Communication in children with Autism Spectrum Disorders
(ASDs): An inquiry, by means of a case study, into how a preschool specialist provision for children with ASDs interpets
theoretical models of practice.
Dimitra Tavulari
Supervisor: Nick S. Hodge
MA Education of Children and Young People with Autism
School of Education, Sheffield Hallam University
March 2004
Dimitra Tavulari
Supervisor: N. S. Hodge
Abstract:
The aims of the study were to identify through a literature review recommended
interventions for supporting the development of communication skills in children
with autism; understand how staff, within a specific pre-school establishment,
select, interpret and apply these methods and to evaluate how successful these
are in contributing to the development of communication skills.
The findings of the study show that a number of structured intervention strategies
are used by the staff with apparent positive affect on the development of
children’s communication and social skills. Also additional strategies are used by
the staff inuitively but are not recognised by them as formal intervention methods
of the nursery. The findings also show that the children appeared to be higly
responsive to and motivated by these strategies suggesting they were received
positively by them.
TABLE OF CONTENTS
Introduction
1
Autism: Definition, Symptoms, Characteristics
4
Communication Impairments in Autism
9
Literature Review
15
The Case Study
41
Methodology
42
Data Analysis
50
Findings
51
Discussion of Outcomes
58
Conclusion
60
References
62
Appendix 1: Transcript of Interview
67
Appendix 2: Notes from Video Tapes
70
Appendix 3: IEPs
72
Aknowledgement
I would like to take this opportunity and thank my supervisor Nick Hodge for his
valuable help and advice in improving my work.
I would also like to thank all the staff at the pre-school setting for supporting me
and helping me throughout this project. Furthermore, I want to thank my close
friend for being present at difficult time, and above all, my parents for supporting
me all these years.
Communication in children with Autism Spectrum Disorders (ASDs): An
inquiry, by means of a case study, into how a pre-school specialist
provision for children with ASDs interpets theoretical models of practice
INTRODUCTION
Since the first identification of the condition of autism by Kanner (1943), many
researchers (e.g. Koegel and Koegel, 1994 and Valdez-Menchaca, 1994) have
suggested that the hallmarks of the condition, which lie at the heart of the autistic
spectrum, are the communication and the social interaction deficit. Therefore,
many educational interventions have focused on these two areas of development
in particular, based upon the belief that almost all the other difficulties frequently
observed in children with ASDs are a result of these communication-based
difficulties.
Different approaches have different principles and use different techniques and
teaching methods to encourage the development of communication and social
skills. Each one of them works differently for different individuals and therefore it
is suggested that not one ''best'' approach that works well for everyone (NAS,
2001). However, the acquisition of effective communicative and social skills for
children with ASDs is of huge importance. The significance of structure, early and
intense intervention and collaborative working in educational settings, as well as
the need to address core deficits of social emotional development, pragmatic
aspects of communication, play skills and comprehension cannot be emphasised
enough.
Therefore the contribution of educational settings and especially pre-school
educational settings to the communication, cognition and learning development
of children with autism, is of particular value. They provide all the above features
such as structure, communication and play skills, essential for the further
development of children.
The present study will identify and evaluate what contribution a pre-school
establishment for children with ASDs, makes to the development of the
communication and social skills of children with ASDs. Detailed data will be
collected on two pupils.
The aims of the study are to:
 Identify approaches, for the development of communication skills in
children with ASDs, reccomended by the body of the literature
 identify the communication intervention procedures that are used in one
particular setting
 understand how staff are applying these strategies
 understand the way in which these interventions might contribute to the
communication development of children
The mode of enquiry is a case study research design, involving staff and two
children of the nursery as research participants. There were eight pupils at the
nursery and the staff consisted of two nursery nurses and two speech therapy
assistants.
The role of the researcher was to observe and analyse as a
participant observer.
The findings of the study establish that: a number of structured intervention
strategies are used by the staff; deliberately selected and that these appear to
have an apparent positive effect on the development of children’s communication
and social skills; that additional strategies were used by the staff intuitively but
were not recognised by them as strategies and that the children appeared to be
highly responsive to and motivated by these strategies suggesting they were
received positively by them.
The case study took place over a period of three months. It involved eight visits;
one interview with the staff’s leader; several observations; analysis of video tapes
of the early days of the children in the nursery, recorded by the staff and analysis
of the Individual Education Plans (IEPs). The parents of the two selected children
were aware of the study and gave their full permission. Furthermore, the names
of the children were changed in order to protect their privacy. They will be named
as Andy and Stewart.
AUTISM: DEFINITION, SYMPTOMS, CHARACTERISTICS
Autism has been defined as a condition since 1943 when Leo Kanner first
described a number of features which identify children with this disorder. He
described the defining features of autism as:
-
A profound autistic withdrawal
-
An obsessive desire for the preservation of sameness
-
A good rote memory
-
An intelligent and pensive expression
-
Mutism, or language without real communicative intent
-
Over-sensitivity to stimuli
-
A skilful relationship to objects
(Jordan, 1999)
Kanner explained that he referred to the work of Bleuler (1911) when choosing
the word “autism” to describe these symptoms. Bleuler used the term to describe
a withdrawal from previous participation, whereas the children Kanner described
had never engaged in social interaction.
As the information provided by Kanner’s observations on the nature of autism
became more widely known, more children were referred for diagnosis. However,
as more children were seen, it became clear that Kanner had only recognised
one small group of children who fitted his particular criteria. The list of Kanner’s
defining features was felt to be too limiting by those who were involved with
diagnosing the syndrome.
There were children for whom it was felt that a diagnosis of autism would be a
useful descriptor yet who did not fit exactly into the criteria outlined by Kanner
(Wing and Gould 1979).
At about the same time, 1943, an Austrian psychiatrist, Hans Asperger,
independently recognised a pattern of abnormal behaviour in a group of
adolescents, which he chose to call “autistic psychopathy”. In 1971, Van Krevelin
compared the two disorders and found that there were many similarities with
Kanner’s subjects, but also significant differences.
Unlike the children described by Kanner, those reported by Asperger had an
adequate spoken vocabulary, with other abnormalities such as an obsessional
interest in factual matters.
Like the children described by Kanner, they had great difficulty in situations
requiring two-way social interaction and communication. Essentially, they did not
seem to be interested in or to understand the responses of other people.
“Autistic” was also the term used by Asperger to describe his group. This
condition bears his name now and is called Asperger syndrome.
Since that time, other researchers have listed their own criteria, and for a number
of years it was usual to diagnose autism by counting up a requisite number of
points (Creak, 1964; Rendle-Short, 1971 cited in Newson, 1979; Rutter et al,
1971; Newson, 1979). Wing and Gould (1979) conducted research in
Camberwell looking at all the children referred for psychiatric help. They were
able to select a group of these children who had severe learning difficulties and
were socially impaired, compared to others who had equally severe learning
difficulties but without social impairment. They also found that three areas of
development were associated with this social impairment, forming a cluster of
features that provide diagnostic criteria for autism.
These are known as the “Autism Triad of Impairments”:

Impairment of social development
this
refers
to
impaired,
developmentvariation
deviant
especially
may be from
and
extremely
interpersonal
delayed
social
development.
The
“autistic aloofness” to
“active
but odd”
characteristics

Impairment of social communication
refers to impaired and deviant language and communication, both verbal
and non-verbal

