading ability and comprehension questions related to the story will be asked to determine their comprehension of reading ability. Hyperlexia Impaired reading comprehension but well-developed word recognition skills is consistent with the pattern of reading behaviour seen in hyperlexia, Strong association between autism and hyperlexia. Many children who have a hyperlexic reading profile are autistic, or show features of autism Flusberg, Paul, and Lord (2005). Show remarkably advanced word recognition skills. They show an ability to read however they have poor comprehension skills. From clinical experience this was observed. 9. SPEECH (ONLY VERBAL CHILDREN)- will only be done if there is concern to do it if parent or teacher reports difficulty understanding and if have difficulty understanding the child in the expressive language task. An informal articulation screener will be used; the child will be presented with pictures and will have to tell the student therapist what it is. Among children with autism who speak, articulation is often normal or even precocious according too Flusberg, Paul, and Lord (2005). However articulation development to be somewhat slower than normal. The student therapist will take note of: o Phonological processes o Rate and tone of voice o Intelligibility o Fluency NB if the child is bilingual and the language of learning and teaching (LoLT) is English and their home language is isiXhosa the functional communication test will also be conducted in isiXhosa so that therapist has a more holistic understanding of the child and is able to observe what the child understands in their home language and if it is consistent with findings in their second language . MANAGEMENT OF AUTISM Goal of intervention is to improve social communication and other language impairments and modify behaviors to improve an individual's quality of life and increase social acceptance. A visual schedule will be used for therapy, as according too (Goldstein & Shneider,2010) children with autism benefit from increased structure in their lives and the use of visual schedules has been seen to reduce behavioral problems and increased compliance as they are able to visualize what they are expected to complete/task requirements or stuational rules. o SLP recommend the use of visual schedules and teach the use of visual schedules to parents, teachers and caregivers. o A visual schedule is an intervention that depicts the sequence of activities, steps, or rules that apply to o o specific individuals and routines. He primary purpose of a visual schedule is to provide the individual with a way to predict or understand upcoming events in order to reduce problem behavior and increase independence. Visual schedules can be developed to provide information about future events across days and weeks (through calendar use), across hours within a day (through day planners and activity schedules), and within specific activities (through activity recipes or mini-schedules) For children who are able to read a social story will be used to address social deficits in children with autism. Social Stories are short stories that identify the situation or behavior and describe appropriate social cues and preferred responses, they have seen to be successful in improving social interaction skills and difficult behaviors (Goldstein & Shneider, 2010). o o Child child directed Older clinician directed Strategies to reduce unwanted behaviors: o Taking breaks during therapy so they don’t become bored o Using visual cues o Supplementing verbal o Reinforcing good behavior o Inform transitions and changes: Recognize that changes can be extremely unsettling, especially when they are unexpected. Refer to a schedule, use countdown timers, o Remove or dampen distracting or disturbing stimuli from my own clinical experience when there was distracting stimuli my child would block his ears and get up. o Show or tell your child what you expect of him using visual aids rules for the session Techniques that will be used during therapy: o Modeling o Handover hand o Visual prompts according to (Goldstein & Shneider,2010) autistic children have strengths in memory and the ability to use visual information. From my own clinical experience the use of visual prompts such as ‘wait’ and ‘listen’ worked well in therapy. o Physical prompts e.g. tapping o Verbal prompts PROMPTING Prompting can be provided to the child to keep them motivated and to enable them to successfully respond to requests given by the RECEPTIVE LANGUAGE Bauman (2010) children with autism typically have delayed or disordered language and it is therefore important to expand their understanding of vocabulary to improve their understanding of different concepts. Improving a child’s understanding of vocabulary will enable them to communicate more successfully as it will decrease their frustration they may have because they are unsure of how to communicate something due to limited vocabulary. Increasing receptive vocabulary will improve understanding of spoken language; improve their ability to follow instructions. Younger children: symbol infused joint attention which is the amount of time spent attending to a shared object that the communication partner is naming and talking about has been seen to improve growth of receptive language (and expressive