Impairment of social understanding and imagination
refers to rigidity of thought and behaviour and impoverished social
imagination.
Also,
ritualistic behaviour, reliance
on
routines and
extreme delay or absence of “pretend play”
Wing and Gould (1979)
Wing and Gould identified a number of children with what they described as
“Kanner’s syndrome” and a larger number of children who showed similarities to
this group but did not fit Kanner’s criteria exactly. Thus in 1988, Wing went on to
use the broader term “Autistic Spectrum”. The term spectrum has been useful in
allowing for a broad definition of autism based on the triad of impairments and in
capturing the idea of a range of manifestations of the same fundamental
disorder.
The manifestations of autism vary considerably among children and within an
individual child over time. There is no single behaviour that is always typical of
autism and no behaviour that would automatically exclude an individual child
from a diagnosis of autism, even though there are strong commonalities,
especially in social deficits.
In general terms, children within the autistic spectrum display a highly unusual
pattern of deficits and skills. Often, they exhibit difficulties in areas other than
these of the Triad. Unusual responses to stimuli for example, such as
oversensitivity to certain sounds, heat or cold, fascination with bright lights or
objects and indifference to pain, may all occur in young children with autism
(Jordan, 1999) and research has indicated that the majority of children with
autism show hypersensitivities or atypical responses to sensory stimulation
(O’Neill and Jones, 1997).
Problems with sensory processing can cause distractibility, disorganization and
discomfort, and the result might be a tendency to hyperfocus or be drawn to the
same repetitive stimulus. Repetition is viewed, in part, as a means to create
order amid chaos (Gradin, 1995; Williams, 1992). Bizarre behaviours such as
abnormal body movements like repetitive arm flapping, rocking, spinning or
jumping frequently observed in children within the spectrum may then be ways of
creating order or self-stimulation.
Additionally, research has suggested that children with autism exhibit
overselectivity, which means that it is difficult for them to attend to the multiple
features inherent in all stimuli (Lovaas, Koegel and Schreibman, 1979). They
also have difficulty determining the most meaningful feature of a given stimulus
(Frith and Baron-Cohen, 1987). Other studies report that children with ASDs
have difficulty shifting attention between visual and auditory stimuli (Ciesielski,
Courchesne and Elmasian, 1990; Courchesne, 1991). This impairs their ability to
follow the rapid pace and complex features of social interaction. Children appear
to struggle to attend to rapidly occurring sensory, language and social events.
Children with autism also appear to suffer a severe difficulty in attributing mental
states-such as intents, feelings and thoughts to themselves and to others in order
to understand social behaviour- they seem to lack what is called a Theory of
Mind (ToM) (Baron-Cohen, Leslie and Frith, 1985).
The development of a ToM is of huge importance, because, according to TagerFlusberg (1997),
it enables the child to interpret human behaviour within a casual-explanatory
framework, and affords understanding that the mind does not simply copy reality
but provides a representation of the world (p.135).
Thus, it should be obvious that a representational view of the world is essential to
the establishment of meaning and to effective communication overall.
On the other hand, some children with autism may also display unusually high
skills in some areas. Some of them appear to have truly savant abilities,
especially in music, in art and in mathematical calculations.
Their rote memory can be remarkably good and some of them may have
extremely good reading skills. Some of them may develop huge encyclopaedic
knowledge on a topic of their interest. These children, however, are in the
minority. Usually, those who are most able may pursue a very narrow interest
which may be very context-dependent and thus may have very limited value
because the individual is unable exercise conscious control and adapt and apply
his or her skill.
Autism is in fact found at all IQ levels but is often accompanied by general
learning difficulties and, the more profound the learning difficulties, the more
likely that the individual will have autism. Such individuals may have a
characteristic unevenness in their skill development but they seldom have
abilities that are remarkable in themselves when compared to a normally
developing population (Jordan, 1999).
COMMUNICATION IMPAIRMENTS ASSOCIATED WITH AUTISM
Communication difficulties are universally present in individuals with autism and
problems in social communication are an early sign that a disability is present
and may persist (Mundy, Sigman and Kasari, 1990). This has led many
researchers (e.g. Koegel and Koegel, Valdez-Menchaca, 1994), to hypothesize
that deficit in social communication or social interaction might be the primary
underlying deficit of autism and that other behavioural problems are secondary
as a result of these underlying communication-based difficulties.
Over the past two decades, there have been major advances in understanding
the communication and language deficits in children with ASDs. Until about 1980,
peculiar speech patterns were emphasized such as echolalia, pronoun reversal,
and unusual intonation (American Psychiatric Association, 1980). Nowadays,
verbal and non-verbal communication is considered a core deficit in the
diagnostic criteria for autistic spectrum disorders (American Psychiatric
Association, 1987; 1994). This change highlights the recognition of the fact that
children with autism not only have difficulty in the acquisition of speech and
language, but also in understanding and using non-verbal behaviour in
communicative interactions.
The level of communicative competence attained by children with autism has
been found to be an important predictor of more positive outcomes (Garfin and
Lord, 1986; McEachin, Smith and Lovaas, 1993). The presence of fluent speech,
defined as using multiword combinations spontaneously, communicatively and
regularly, before the age of 5 is a good prognostic indicator of subsequent IQ
scores, language measures, adaptive skills and academic achievement in
adolescence (Lord and Paul, 1997).
There is much heterogeneity in the speech, language and communication
characteristics of children within the autistic spectrum. There is a huge variation
in their language and communication abilities, ranging from children who are
non-verbal to children who have developed fluent speech but who find difficulty
with using their language to communicate effectively.
For those children who develop speech, echolalia is a frequent phenomenon.
Echolalia refers to the repetition of utterances heard in the immediate or distant
past. Whereas imitative repetition is a natural part of typically developing
children’s language, its persistence past the first few years of language learning
is used as one of the diagnostic criteria for autism. In addition, in contrast to
neurotypical language learners, children with autism lack clear evidence of
communicative intent in their echolalic utterances (Koegel, 1995). Echolalia can
be used to initiate communicative acts (e.g. requesting, calling or protesting) or
maintain communicative exchanges (e.g. turn-taking or providing information)
(Quill, 2000).
It often appears to be produced as a method of avoiding appropriate language.
For example, if an adult asks a child “Do you want milk?” and the child responds
“milk” s/he may appear to be using appropriate language but in reality the child
may be simply repeating the last portion of the previous utterance. It might be
that the child is doing their best to do what is expected, thus, just that repeating
the last thing they have heard is the best that they can do at that instance.
Lovaas, Varni, Koegel and Lorsch, (1977) have also suggetsted that delayed
echolalia, is usually emitted as self-stimulatory behaviour, apparently to provide
some sort of sensory input.
Another aspect of the language ofchildren with ASDs that appears to be impaired
is the use of pronouns. Many children with ASDs make pronoun reversal errors,
referring to themselves as “you” and to other people as “I” or “me” (Sigman,
Ungerer, Mundy and Sherman, 1987).
When Kanner originally observed
pronoun reversals in his patients, he attributed it to a form of echolalia. He
assumed that children with ASD repeated what they heard last and thus did not
always changed the pronouns appropriately.
However, psychoanalytic explanations (Despert, 1951, Bettelheim, 1967) saw the
pronoun reversal errors as a child’s inability to separate himself/herself from
others.
According to Baron-Cohen (1989), the pronoun errors are directly linked to the
children’s lack of Theory of Mind (ToM). He argues that if children with autism
lack a ToM they confuse discourse roles because they cannot understand that
individuals might have different conceptual perspectives.
Another frequent characteristic of the communication of children within the
autistic spectrum is the over-literalness of their language. They often display
great difficulties with the understanding of intentions behind speech. Thus they
have huge problems with understanding metaphors, similes, humour, sarcasm or
irony. A characteristic example of such over-literalness is that of responding to
questions like “can you pass the salt?” by simply “yes” or the little boy who runs
to the window and is looking for cats and dogs when his mother says “It’s raining
cats and dogs”. According to Baron-Cohen (1989) this again is directly linked to
their lack of a ToM. Since they lack of ToM they are unable to understand the
hidden meaning behind speech and therefore get very confused and upset.
Paralinguistic features such as vocal quality, intonation, pitch, and stress patterns
are other often deviant speech characteristics of verbal children with autism
(Tager-Flusberg, 1990). Children with ASDs are frequently described as
speaking in a “monotone”, and their speech may sound unnatural, or “robot like”.
They lack the ability to express the emotional intensity such as surprise,
emphasis, anger, or excitement when communicating a message, and they also
lack the ability to recognise such cues in a speaker’s voice. All these intonational
phenomena however, are also used to mark topic/comment relations that aid
listeners in processing discourse elements. For example, they can signal that
sentences marked as assertions are in fact questions (i.e. “You’re going home
now?”); and they help to segment longer strips of discourse into processable
units (Paul, 1987).
Thus, failure to use and appreciate intonational cues, will not only affect the
emotional tone of an utterance but it will also hamper its comprehensibility.
Moreover, children with ASDs, may also exhibit repetitive stereotyped, inflexible
and often idiosyncratic use of words and phrases, immaturity of grammatical
structure of spontaneous speech and problems in sequencing and in
understanding meaning (Paul, 1987).
Communication impairments in children with ASDs are also present in the nonverbal domain. The understanding, as well as the use of non-verbal cues such
as gestures, facial expressions, eye contact or bodily posture can be severely
affected in children with ASDs. Some of them predominantly use primitive
motoric gestures to communicate, for example leading, pulling or manipulating an
adult’s hand; and some also lack the use of many conventional gestures such as
waving, nodding and symbolic gestures depicting actions (Loveland and Laundry,
1986; Stone and Caro-Martinez, 1990; Stone et al, 1997).
Eye contact can often be inappropriate, being too fixed at some times and
averted at other times when it would be socially appropriate to make contact
(Atwood, 1987). Facial expressions as well are often an area of difficulty for
children with ASDs. Some of them appear not to recognize facial expressions
that declare happiness, fear, anger etc. In addition, their use of facial expressions
can sometimes be impaired.
According to Koegel (1995), the communicative difficulties, both in the verbal and
in the non-verbal domain, that are common in children with autism, as well as the
lack of sufficient language development, can lead to a significant disability in the
area of pragmatic competence.
Pragmatics is a component of language central to effective communication. It
includes ways of using language to convey different speech acts such as
requests, assertions, or promises; the appropriate use of language in specific
contexts such as dialogue, monologue, or narrative; and also structuring
utterances to distinguish between already given and new information (Sperber
and Wilson, 1986).
Moreover, the area of pragmatics include several aspects related to topic, such
as selection, introduction, maintenance and change (Prutting and Kirchner, 1987)
and turn-taking, including initiation, response, pause time, interruption/overlap,
feedback to speakers, contingency and politeness (Koegel, 1995).
Children with autism very often violate the unwritten rules of pragmatics. They
can, for example, introduce their favourite topic and talk excessively about it
without taking into account their listener’s needs. They may ignore the rules of
turn-taking, be unable to understand how long it is appropriate to talk about the
same topic or that their listener may be bored or might need additional
information in order to understand.
Non-verbal aspects may include such
behaviours as eye gaze or proximity between the communicative partners. These
rules can also be corrupted by children with autism.
Furthermore, tantrums,
aggression and other avoidance or attention-seeking behaviours often displayed
by children with ASDs are also included in the pragmatics area if they are used
for communicative purposes (Koegel, 1995).
In general terms, research since the 1980s has identified communication deficits
in children with autism that fall into two major areas: the capacity for joint
attention, which reflects difficulty coordinating attention between people and
objects, and the capacity for symbol use, which reflects difficulty learning
conventional or shared meanings for symbols and is evident in acquiring
language as well as symbolic play (Wetherby, Prizant and Schuler, 2000).
From all the above, it will be apparent that what is distinctive about the
communication of children with autism is that it reflects the cognitive and social
impairments associated with the disorder (Aarons and Gittens, 1992). For both
verbal and non-verbal individuals, impairments in social aspects of language and
related cognitive skills are the most salient (Lord and Paul, 1997; Wetherby,
Schuler and Prizant, 1997).
Non-autistic children with a language disorder will certainly show difficulties with
the understanding as well as the expression of language but, although probably
immature, their social development is not deviant. They are likely to find
alternative means of expressing themselves and are capable of engaging in the
sequence of attracting attention, and sharing their varied interests.
Children with autism on the other hand, may even not be aware of the valuable
role of communication in expressing their needs and wants and in being an
active part of a social world. This emphasizes the importance of communication
intervention as a primary goal in the education of children with ASDs in order to
improve their quality of life as much as possible.
COMMUNICATION INTERVENTIONS FOR CHILDREN WITH AUTISM
The complexities of social and communication development and the significant
diversity that is observed in children with a diagnosis of ASD led researchers
(e.g. Prizant, Wetherby and Rydell, 2000; Quill, 2000) to conceptualize
approaches to enhancing language and communication abilities along a
continuum, with traditional behavioural approaches such as discrete trialtraditional behavioural approaches at one end (Lovaas, 1977, 1981) and
developmental social-pragmatic approaches at the other end, which include
“relationship-based” approaches that are individualized and grounded in a
transactional model (Greenspan, 1992; 1997; Greenspan and Wieder, 1998;
MacDonald, 1989; Prizant, Schuler, Wetherby and Rydell, 1997). Contemporary
behavioural approaches fall between these two ends of the continuum,
incorporating aspects of each (Warren, 1993).
Traditional behavioural approaches in the 1970’s used teaching procedures
which were characterized by a one-to-one massed trial drill format to train early
“readiness” skills in eye contact, attention, and sitting followed by more advanced
skills in matching, verbal imitation, receptive and expressive language, play and
so forth. These approaches received much attention, mostly because they were
the first to objectively demonstrate that children with autism were capable of
acquiring a variety of skills through systematic teaching methods (Quill, 2000).
According to Lovaas (1981), the justification for a highly repetitive one-to-one
approach was the belief that children with autism were not able to learn in more
natural environments because of their extreme learning and attentional difficulties
and the lack of practice opportunities and systematic reinforcement in more
natural events.
However, in the 1980s, the movement of developmental pragmatics (i.e. the
study of language and communication development in social contexts) (Bricker,
1993), engendered a number of principles, that guided clinical and educational
practice with children with ASDs and other severe communication disabilities,
which appeared to be antithetical to traditional behaviour approaches in theory
and in practice (Prizant, Wetherby and Rydell, 2000).
For example, the social context of naturally occurring interactions was
considered to be of primary importance for communication and language
development. Also, the child was viewed as an active learner and social
participant rather as a learner primarily under the control of the teacher.
Furthermore,
the developmental pragmatics movement
emphasized
the
importance of deriving individualized goals and strategies in communication
abilities as well as learning strengths and needs (Prizant and Wetherby, 1989;
1990b; Wetherby and Prizant, 1992). This was in contrast to programmes using
the same sequence of goals and teaching curriculum, as was common in some
traditional behavioural approaches, especially in early stages of training (Bricker,
1993). Finally, the pragmatics movement has emphasized the need to focus on
meaningful preverbal and verbal language and functional communication abilities
at the onset, rather than to build repertoires of speech sounds, words and
sentences largely devoid of conceptual understanding and social impact (Prizant,
Wetherby and Rydell, 2000).
Nowadays, several viewpoints exist among the professional community about the
social and communication skills intervention. Dawson and Osterling (1997)
reviewed eight early intervention programmes for preschool children with autism,
ranging from intensive, one-to-one discrete trial approaches, to programmes in
inclusive educational settings using naturalistic procedures. They concluded that
the level of success achieved across these programmes was fairly similar. The
level of success was determined based on changes in measures such as IQ
scores and academic achievement. These conclusions provide important
implications for intervention programmes and directions for future research.
Firstly, there is no evidence indicating that one approach works better than
others, and therefore, caution is reasonable in drawing conclusions about
intervention efficacy. Secondly, given that impaired social and communication
development is the hallmark of autism, a true understanding of the “best” means
to support social and communication development in children with ASDs has not
been empirically studied, and thus, is unknown. There is a need to recognise
which specific intervention methods work best to accomplish which goals, for
which children. According to Quill (2000), an understanding of best practices to
enhance social skills and communication in children with autism, it seems is just
beginning.
Moreover, the combination of beneficial components of behavioural technology
with pragmatic developmental principles is likely to be the logical way to enhance
social and communicative competence in children with ASDs. Approaches that
combine behavioural and developmental principles incorporate specificity of
goals and objectives, promote the child’s level of motivation and interest, use
developmental activities, use instructional cues and prompts in a systematic
manner, and emphasize meaningful interactions within the context of adult
structured, organized learning environments (Quill, 2000).
This blend of behavioural and developmental principles to augment social and
communication skills is described in many popular approaches used for children
with various developmental disabilities and/or children with autism. This study will
describe some communication intervention approaches that come from
traditional ABA procedures, however modified to include developmental, more
child-centred principles, and some more developmental social-pragmatic
approaches which however include elements of traditional ABA techniques.
The selection of these approaches was made in order to show the contrast
between more behavioural to more developmental programmes and because the
pre-school establishment participating in this research, uses most of the more
developmental social-pragmatics ones.
 Incidental Teaching (Hart and Risley, 1982)
 Pivotal Response Training (Koegel and Schreibman, 1991)
 TEACCH
(Treatment
and
Education
of
Autistic
and
related
Communication Handicapped Children; Schopler and Mesibov, 1985,
1986)
 Picture Exchange Communication System (PECS, Bondy and Frost,
1994)
 Proximal Communication Approach (Whittaker, 1996)
 Musical Interaction (Prevezer and Chandler, 1998)
FROM ABA TO INCIDENTAL TEACHING
Behavioural methods have been used in the education of children with autism
and severe learning difficulties for many years, and as such, applied behavioural
analysis (ABA) is not autism specific (Wallin, 2000).
The primary teaching method of ABA is discrete trial. A discrete trial is a single
cycle of behaviourally based instruction routine. Every skill the child with autism
does not demonstrate-from relatively simple responses like looking at others, to
complex acts like social interaction-is broken down into small steps. Each step is
taught (usually into on-to-one teaching situations, to begin with) by presenting a
specific cue or instruction (Green, 1996). Sometimes, a prompt may be added to
help the child respond correctly. Appropriate responses are followed by
consequences that have been found to function effectively as reinforcers-that is,
when those consequences have consistently followed the child’s response it has
been shown that the response was likely to occur again. Problematic responses,
such as tantrums, stereotypies, self-injury or withdrawal, are explicitly not
reinforced, which often requires systematic analyses to determine exactly what
events function as reinforcers for those responses (Green, 1996).
Discrete trial is so widely known in the treatment of autistic spectrum disorders,
that many regard it as synonymous with ABA. However, ABA is not defined by
any single intervention procedure (Fenske, Krantz and McClannahan, 2001).
Although discrete trial training has been found effective in building language and
other skills in children with autism (Lovaas, 1977, 1981; Wolf, Risley and Mees,
1964), it is only one of the procedures that may be used to promote verbal and
other behaviour and it has certain limitations. For example, the structured
learning environment that occurs typically with discrete trial training, may fail to
promote generalization of skills across situations (Anderson, Taras and Cannon,
1996).
Incidental Teaching, although based on traditional ABA, uses techniques that
promote generalization and spontaneous use of emerging skills, (Hart and
Risley, 1968, McGee, Krantz, Mason and McClannahan, 1983).
According to Hart and Risley (1982),
incidental teaching is used to get elaborated language by waiting for another person to
initiate conversation about a topic and then responding in ways that ask for more
language for that person (p.5).
There are four steps involved in incidental teaching, which include: arranging a
setting that contains materials of interest to the child, waiting for the child to
initiate an interaction about an object of interest, asking for more elaborate
language or approximations to speech and providing the object for which the
child initiated the interaction.
Children’s initiations of interactions are reflective of their current language
abilities. Children who have acquired productive language may initiate for items
or activities with phrases, labels or word approximations (i.e. “m” to signify
“more”). However, even non verbal children can be candidates for incidental
teaching. They can initiate interactions by reaching for, pointing to or gesturing
towards activities or objects of interest (Fenske, Krantz and McClannahan,
2001).
When selecting target skills to teach, it is important to consider the child’s current
language repertoire. Incidental teaching helps children take the next steps, but
must not request skills that are presently out of their reach. Furthermore,
teaching is more effective and children progress more rapidly if teachers select
only one or a few language targets at a time, instead of trying to teach multiple
responses (Fenske, Krantz and McClannahan, 2001). For example, a teacher
might initially target the pronouns “I” and “you” and reserve instruction on the use
of other pronouns until the child masters these. The procedure of incidental
teaching is effective for shaping new language skills even before children learn to
imitate verbal models or follow adults’ directions.
A child, for example, who initiates interaction by pulling an adult towards a
preferred item, presents opportunity for incidental teaching. An initial instructional
goal could be “Point to the ………” or “Do you want ……..?”
Moreover, opportunities to promote initiations of interactions for children, can be
maximized by arranging the children’s usual environments in such ways that they
encourage initiations; favourite snacks, toys, books can be put on visible places
but out of reach of children, so that they are likely to evoke initiations.
Fenske, Krantz, and McClannahan (2001), have suggested several ways other
than controlling access to materials for adults to increase children’s initiations:
play with toys that are of special interest, set up repetitive play situations,
withhold materials needed to pursue activities, display photographs of preferred
activities, begin favourite activities and then pause, glance at the materials and
then look expectantly at the child, and move the materials closer to the child.
After the child initiates an interaction, the adult’s request for a more elaborate
response should cue the child to display the language skill that has been
identified as the target for instruction. For example, when a child who is learning
to imitate words reaches for a cracker, the teacher moves the cracker beyond
his/her reach, models the word “cracker” and provides access to it only when the
child imitates the target word. Later, words can be expanded to phrases (e.g.
“Say cracker please”) and phrases can be expanded to sentences or questions
(e.g. “Say can I have a cracker?”)
It is important to note here that requests for elaboration are prompts. Some
prompts however can be quite general like “what do you want?” and do not
indicate the correct responses. If the child does not respond or respond
incorrectly, the adult may provide a more specific prompt such as “say I want
cracker”. The decision about the type of prompt to be used depends on the
child’s language repertoire and on data based on his/her performance (Fenske,
Krantz and McClannahan, 2001).
After a teacher requests an elaboration, a child may respond appropriately, may
respond incorrectly or incompletely or may not respond at all. If the child provides
a correct elaboration, the adult confirms that s/he is correct and immediately
provides the object or activity of interest.
If the child does not respond correctly or does not respond at all the adult
models the correct response and delivers the item only if the child imitates the
verbal model. Incidental teaching occurs only if the adult provides the child with
the requested object or activity.
There is also a possibility for the child to display problem behaviours during
incidental teaching. In that case, the adult should direct the child to another
activity or should use other procedures that have been proven effective for
reducing challenging behaviours for the particular child; but should not provide
the item for which the child initiated. In this way, the danger for the child to learn
that crying and screaming are effective ways of communicating with others is