language) (Adamson, Bakeman, Decker & Romski, 2009) . This suggests that working towards increasing receptive language would include: o Sharing interesting objects and activities with the client o Actively attracting their attention and gaze to the object and to the communication partner o Providing simple, receptive language to accompany activity. Verbal or nonverbal: Functional communication e.g. wants and needs, toilet, greeting Basic concepts Goals passed on the results of the assessment EXPRESSIVE LANGUAGE Verbal children to improve their ability to use vocabulary in their speech and to express themselves to enable communication partners to understand them. o Functional communication and basic communication- colours, prepositions, shapes, object function Toddlers According to Paul and Norbury (2012) the techniques of the Milieu teaching such as following the child’s lead, labeling the objects the child shows interest in, modeling, withholding objects child shows interest in and using expectant waiting have been shown to be associated with increase vocabulary with children with ASD and they seem to be effective when done with parents and clinicians. o A set of tools to facilitate a child’s communication growth are used. For children who are preverbal or nonverbal (Bondy & Frost, 2001) it is important to establish a functional mode of communication to enable them to communicate. The Picture exchange communication system (PECS) was developed to teach children with ASD a rapidly acquired, self-initiated functional communication system. From my own clinical experience it was seen that when PECS was introduced and my patient stared to understand how to use PECS the presents of his unwanted behaviors reduced, as he was able to successfully communicated what he desired. The principles of PECS will be used. Picture-based AAC systems are used more frequently and successfully with individuals with ASD than unaided systems (e.g. sign language), due to a match between the characteristics of ASD and the ease of use of such systems. (Bondy & Frost, 2001) Benefits: o No evidence that using PECS inhibits the development or use of speech o Critical members of the community do not have to be specially trained in the system- the pictures are readily understood Protocol 6 phases that teaches children how to communicate with pictures. Before beginning PECS the student therapist will ask the teacher and parent what the child enjoys. Phase 1: The outcome for Phase 1 is for the child to look at, reach for, pick up and hand the picture to their communication partner. These are the basic skills needed to effectively communicate using PECS. The following should be considered: o Only one picture is given to the child as an option. o Use motivator as item for which the child must ask o Prompt if necessary o The child should be provided the item immediately after they provide the picture to you Prompts should be faded using a strategy known as backward chaining. With backward chaining, the helper assists through to the final step of the exchange and then gradually fades assistance as the student becomes more independent. Language should be incorporated into the session through labelling of items and labelling what is being done. Phase 2: The outcome of this phase is to increase the child’s spontaneity and generalization of the picture exchange. It is the same as phase 1, BUT: o The adult(s) moves further away from the child o The picture is moved out of reach Phase 2 should be implemented throughout the day (e.g. during meal times, play time, teaching, etc) and with different people so that the child can learn that the same exchange system is effective across people, places and activities. Phase 3: The child will need to be able to discriminate between pictures (i.e. desired versus non-desired). o Use an item the child likes and one that they clearly do not want (as well as appropriate pictures for these items) o The child must give you the option that they want. o As soon as they touch the ‘correct’ item, you should provide positive verbal reinforcement. o You should provide the item to the child immediately, whilst labelling it o You should also increase the desirability of objects o If incorrect, prompt by covering up the incorrect picture. You can also pick up the correct picture, show it to the child and label it. You should then hold out your hand and wait for the child to place the correct picture in your hand (provide physical prompting if necessary). Phase 4: The child learns how to construct simple sentences on a detachable sentence strip using an “I want” picture followed by a picture of the item that they are requesting. The use of the sentence strip may provide the structure to elicit spoken words. Other factors involved in Phase 4 include: o Place the “I want” symbol on the left side of the sentence strip and wait for the child to initiate the communicative exchange o When the child takes the picture from the board, guide the child to place the picture next to the “I want” symbol on the sentence strip o Guide the child to take the sentence strip and hand it to their communication partner o The communication partner should read the sentence strip, point to the symbols on the strip and then give the requested item to the child o Prompting should be faded quickly using the backward chaining strategy o