avoided.
To conclude, incidental teaching has been proven to be an effective behavioural
educational intervention for children with ASDs (Hart and Risley, 1968, 1982;
McGee, Krantz, Mason and McClannahan, 1983; Anderson, Taras and Cannon,
1996; Fenske, Krantz and McClannahan, 2001). In contrast to discrete trial
training it is conducted on the child’s natural environment and this helps to the
generalization of skills learned in several situations. Furthermore, incidental
teaching typically involves child-directed activities which are likely to be more
meaningful and interesting for the child than adult-directed activities, thus
motivating the child to interact more frequently. In addition, the materials in
incidental teaching are chosen by the children and the rewards for correct
responses are the same materials for which the children initiated the interaction.
This may help children understand the valuable meaning of communication with
others, since they receive what they communicated for, contrary to discrete trial
where children may receive totally irrelevant with the learning activity rewards.
Nevertheless, both discrete trial and incidental teaching are effective ABA
programmes and should be used at different times depending upon what specific
skill is being taught as well as the child’s ability. For example, it may be
necessary to teach some vocabulary to a distractible child who needs the highly
structured environment and the frequent repetition that discrete trial provides.
Then, once a small vocabulary has been acquired, incidental teaching should be
used to make the skill functional.
According to Reichle and Keogh (1985), and Sundberg and Partington (1999),
both are effective for teaching receptive and expressive language skills to
children with ASDs and both are important components of a language curriculum.
However, it seems that incidental teaching is more appropriate for verbal children
with ASDs, although researchers support the view that non-verbal children can
also initiate interactions. It seems though that non verbal children will need much
more time to reach the point where more elaborated language is requested from
them.
PIVOTAL RESPONSE TRAINING
Another educational intervention programme for children with autism, which
comes from a discrete trial applied behavioural analysis approach, is the Pivotal
Response Training Model. It started in 1979 at the University of California at
Santa Barbara with the ultimate goal to provide children with ASDs with the
social and educational proficiency to participate in inclusive settings. In early
stages this model used discrete trial procedures, but there has been a shift
towards use of more naturalistic behavioural interventions (National Research
Council, 2001).
The overriding strategy of the Pivotal Response Model is to aim at change in
certain pivotal areas, such as responsiveness to multiple cues and motivation
(Koegel et al 1999). According to Koegel and Frea (1993), change in these
pivotal behaviours may lead to important collateral changes in a broader range of
atypical behaviours within the syndrome of autism. Since these behaviours are
central to a wide area of functioning, positive changes in these behaviours should
have widespread effects on other behaviours. For example, research suggests
that if one can affect joint attention development in children, then this change
may be expected to contribute to the development of symbolic abilities (Hobson,
1993; Mundy et al, 1993), the development of language abilities (Baldwin, 1995;
Bates, Benigni, Bretherton, Camaioni and Volterra, 1979) and the development
of general social-cognitive processes (Baron-Cohen, 1995; Mundy, 1995;
Tomasello, 1995).
According to Stone (1997), and to Rogers and Pennington (1991), the idea of
pivotal skills to be targeted as goals may also hold for behaviours such as
imitation, maintaining proximity to peers (Hanson and Odom, 1999) and learning
to delay gratification.
Similarly to incidental teaching, pivotal response training uses systematic
teaching trials that are initiated by the child, and focus on the child’s interests;
they are interspersed and embedded in the natural environment and they use
natural reinforcers that follow what the child is trying to communicate.
Furthermore, pivotal response training uses multiple components in an
interaction. For example, during language training, a teacher can teach the same
verb but use two different objects (i.e. “roll car” and then “roll ball”).
Multiple components also mean using adjectives to describe objects like “red car”
or “big ball” versus just “car” and “ball”. This is done in order to increase
children’s responsiveness to multiple cues (www.spectrumcentre.org)
Generally, the pivotal response training like the incidental teaching and others
contemporary ABA approaches, such as Natural Language Paradigm (Koegel
and Johnson, 1989; Schreibman and Pierce, 1993) and enhanced milieu
teaching approaches (Kaiser, Yoder and Keetz, 1992) were developed as
methods of achieving a more naturalistic approach to enhancing language and
communication development for children with autism and other childhood
communication disabilities.
The focus and ultimate goal of all of these
approaches are to facilitate spontaneous communication and interaction. Childpreferred and child-selected activities provide the primary contexts and topics for
communicative exchange (Schreibman and Pierce, 1993), with the adult being
highly responsive and following the child’s lead, so that interactions are more
natural and loosely structured than in traditional ABA discrete trial programmes.
TREATMENT AND EDUCATION OF AUTISTIC AND OTHER
COMMUNICATION RELATED HANDICAPPED CHILDREN
(TEACCH)
A developmental social-pragmatic intervention for children with ASDs, which also
uses elements of behavioural methods, is TEACCH.
TEACCH is a whole life approach in helping people with autism, which aims to
equip children for a productive life in the community. It sets out to provide visual
information, structure and predictability. It was devised in 1966 by Eric Schopler
and his colleagues. The approach requires that adaptations must occur in the
three major areas of the child’s life: home, school and community.
The major priorities include centering on the individual, understanding autism,
adopting appropriate behaviours, and a broadly-based intervention strategy
building on existing skills and interests (Mesibov, 1999).
Structured teaching is an important priority of the TEACCH approach. Organizing
the physical environment, developing schedules and work systems, making
expectations clear and explicit, and using visual materials have been effective
ways of developing skills and allowing children with autism to use these skills
independently of direct adult prompting and cueing (Mesibov, 1999). Cultivating
strengths and interests is another important priority. TEACCH suggests that
capitalising the children’s interests, helps increase their motivation and
understanding of what they are doing.
An important part of any TEACCH curriculum is developing communication skills,
pursuing social and leisure interests, and encouraging people with autism to
pursue more of these opportunities (Schopler and Mesibov, 1994).
The TEACCH programme employs a number of educational techniques, such as
physical organisation, schedules, visual structure and routines, which have been
proven to help develop skills and minimise behavioural problems (Mesibov,
1994).
Providing structure and organisation in the classroom or any other learning
environment on a students’ level of understanding can help to alleviate or
moderate these problems and the resulted ineffective learning situations. The
first component of structured teaching that the TEACCH approach adopts is the
structure of the physical environment. This refers to the way in which the
environment is organised. The physical layout of the classroom is an important
consideration when planning learning experiences for autistic students. Even the
arrangement of the classroom furniture can help or hinder a student’s
independent functioning and his/her recognition and compliance with rules and
limits (Marcus, 2002).
Many students with ASDs have organisational problems not knowing where to be
and how to get there by the most direct route. Structuring the environment gives
them visual cues to help them understand. Physical organisation might also
involve structuring the environment so it is not distracting. Lighting, noise, size of
the room and distracting wall spaces are some of the features that attention is
given to (www.teacch.com/structur.htm).
Having specific areas for learning specific tasks, marking clear boundaries and
making materials easily accessible, helps children independently know where
they are supposed to be and where to get their own materials. Establishing areas
in the classroom begins with the natural setting. For example, work areas are
avoided to be set up near distracting windows or mirrors. It is beneficial to have
work areas near shelves or storage, so that materials are easily accessible
(www.teacch.com/structur.htm). Blank walls are also good to build a work area
around. Students’ tables face the blank walls and some distractions are thus
eliminated.
Additionally, several materials of the classroom such as rugs, bookshelves,
partitions, tape on the floor or arrangement of the tables are used to mark clear
boundaries. For example, a work area may be outlined by shelves and work
tables; or the carpeted area may indicate the leisure area; a small rug in front of
the sink may be used to show students where to stand when they are washing
their hands or when washing dishes.
Materials are also clearly marked. Pictures, colour coding, or numbers are used
to help students label and obtain or put away materials by themselves. However,
along with the physical structure of the environment, TEACCH considers the
individuals needs of students as well. For example three work tables could be
used to provide the structure needs of different students.
One table could be placed in the middle of the class, for students who are not
easily distracted by other people’s activities; another table could be placed facing
a blank wall and pieces of tape on the floor can be used to show where chairs
should be while working. This could be for students who are more easily
distracted and tend to wonder around when they are not busy working. The third
work table could be placed facing a blank wall and is parted on two sides with
dividers, and would be for students who are easily distracted from what others
are doing and who might exhibit behaviours that are disturbing to others while
working (www.teacch.com/structur.htm)
Another component of structured teaching is scheduling. This tells the students
visually what activities will occur and in which order. Using objects, photos,
pictures or numbers, depending on children’s developmental level, children are
helped to understand a sequence of events (www.teacch.com/structur.htm).
Schedules can help children organise and predict daily and weekly events.
Besides knowing what activity will happen during a time period, a schedule lets
them know where they should go next. Also, children with low initiative may be
more motivated to complete a difficult or dreaded task if they see on their
schedule that it will be followed by a more enjoyable task or activity.
There are usually two types of schedules being used simultaneously in
classrooms. The first type is the general overall classroom schedule. The second
type is the individual student schedule. The overall classroom schedule outlines
the events of the day. It does not specify work activities for students but does
show general work times, break times, lunch time etc. The general classroom
schedule should be posted somewhere in the classroom for all to be able to see
and use.
The format may be written or for students who do not comprehend written
language can be made by pictures or drawings. During the work times of the
general schedule, teachers and students might be involved in a variety of
activities. These are reflected in the individual student schedules. These, can
take a variety of forms but must be individually oriented; i.e. age appropriate,
balanced with difficult and enjoyable activities, based on the child’s level of
comprehension and based on a student’s endurance level; in terms of how often
reinforcement or change in activity is needed (www.teacch.com/structur.htm).
As students learn to comprehend and follow schedules, they develop good
independent functioning skills both of which are very important skills to have for
successful functioning in future placements like vocationally and residentially
(Marcus, 2002).
Another way structure is used to help children function successfully is in the
setting up of teaching tasks. Direction of all tasks and the use of prompts and
reinforcers are organised and systematic in order to build success experiences
for students. This makes learning situations more predictable for students and
help to overcome distractibility, resistance to change, and lack of motivation
(www.teacch.com/structur.htm). Directions can be given to children verbally or
non-verbally according to the child’s level of understanding. For verbal directions,
this means using the minimum amount of language needed. Furthermore, they
are also accompanied with gestures to help children understand better.
Non-verbal directions are given with contextual visual cues, like systematically
presenting and positioning materials, and using jigs and written instructions.
Setting up a students work from left to right for example, gives an organised and
systematic base for the student to work, completing tasks more easily without as
many verbal instructions. Placing materials in the setting where they will be used
can also help a student complete directions and complete tasks more
successfully. Jigs and written instructions also help a student to get and stay
organised while working. Samples of pictures of finished products are used to
show students what needs to be done. Moreover, pictures and written
instructions are used to help a student complete a sequential task in the right
order (www.teacch.com/structur.htm). Prompts are also used to help children be
successful in what they are learning and doing.
The TEACCH approach also takes into account that students with ASDs are
usually not motivated by social reinforcements. Thus, teachers need to discover
reinforcements that the children understand and enjoy. However, in order for the
teacher to use reinforcement as an effective teaching tool, s/he must be
systematic in the use of it. The type and frequency of reinforcement for individual
students are planned prior to activities. The teacher also needs to make sure the
reinforcing consequence immediately follows the skill been learned or increased
so
that
the
relationship
between
the
two
is
clear
to
the
student
(www.teacch.com/structur.htm)
Significant improvement in appropriate behaviour and communication are the
main reported benefits of TEACCH (Cumine, Leach and Stevenson, 2000).
Some may feel that TEACCH over-structures children, limiting their decision
making and creativity. However, flexibility is encouraged within the structured
framework, particularly in developing problem-solving skills.
PICTURE EXCHANGE COMMUNICATION SYSTEM
(PECS)
The Picture Exchange Communication System (PECS) is an augmentative
communication system developed to help children and adults with autism and
other developmental disabilities, to rapidly acquire functional communication
skills (Bondy and Frost, 1994a). It is one of the intervention approaches for ASDs
which integrates theoretical and practical perspectives from the fields of ABA and
speech and language pathology. Several techniques developed within ABA are
used as the fundamental teaching strategies. For example, to implement PECS,
the teacher must first identify powerful reinforcers for which a child will be
motivated to communicate. Teaching strategies use a variety of prompting,
shaping, and fading techniques to gradually improve and modify the way children
use the system. Techniques are drawn from discrete-trial and sequential formats,
as well as incidental teaching formats (Bondy and Frost, 1994).
PECS is an appropriate programme for children who do not use speech or who
may speak with limited communication effectiveness. Children using PECS are
taught to give a picture of a desired item to a communicative partner in exchange
of the item. By doing so, the child initiates a communicative act for a concrete
outcome within a social context (Wallin, 2002).
There are typically six phases involved in the teaching of PECS use. While these
phases should be approached and taught sequentially, there may be times when
a child is working on two or more phases simultaneously (Wallin, 2002).
During phase one, the lesson taught is to spontaneously request items and
activities. To do this, the teacher first needs to identify what items the child
persistently wants, those things for which s/he would be willing to make a
request. When preferences emerge, two adults start working with the child at this
initial stage. The first adult entices the child with an object s/he really likes. The
role of the second adult is to stay behind the child and wait for him/her to reach
for the item and then to physically assist the child to pick up the picture of that
item and hand it to the first adult.
When the first adult receives the picture s/he immediately gives the child the
reward, along with an appropriate comment (e.g. “Oh, you want the candy!”). As
soon as possible the physical assistance from the second adult should be faded
out until the child is exchanging a picture for the item independently with the first
adult. Because the goal for the child is to initiate communication, rather than to
simply respond to requests, it is very important not to ask the child what s/he
wants or to use other verbal prompts. The goal is for the child to seek a
communicative partner, from the start (www.polyxo.com:PECS)
After the child can reliably exchange a picture for a requesting object, the move
is made into the second phase. The child is now encouraged to use greater
spontaneity and persistence, and to generalise the skill s/he has acquired. The
child continues to request motivating items and activities, but now is required to
move a longer distance to get to the communication partner or to get to the
picture. S/he also begins to make requests in settings different from those in
which s/he was taught the initial phase (i.e. different rooms, at the local store, at
the grandparents’ house etc) and with a variety of different people. Furthermore,
the child begins to expand his/her vocabulary of symbols, requesting different
reinforcing objects or activities. According to Bondy and Frost (1994), the
successful completion of phase two is often vital if the child is to be a
spontaneous communicator.
In the third phase of PECS, the child is beginning to be asked to discriminate
between a number of items on a board, making choices as to what items s/he
may want, to try. The child begins by answering questions like “what do you
want?” but these are faded quickly so the child will make choices spontaneously
as well as in response to questions. If discrimination is a new skill for the child,
the teacher uses just two items and as the child becomes more comfortable with
discriminations more items can be added. At this point of the training, several
technical decisions are to be made, such as whether to reduce the size of the
pictures, change the format of the board and so forth (Ryan, 1990).
Once the child is able to discriminating and making requests for a variety of
items, to a variety of people and in a variety of environments, phase four begins,
which focuses on sentence structure. The child will start combining a picture for
“I want” with the picture of the requested item or activity. The two pictures are
attached to a sentence strip and the entire strip is exchanged with the adult for
the item or activity (www.polyxo.com:PECS)
The fifth and sixth phases occur at the same time, focusing on different
extensions of the child’s skill with picture exchange. The fifth phase extends the
sentence structure begun in phase four. Adjectives and other words can be
added to the child’s repertoire to encourage him/her further refine his/her
requests. The sixth phase is considered to be a fundamental shift in the child’s
communication and the expected outcome from the teachers or peers. Through
the use of pictures for “I see”, “I hear”, “I feel” etc the child is able to comment on
elements of his/her environment.
The PECS system has gained widespread use internationally and is appealing
for several reasons (Siegel, 2000; Yamall, 2000). Each exchange is clearly
intentional and readily understood. From the start, communication is initiated by
the child and is always meaningful and highly motivating for the child. Also, the
materials used are cheap, easy to prepare and portable.
Furthermore, several informational reports have suggested that a large number
of children who learn PECS, also develop spoken language (Bondy and Frost,
1994; Shaartz Garfinkle and Bauer, 1998). Moreover, anecdotal reports have
indicated that the use of PECS may result in a decrease in problem behaviour
and improved social behaviour (Bondy and Frost, 1994; Peterson, Bondy,
Vincent and Finnegan, 1995).
PROXIMAL COMMUNICATION APPROACH
According to Whittaker (1996), the term Proximal Communication is applied to a
range of non-verbal techniques that adults can use to engage children with
autism in social interactions. It is an autism specific interactional approach based
upon the social strengths of children.
Whittaker (1996) and Whittaker and
Reynolds (2000), identified children's strengths in non-verbal communication
which include: approaching adults who were passive and did not talk, maintaining
proximity to adults in situations where no toys or objects were being used,
reaching out to adults after being tickled to ask for more, and so forth.
The aim of Proximal Communication is to engage the children in playful and
pleasurable non-verbal interaction to develop their early social skills (Potter and
Whittaker, 2001).
One of the major strategies used in the proximal
communication approach is the burst/pause activity. The adult does something
the child appears to enjoy-the active, burst phase. The adult then stops and waits
for the child to communicate that s/he wants the activity to start again-the
passive, pause phase.
If the child is not exhibiting intentional communication, the adult treats a chosen
aspect of the child's behaviour as if it was intentional. For example, the adult may
tickle the child and then stop and wait for the child to communicate that s/he
wants more. As soon as the child looks at the adult, s/he immediately tickles
again so that the child realizes that it was the looking at the adult that caused
him/her to repeat the tickling. Once the child has realized this, then s/he begins
to look at the adult, expecting that the look will have particular effect and finally
s/he looks in order to achieve that effect. Based on their knowledge of the child,
the adults must decide which behaviour they want to shape as communication.
Potter and Whittaker (2001) have identified several such behaviours like hand
signalling for example.
Another major strategy that the proximal communication approach adopts is the
minimal speech approach. This means that adults should consistently use one or
two relevant concrete words when interacting with children who understand little
speech. According to Potter and Whittaker (2001), such an approach can be
highly effective and is very important in the creation of more communicationenabling environments for children with autism. Furthermore, such an approach,
in conjunction with strategies such as the visual cues, and adult use of pointing
and multipointing, is likely to enable children to progress in their understanding of
individual words (Potter and Whittaker, 2001).
Appropriate rough and tumble play is also a strategy frequently used in proximal
communication. Rough and tumble is a term that covers a broad range of playful
interaction behaviours generally involving large body movements and some form
of physical contact. Observation of the child prior to proximal communication
sessions will enable the adult to decide about how much physical activity the
child would enjoy. The important thing here is not the actual running or chasing
but rather, a slow motion chase. Exaggerated movements and facial expressions
from the adult, help on the building up of the anticipation of the child for the final
tickle.
Potter and Whittaker (2001) also suggest that adults should make use of nonspeech vocalizations in imitation of the child's sounds. They point out that this is
generally effective in engaging children in proximal communication sessions. By
using bursts of vocal imitation, followed by pauses, some children could be
engaged in a non-speech vocal dialogue, with the amount of vocalization used by
the children increasing significantly compared to when the adult was silent.
However, they emphasize that the main purpose of this is to engage children with
the adults and not to teach different sound patterns.
Proximal Communication is about engaging children in social interactions that
they
understand
and
enjoy,
and
teaching
children
the
meaning
of
communication-the cause and effect relationship between them and their
communicative partner.
MUSICAL INTERACTION
Musical interaction is another educational intervention for children with ASDs
which aims to engage each child in the process of interaction, to build up the
desire for communication. It aims to enable students to develop social and
communication skills, including the pragmatics, by interacting through songs,
games, and musical ‘conversations’ (Prevezer and Chandler, 1998).
At the beginning, the adult respond to the child’s spontaneous sounds and
movements as if they were communicative intents-this may encourage the child
to start using them intentionally. Prevezer (1990) suggests ways of ‘tuning in’ to
the child. She begins by creating shared attention, by joining in with or imitating
the child. She then gives a simple running commentary to the child’s actions,
which is chanted, sung or played on an instrument. Use of songs, rhymes and
play routines as frameworks for communication, creating pauses for anticipation,
helps to underscore the interaction. Using mainly keyboard and voice, the adult
helps
the
interaction
to
flow
and
develop
played
improvised
music,
accompanying songs, initiating activities and supporting or prompting in various
ways.
Activities, as well as ways of responding are based on the child’s individual age
and circumstances. Whether in lap play with younger students or instrumental
play with older ones, skills such as turn-taking, social timing, eye contact and
imitation are made easier and more meaningful with music. According to
Prevezer and Chandler (1998), gaining these fundamental conversation skills
gives a framework for further communication development.
Musical interaction is another intervention which recognises that children with
ASDs appear to lack the basic motivation to interact, and by teaching the skills of
communication in an interactive way, it facilitates an enjoyment of being in an
interactive process. It is again a child-centred method, with the adult following the
lead of the child, and interacting with the child at the developmental level, rather
than the age level.
ESSENTIAL CHARACTERISTICS OF EFFECTIVE INTERVENTIONS
As already mentioned above, there is at least some evidence (i.e. Dawson and
Osterling, 1997) for each of these approaches which suggests that all of these
communication intervention programmes have been proven effective for different
children with autism and their level of success, on the development of social and
communicative skills of children, has been determined by changes in measures
such as IQ scores and academic achievement.
However, according to Lord (1999), it is very time consuming to implement a
thorough evaluation of social and communicative areas especially because
communication varies in different contexts, among various communicative
partners and over time. However, there is a large and growing corpus of rigorous
single-subject experimental studies and some group comparisons documenting
individual differences in outcomes that contribute to an understanding of current
research opportunities and gaps (Koegel, 2000).
In general, there is consistent agreement across intervention programmes about
a number of features, through practical and, sometimes ethical considerations
have made well-controlled studies with random assignment very difficult to
conduct without direct evaluation (National Research Council, 2001).
Characteristics of the most appropriate intervention for a particular child must be
tied to that child’s and family’s needs. However, without direct evaluation it is
difficult to know which features are of greatest importance in a programme.
Across primarily pre-school programmes, there is a very strong consensus that
the following features are critical:

Entry into intervention programmes as soon as an ASD diagnosis is
seriously considered

Active engagement in intensive instructional programming for a minimum
of the equivalent of a school day, 5 days a week, with full year
programming varied according to the child’s chronological age and
developmental level

Repeated, planned teaching opportunities generally organized around
relatively brief periods of time for the youngest children, including sufficient
amounts of adult attention in one-to-one and very small group instruction
to meet individualized goals

Inclusion of a family component, including parental training

Low student/teacher ratios

Mechanisms for ongoing programme evaluation and assessments of
individual children’s progress, with results translated into adjustments in
programming
(National Research Council, 2001)
All of the above programmes share these key elements. They are all embedded
into the above approaches as important factors for the effectiveness of the
programmes.
Overall, many of the programmes are more similar than different in terms of
levels of organization, ongoing monitoring and the use of certain techniques,
such as discrete trials, incidental teaching and structured teaching. Furthermore,
they all share the view that family involvement is a vital component of an effective
intervention programme, and moreover, they all suggest that early and intensive
intervention is likely to lead to huge progress.
However, curricula across these programmes differ in several ways. They include
the ways in which goals are prioritized, affecting the relative time spent on verbal
and non-verbal communication, social activities, behavioural, academic, motor
and other domains. They also differ in the teaching methods they use, with
others adopting one set of procedures, and others adopting combinations of
approaches.
There is no outcome study published that supports comparative statements of
the superiority of one programme or approach over another. Rather, with few
exceptions, much of the current outcome information is in the form of programme
evaluation data or measures of children’s progress when comparisons are made
before and after intervention.
The available research strongly suggests that a substantial subset of children
with ASDs are able to make marked progress during the period that they receive
intensive early intervention, and nearly all the children appear to show some
benefit.
The fact that there are real differences in philosophy and practice of different
approaches, provide a range of alternatives for parents and school systems
considering various approaches.
The key to any child’s educational programme lies in the objectives specified in
the IEPs and the ways they are addressed.
Thus, effective intervention programmes, are and should vary considerably
across individual children, depending on a child’s age, cognitive and language
levels, behavioural needs and family priorities.
THE CASE STUDY
The present study aimed to identify how practitioners in a particular pre-school
setting for children with ASDs are interpreting and applying strategies, proposed
by theorists as methods of good practice in the teaching of communication skills.
The literature review identified the various strategies recommended while the
practical investigation, the actual case study,
looks at how practitioners are
interpreting and applying these strategies in their everyday contact with the
children.
Although much has been written about the implementation and the evaluation of
specific intervention strategies for children with ASDs, usually by those proposing
a specific approach (e.g. Schopler and Mesibov, 1985; Bondy and Frost, 1994),
there has been very little investigation into how practitioners are interpreting and
applying this varying and often conflicting advice. This current study therefore, by
making detailed observation of the implementation of the strategies in a real life
setting, informs the debate on how children with ASDs are being taught by
evaluating how theorists are impacting upon classroom practice.
The particular pre-school establishment is a specialist provision for children with
ASDs and it accommodates children from 2 to 4 years of age.
The nursery is staffed by four members, two nursery nurses and two speech
therapy assistants.
There were eight children in the group studied, attending the nursery everyday
from 9.30 to 11.30 am.
The findings of the study identified the particular intervention methods used in the
nursery, identified the way that practitioners interpret and apply these methods
and showed that they indeed positively contribute to the communication
development of the children.
METHODOLOGY
The research questions which formed the focus of the study were:

To identify through a literature review recommended interventions for
supporting the development of communication skills in children with
autism

understand how staff, within a specific pre-school establishment, select,
interpret and apply these methods and

to evaluate how successful these are in contributing to the development of
communication skills
A qualitative method of research was selected for this study. This was felt to be
the most appropriate methodology because qualitative perspectives commonly
focus upon the constructed nature of social reality (Gillham, 2000).
The present study was conducted in a real-life setting and it aimed at a detailed
description of it.
It took the form of a group case study. A case study is one which investigates an
individual or a group of individuals, in order to answer specific research questions
and which seeks a range of different kind of evidence; evidence which is there in
the case setting and, which has to be abstracted and collated to get the best
possible answers to the research questions (Gillham, 2000).
Nisbet and Watt (1984) suggest that a case study is a specific instance that is
frequently designed to illustrate a more general principle; it is the study of an
instance in action. The single instance is of a bounded system, for example, a
child, a clique, a class, a school or a community. It provides a unique example of
real people in real-life situations, enabling readers to understand ideas more
clearly than simply by presenting them with abstract theories or principles.
In the present study, it was felt particularly appropriate to use a group case study
approach. Since I wanted to investigate a particular group of children in a specific
context, a case study approach allowed the selection of two children of the
nursery, and the collection and presentation of detailed information about this
group of children.
In depth and detailed observation of these children was essential, because I
wanted to look at all the aspects of their everyday communication within the
nursery. The most effective methods of identifying what communication
strategies are being used within a particular setting are observation and
interview, traditionally the tools of qualitative research.
Two boys aged from 2 to 3 years old were randomly selected to take part in the
study. For the limited time span that this study was conducted, it was felt that for
in depth and detailed observation and data collection, two children would be most
appropriate.
The researcher enquired as to whether there might be a cause and effect
relationship, between the communication strategies used in the nursery and the
development of communication skills of children.
According to Cohen, Manion and Morrison (2000), case studies can also
establish cause and effect, and indeed one of their strengths is that they observe
effects in real contexts, recognizing that a context is a powerful determinant of
both causes and effects.
Case studies are thought to have several strengths and weaknesses. Nisbet and
Watt (1984), point out, that strengths of case studies are:

The results are more easily understood by a wide audience as they are
frequently written in everyday, non professional language.

They can be undertaken by a single researcher without needing a full
research team

They can embrace and build in unanticipated events and uncontrolled
variables.
However, there are also weaknesses, which involve:

The
results
may
not
be
generalizable
except
where
other
readers/researchers see their application

They are not easily open to cross-checking; hence they may be selective,
biased, personal and subjective.

They are prone to problems of observer bias, despite attempts made to
address reflexitivity.
(page 184)
Yin (1989), describes a case study as being one of three types in terms of
outcomes: exploratory, descriptive and/or explanatory. Exploratory cases are
sometimes considered as a prelude to social research. Explanatory case studies
may be used for doing casual investigations. Finally, descriptive cases require a
descriptive theory to be
developed
before starting the project.
This case study could be described as “Descriptive” as it relies heavily on the
theories of several communication interventions analysed in the literature review.
In order to enhance objectivity, triangulation of methods was used. Triangulation
refers to the use of different methodological standpoints, in order to aid reliability
and objectivity (Stake, 1995).
In the present study, several methods for data collection were used.
The major data collection instruments were:
 Review of literature
 Direct observation
 Interviews
 Video analysis
 IEPs analysis
These tools for data collection were chosen in order to provide the researcher
with information about the children, the staff, the environment of the setting, the
intervention methods, the application of the methods as well as the possible
progress of the children.
Evaluation of the tools used
Review of the literature
The review of the relevant literature on the communication-based interventions
for children with ASDs was felt to be very useful to the present study. The
selection of the specific intervention programmes analysed in the literature
review was made in order to firstly show the difference between behavioural and
more developmental approaches, and secondly, in order to identify and describe
the approaches mostly used in the nursery-it provided a framework by which the
researcher could identify what might be termed “strategies” used in the nursery.
Thus, the Incidental Teaching and the Pivotal Response Training approaches
were described in order to show the strong behavioural elements involved in
them, as well as the combination of behavioural and developmental techniques
they use.
TEACCH, PECS, Proximal Communication approach, and Musical Interaction
were described as they are the main approaches used in the nursery although
some of them are not being “formally” adopted in the nursery, but many elements
of them are frequently used by the staff.
The collection of information about all the approaches was made using books,
journals and the Internet.
Observation
Observation is a very important method of data collection in every case study.
There are two principle kinds of observation known as “participant” and “nonparticipant” or “detached/structured observation” (Gillham, 2000).
Participant observation occurs when the researcher is actively involved in what
goes on, and is mainly descriptive.
Non-participant observation occurs when the researcher is watching from
“outside” in a carefully planned and specified way-counting and classifying what
s/he sees.
I adopted the role of a participant observer since I was actively involved in the
everyday activities of the children in the nursery. Being actively involved in all the
activities and tasks in the nursery I gained a more in-depth view of the
practitioners’ suggestions and way of work.
The overpowering validity of observation is that it is the most direct way of
collecting data. It is not what people have written on a topic, or what people say
they do, but it is what they actually do. Because the present study involved very
young children with severe communication difficulties, observation seemed to be
the strongest way of collecting data about their everyday interactions.
However, from the point of view of positivist “objectivity” a major objection to
observation is the effect of the researcher’s presence on those who s/he is
observing. This is known as the “observer effect” (Stake, 1995). According to
Robson (1993)
this can be overcome-for example by seeking to ensure that the observed are unaware
of being observed, at one extreme; or by them being so accustomed to the presence of
the observer that they carry on as if the observer was not there, at the other extreme
(page 191).
For the particular case study, it was felt that the children were unaware of being
observed. Of course, it is very difficult to ascertain whether this is a true fact.
However, according to staff’s comments nothing seemed to have changed in
their usual behaviour with the presence of the researcher.
Morrison (1993), points out that observation enables the researcher to gather
data on:

The physical setting-physical environment and its organisation

The human setting-organisation of people

The interactional setting-interactions that are taking place-formal, informal
etc

The programme setting- e.g. resources and their organisation
The present study provides an analytical description of the above data that is
analysed in the Findings section.
Field notes were collected from the observation of the environment of the
nursery, the staff, the children and the resources and techniques used to
enhance communication development of children.
The observation data were collected in eight visits to the nursery. Specifically:
Visit 1 (27/05/03)

Observation of the physical environment and the everyday routine of the
nursery

Observation of Andy in threading, computer and painting activities

Observation of Stewart in painting, water tray and jigsaw activities.