After the exchange is established, guide the child in placing the “I want” symbol before the picture of the desired item. This can be done with physical prompts. o Guide the child in point to the symbols on the sentence strip as the communication partner reads it. Physical prompts can be used. When the child is able to point to the symbols as the communication partner reads the words, the communication partner pauses after saying “I want” and before identifying the pictured item, thus leaving time for the child to name/verbalize the item for themselves. Any attempt to vocalize during this pause should be immediately reinforced with the learner obtaining the requested item, even if he is unable to say the word properly. Phase 5: The child learns to answer the question: “What do you want?” o The communication partner points to the “I want” card and asks, “What do you want?” The goal is for the child to complete the sentence strip with the “I want” picture followed by the desired object Phase 6: The child is taught new communicative functions; labelling and naming things. This is an important step in the development of communication skills. o Get a new sentence starter, for example, “I see”. o Hold an item and places the “I see” symbol and the picture near the sentence strip o The communication partner holds up the item and asks, “What do you see?” and then points to the “I see” symbol. o DO NOT GIVE DESIRED ITEM (teaching commenting, not requesting) PHONOLOGICAL AWARENESS SKILLS o Letter knowledge is vital for the development of spelling, writing, reading and decoding of words (Paul & Norbury, 2012) developing letter knowledge is vital for his academic success. o Phonological awareness skills are critical for literacy learning and success (Paul and Norbury, 2012) phonological awareness skills are important to master so that he can efficiently use the phonic attack strategy to aid his reading and spelling (Paul and Norbury, 2012) Phonological awareness skills will be taught in an order of hierarchy; o Rhyming o o o o Isolated phoneme awareness (initial, medial and final position) Segmentation (beginning at a sentence, then syllable and then sound level) Blending Manipulation (substituting sounds and making new words) LITERACY Goals: based on the participation model Hyperlexia according to Paul & Norbury (2012) children with ASD and hypelexia have difficulty making inferences and comprehensing what they read. To imporve their comprehension of text by teaching them techniques on how to remember the story. From my own clinical experience I had a child with lyperlexia and I taugh him stratergies such as visualising the story (A picture was used as a visual aid), relating the story to his own personal experiences, asking questions and summarising information. This slowly started to help him remember information. WORKING WITH ECHOLALIA (Paul & Norbury, 2012) : o Using a puppet or third person to model what should be said. o Mitigated echolalie when an echoed utterance is produced, the client echos it back, then rung a slight change and invite immitation of change. E.g. if child says ‘yellow balloon’ the clinician can say “I like yellow balloon! I like blue balloon! Blue balloon!”. Avalibale materials that correspond to the modified model can be offered and withheld until the migrated form is produced. o FAMILY AND TEACHING EDUCATION: o Management should also be extended to care of the family of an ASD child, as anxiety and depression are higher in parents of children with ASD than those with other developmental syndromes. o Support should include emotional support, guidance and help in locating useful intervention resources and referral for counseling or other appropriate services. NB If you assessing a child that is Bilingual but you assessing the child in their second language because it’s the Language of learning and teaching (LoLT), it is important to take into consideration the child’s first language. In therapy use the child’s strengths to supplement their weakness, if they having difficulty understanding a concept in the LOLT use their first language to help them understand. REFERRALS: OT: o Individuals with autism have also been found to have deficits and delays in fine and gross motor skills, as well as in sensory processing. OT’s are also important to address different patterns of sensory processing, which many autistic children display (Bauman, 2010). Child Psychiatrist: o Some children with autism are placed on medication for behavioral difficulties, hormonal dysfunction, sleeping difficulties and seizures according to Bauman (2010), Audiologist: o To have hearing screening test as hearing can deteriorate and is important for communication and speech skills (Bauman, 2010). Educational psychologist: o If the child is not in the correct school placement the educational psychologist can assist with this. Autism western cape: o If the patient is newly diagnosed or feels the mother needs support. Refer the mother to autism western cape where she can join a support group. o According too Autism Western Cape- Support groups provide parents and caregivers with invaluable support network where they have the opportunity to meet and socialize with others who are experiencing similar challenges. o The groups provide opportunities to share experiences and learn from one another .