Observation of both Andy and Stewart during snack time.
Visit 2 (29/05/03)

Observation of Andy throughout his day at the nursery.
Visit 3 (05/06/03)

Observation of Stewart throughout his day at the nursery.
Visit 4 (10/06/03)

Viewing and analysis of videos of both Andy and Stewart during their first
months at the nursery
Visit 5 and 6 (18/06/03-02/07/03)

Observation of both Andy and Stewart throughout the day
Visit 7 (23/07/03)

Interview with the leading nursery nurse
Visit 8 (17/09/03)

Observation of the whole group in the nursery
Interview
Interviews are one of the most commonly recognised forms of qualitative
research method. The overwhelming strength of a face-to-face interview is the
richness of the communication that is possible.
For the purposes of the present study, the lead teacher of the nursery was
interviewed, after several weeks of the researcher’s observation of the children.
A 20 minute semi-structured interview which was tape-recorded took place in the
nursery, in order for the researcher to clarify issues she had observed and to
gain a more in-depth view of the communication strategies used in the nursery.
Furthermore, the interview was used as a method of triangulation for the present
study. In addition to the observation, which was the main data gathering tool, the
interview as well as the video and the IEP’s analysis aimed to serve as different
kind of sources (or data) to prove the same kind of evidence-that was to
investigate
how
the
nursery
actively
encourages
the
development
of
communication skills of children.
According to Gillham (2000), there are several strengths in interview techniques.
For the present study, where a semi-structured interview was used these are the
most relevant:

Small number of people are involved (just the leader of the team of
staff)

They are accessible

The questions are mainly open and require an extended response with
prompts and probes from the researcher to clarify the answers
(page 62)
The leading teacher of the nursery was selected to be interviewed, due to the
fact that she has been working in the nursery longer and had the most
experience with children with ASDs. A transcript of the interview is included as
Appendix 1.
Video Tape Analysis
Video analysis was used as another tool to give evidence of the communication
development of the children of the case study. Andy and Stewart were
videotaped by the staff on their first day at the nursery as well as on later
sessions. In order for the researcher to discover progress in the communication
skills of these children, she observed their behaviour on these first days and
compared it to the communicative behaviour they displayed when she visited the
nursery-that was three months later.
Individual Educational Plans (IEPs) Analysis
Every child receives an IEP that focuses on the development of goals and
objectives for him/her to achieve. The first IEPs of the children involved in the
study were compared with the latest ones in order to find evidence of progress
especially on their communication development. The change of the goals and
targets on each IEP as well as the remarks of the staff on whether goals and
targets were achieved were carefully examined and analyzed.
DATA ANALYSIS
All the data collected, were categorised according to the source which they were
provided from. For each specific aim of the study, data were collected from the
literature review, from the observation, the interview, the video tapes and the
IEPs. Data from the literature review can be found in the according section. Data
from observation can be found in the appendices section along with data from
the IEPs. A transcript of the interview can also be found in the appendices
section, as well as data from the video tapes in the form of notes.
Each aim of the study was addressed using different sources of data or
combinations of sources of data. For example, several points or arguments were
supported by data from one source, i.e. observation, while others were supported
by combinations of sources i.e. interview and observation, or literature review
and observation.
Furthermore, the appendices section can provide the reader with detailed
information about the data collected and used to support arguments made in the
study.
FINDINGS OF THE STUDY
One of the main aims of this study was:
 to identify the particular communication intervention procedures used in
the nursery.
From the first visit of the researcher to the nursery, it was identified that the
TEACCH and the PECS methods were the interventions mostly used in the
nursery. Children are communicating with adults using the PECS system and
the environment follows the TEACCH principles of physical structure, and visual
clarity. Everything is labelled, there are clear visual boundaries segmenting the
space into recognisable parts and the visual schedule tells the children which
activities will occur and in which order. Tasks and activities are presented visually
so as to make the expectations clear and highlight the important information.
The interview with the leader teacher of the nursery, I will name her Dawn, also
confirmed that these two methods were the main approaches used in the
nursery; and were used deliberately and knowningly in the knowledge that they
are recognised strategies.
Dawn: “PECS is the first communication strategy introduced to the children when
they first arrive at the nursery. After we find out what motivates the child and
what does not, we introduce the first phase of PECS”.
.......... The other way we encourage communication is with the TEACCH
timetable that we introduce.
The staff also make home visits to the children, twice a week in order to teach
them to use PECS in places other than the nursery, and in order for the parents
to practise the use of it at home. According to the interviewee, it is the main
method used within the nursery for the encouragement of the communication
development in children.
Furthermore, TEACCH is also introduced at children’s homes earlier or at the
same time that they join the nursery.
However, from the researcher’s observation of the staff and the children in the
nursery, it appears that, in addition, there is use of many elements of other
communication interventions, such as proximal communication and musical
interaction. Although these two methods are not part of the formal interventions
used in the nursery, many strategies of them are frequently used by the staff,
embedded in their overall attitude to the children.
The “minimal speech approach” for example, a basic strategy of the Proximal
Communication was observed to be adopted by the staff, especially towards
children who are not vocal and who seem to not comprehend speech. Staff were
observed to give quite a lot verbal requests to Stewart for example, whose verbal
comprehension level is quite high, while they keep a minimal speech approach
with only keywords involved towards Ben who does not understand speech.
The “burst/pause” activity of Proximal Communication’s strategies was also
observed to be involved in many non-directive activities like chasing games or
tickling games or blowing bubbles games.
Dawn identifies that staff may intuitively use these strategies to encourage more
initiations of communication by the children.
Dawn: “we try to create as many “communication temptations” as possible with
the children, in structured as well as in non-structured activities. Depending on
the level of ability of each child and on what they are working on at the time, we
create opportunities for the children to practice the use of the communication
means each one has and initiate the interaction him/herself”.
For example, in visit 2 of the researcher, Andy is observed blowing bubbles with
the speech therapist in a structured activity. When she stops, she prompts Andy
to use PECS in order to request for more bubbles.
In a similar game with Stewart however, who is more vocal than Andy, she
encourages him to say “bubble” or “again” when she stops.
In visit 6 of the researcher, Andy is observed in the multisensory room, in a nonstructured activity. He and one of the teachers are engaged in a tickling game.
When the teacher stops tickling, she turns her back and stops looking at him.
Andy is approaching her and touches her on the shoulder to indicate he wants
more.
These observations support the interviewees comments that staff differentiate
their approach towards different children according to their level of ability and the
target they are working on, as well as the staff efforts to make the children initiate
interactions and practise their communication skills frequently.
Furthermore, staff was also observed using another strategy of the Proximal
Communication approach which involves the adult’s imitations of the children’s
vocalisations. This strategy was observed to be used regularly by the staff with
one specific boy, who is not vocal. In visit 8 for example, the teacher is observed
approaching the boy while he is playing alone with car toys and she joins in. She
imitates the vocal sounds he is making and he seems to take notice, and enjoys
it. They engage in a “babbling conversation” where turn taking and eye-contact
are used.
The staff have also adopted techniques of the Musical Interaction approach. In
several occasions for example, staff were observed singing their words to
children or giving chanted commentaries of the children’s actions. Furthermore,
several singing games are part of the everyday activities in the nursery in order
to encourage interaction and turn taking between the children.
According to Dawn's comments, although all these strategies are not part of the
formal communication interventions used in the nursery, the staff feel that “some
of them may encourage development of communication skills for some children”.
Therefore, they use elements of these approaches embedded in the methods
formally used at the nursery, according to each child’s abilities and needs, in
order to further encourage their communication and social interaction skills.
The second and third aim of this study were to:
 identify the communication intervention procedures that are used in the
nursery and
 understand how staff are applying these strategies
The literature review provides an analytical description of the principles and the
aims of each communication intervention, as well as the way each one of them
might contribute to the communication development of different children.
Different communication approaches, take into account the different strengths
and weaknesses as well as the different needs of children and their families, and
modifying their principles upon them contribute to the social and communicative
development of children.
The interview with the leading teacher of the nursery also gives evidence that the
methods used actually help children to develop their communication skills.
According to her, the fact that children learn to use PECS gives them a means of
communication that they did not have before their entry into the nursery.
Moreover, the “communication temptations” that the staff create for the children,
give them the opportunity to use and practice their means of communication and
improve their communication skills everyday.
She very strongly believes that the strategies used in the nursery actively
contribute to the communication development of the children. “Take Andy for
example! When he first attended the nursery we couldn’t get him out of his
mother’s arms. He would not do nothing but scream and cry. Now he can
communicate his requests and dislikes effectively and he definitely is more
independent and happier!”
The fourth aim of this study was to:
 understand the way in which these interventions might contribute to the
communication development of children
The progress in the development of communication skills of the children was
recorded through observation, video-tapes and IEPs.
The researcher, on her fourth visit, watched a video-tape of Andy and of Stewart,
on their early days at the nursery.
From the comparisons of her previous
observations of the communication skills of children with those recorded on the
tapes, it appeared that there was significant progress achieved by the children.
However, this progress is different for each child depending on their
communication abilities before they joined the nursery.
Notes of the children’s performance during their early days at the nursery are
included in Appendix 2.
Stewart:
Stewart already had some experience of PECS before his entrance at the
nursery. He used to go to playgroups of the same nursery and he also had home
visits from the speech therapist assistant once a week. From the video tape of
his early days at the nursery, it is obvious that Stewart has made great progress
with his communication skills. He reached the 6th and final phase of PECS in very
little time; his spoken vocabulary has increased as well as his intention to
communicate with the adults.
The children’s IEPs can also provide evidence of their communication and social
development during their attendance at the nursery. The detailed IEPs can be
found in the appendices section.
From the comparison of Stewart’s January IEP with his April one, it is obvious
that he has achieved great progress with his communication skills during his
attendance to the nursery. By achieving the targets in his January IEP he has
moved towards working on new ones and he gradually improves his
communication skills.
His spoken language has significantly increased as well as his comprehension
of spoken language. Moreover, Stewart has become more social. He tolerates
adults and children in his play for longer periods and he appears to be enjoying
his day at the nursery.
Andy:
Andy seems to have made great progress as well. Unlike Stewart, Andy had no
experience of PECS before attending the nursery; he had no spoken language
and no effective means of communication.
From the video tape of his recorded performance during his early days at the
nursery, it appears that Andy very quickly adjusted to the nursery routine and
learned to use PECS. He seems to have grasped the concept of communication,
although he still needs quite a lot of prompts to use it.
Progress in the social and communication development of Andy is also obvious
from the analysis of his IEP. Comparison between Andy’s IEP of January 2003
with his IEP of April 2003, shows that he has achieved certain goals and targets
in that period, and he continues to develop communicatively.
In general terms, after a period of five months in the nursery, Andy seems to
have made great progress on his communication and social skills. The TEACCH
visual aids and labels have helped him to make sense of what is expected from
him in the nursery.
With the use of PECS he is now able to communicate what he wants. Having
moved to the sixth phase of PECS he can even comment about the environment
around him.
With the everyday practise of these communication interventions at the nursery
as well as at home, Andy seems to have found ways to interact with the world
and most significantly to initiate these interactions himself. Furthermore, he can
now tolerate other people close to him and he even seems to enjoy it in certain
situations.
DISCUSSION OF OUTCOMES
The present study attempted to identify the possible ways in which a specific preschool establishment might contribute to the development of communication and
social skills of two children with ASDs. The PECS and TEACCH are the main
intervention approaches used in the nursery and have already been proven to
work effectively for different children with ASDs as well as the several elements
of the other communication interventions used by the staff.
The findings showed that both the children involved in the case study made
significant progress during their attendance at the nursery. According to staff
comments and to the researcher’s observations both Stewart and Andy showed
substantial increases in their intentional communication and seemed to be highly
responsive to the interventions used in the nursery. They developed effective
ways of communicating their needs, making choices, commenting about their
environment and enjoying their everyday routine at the nursery. Furthermore the
introduction of PECS and TEACCH at their homes gave them the opportunity to
practise further their acquired communication skills in places outside the nursery
and with a range of different people.
The contribution of the nursery then to their communication and social
development can be characterised as highly important. The high ratio of adults
and children in the classroom allows teachers and speech therapists to
differentiate and modify the philosophy and principles of several communication
interventions according to each child’s strengths and needs.
Moreover, the repeated communication opportunities that the staff creates for
children help them to practice their communication skills frequently and for
several different occasions.
Stewart and Andy had very different abilities and skills when they first joined the
nursery. By working on these different strengths staff enabled them to develop
effective means of communication and to adjust at the nursery with the best
possible way. According to staff’s comments, the development of communication
and social skills made both Andy and Stewart more independent, more social
and happier.
However, the interventions used in the nursery are not the only factor of success.
It is also the enthusiastic and committed staff, who treat each child as an
individual and always differentiate and modify their approach according to the
particular child, and of course the parental involvement; parents are a key factor
to the success of any intervention programme and the nursery is working closely
with them in order for the children and the families to have their needs met.
Prizant and Wetherby (1998) suggest that in measuring efficacy of intervention,
researchers need to go beyond traditional measures of communicative and
language skills such as improvement on standardised tests and include broader
characteristics, such as degree of success in communicative exchange, related
dimensions of emotional expression and regulation, sociocommunicative
motivation, social competence, peer relationships, and the child’s competence in
natural environments. Future research then, should strive to document
meaningful changes that reflect the core domains associated with ASDs as well
as measures of family functioning.
CONCLUSION
The present study attempted to identify and evaluate what contribution a preschool establishment for children with ASDs, makes to the development of the
communication and social skills of the children.
The three main aims of the study were to:
 identify the particular communication intervention procedures that were
used in a particular educational setting for children with ASDs
 understand the way in which these interventions might contribute to the
communication development of children
 identify
any
potential
relationship
between
the
development
of
communication skills and the strategies used
The findings of the study showed that all three of these aims were addressed
effectively with the use of several methodological tools.
However, there are several questions arisen which, due to the limited time span
of the study, could not be addressed, and which could be characterised as
methodological weaknesses of the study.
For example, the parent’s view on the interventions of the nursery as well as on
their children’s progress would be of valuable importance. An interview with the
parents of the two children studied would have provided the researcher with data
that would have added greatly to the arguments made about the contribution of
the nursery to the children’s communication development. Additionally, a visit to
the children’s house would have been an opportunity for the researcher to see
the practice of the children’s communication skills in places outside the nursery.
Moreover, another important question that also arises is what would be the
communication abilities of the children if they did not attend the nursery, and did
not have access to the particular intervention methods. Although there is great
progress recorded for both the children studied, one can not be certain on
whether their communication development is due to the strategies used in the
nursery. If the children received different intervention strategies or even if they
did not receive any intervention at all, would their communication abilities be
different or would they exist at all? This is a very important issue concerning
intervention methods for children with ASDs which was not addressed in the
present study.
Another important issue that arises from the present study is that of the way that
children might experience the intervention approaches used in the nursery. It
would have been very interesting to know the children’s views on the everyday
routine of the nursery, what do they find helpful and what not, what they like or
dislike. Again, this is an issue of great importance which however is quite difficult
to address since it has to do not only with very young children but also with
children with communication difficulties.
Nevertheless, all of the above issues that have risen from the present study can
be future issues for further research.
Moreover, the present study can be replicated with a longer time span, which will
allow the longer systematic observation of more children, in different places
(nursery, home environment), with interviews of parents, siblings or more staff
members.
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www.teacch.com/structur.htm: accessed on 02/06/03
www.polyxo.com:PECS: accessed on 13/03/03
APPENDIX 1
Transcript of Interview
Researcher: What are the intervention methods you use to encourage
communication development of the children?
Teacher: The first communication method we introduce at the nursery is PECS.
The first few weeks we are actually getting to know the children, we find out what
motivates them, what they like, what they dislike and then we start them of with
phase 1. The other way we encourage communication is with the TEACCH
timetable that we introduce. All the visual cues and aids that TEACCH involves
are very helpful for the children to know what is going on at any time and what is
expected of them.
Also, the speech therapist makes home visits usually twice a week so that
children learn to use PECS at home and the parents have the chance to see how
it works so that they can practice it as well…
The TEACCH approach is also introduced at home sometimes even earlier than
the children’s attendance at the nursery.
So what we do at the school environment can then be reinforced at the home
environment….
R: I have noticed that there some other ways that you try to engage children in
interactions, other than TEACCH and PECS. In several unstructured activities for
example, you use techniques which are not part of TEACCH or PECS… to make
children initiate interactions.
T: We do what we call “communication temptations” with the children. Depending
on what are we working on and on what level the children are we try to get them
to engage in communication we think it is meaningful for them…We know what
motivates them and we try to get them to communicate about it…
R: For example the fact that you use minimal speech with specific children or that
you use singing utterances…
T: Yes, there are some things that we find they help specific children. We use
little speech with a child that does not comprehend speech and we try to get him
to communicate with PECS; with a child that is more vocal we use greater
amount of speech and we try to get him to communicate with a sound for
example to show us that he wants something. Stewart for example…. He is in a
level that can understand language and can use it, so we try to get him to speak
more than using PECS.
R: Do you encourage communication between the children at all or do you only
focus in the communication between children and adults?
T: It depends on what stage they are ready for. We always try to encourage
communication between them like in snack time, or singing
time and outside play. But to be honest it never really gets to the stage that
children are actually aware of even their peers names….What we do here is to
get them ready for nursery and hope that they will move on a lot more….
R: So, do you think that the strategies you use in the nursery contribute to the
communication development of children and in what way?
T: Yes, of course! I very strongly believe that both TEACCH and PECS actually
help children to develop communication skills! We can see their progress day by
day…Take Andy for example! When he first attended the nursery we couldn’t get
him out of his mother’s arms. He would not do nothing but scream and cry. Now
he can communicate his requests and dislikes effectively and he definitely is
more independent and happier! The great thing is that they acquire a means of
communication that they did not have before… they can express themselves…
R: So you think that children respond positively to the communication strategies
you use?
T: Well, all children are very different… but in general…it always seems to be a
very positive response from them…Sometimes it might take quite long…but
definitely the TEACCH and PECS are helping children and there is definitely
progress…
APPENDIX 2
Notes from the video tapes
Stewart

On his first day at the nursery, 09/01/03, although no communication skills
are recorded on the tape, Stewart investigates the new environment and
seems interested in the toys as well as the activities that are going on. He
approaches the water tray where an adult and a boy are playing and he
imitates them. He tries several toys and plays quietly.

A week after, Stewart is recorded using the third phase of PECS. When
the speech therapist stops blowing bubbles, he gives her the sentence
strip “I want..bubbles” and he articulates the word “bubbles”. He uses
PECS spontaneously.

On the 18/02/03, he seems totally adjusted to the routines of the nursery.
With the TEACCH visual timetable he knows what he has to do and when.
He also uses spontaneously key words that the staff is using with him, like
“finished”, or “painting”, or “bye”.

Three months later, Stewart is recorded making attempts to speak. While
playing with an adult close to the window, he points out. The adult says
“tree”, Stewart repeats it. He points to the light; the adult says “light” he
repeats it. He then says “again” and gives the adult the toy car to continue
playing with him. On singing time, he joins in happily, trying to pronounce
all the words he can.
Andy

On his first day, 09/01/03, there is no evidence of communication skills
recorded on the tape. Andy seems to investigate the new environment, the
children and the toys. However, he does not tolerate people and
especially children close to him. Most of the time he runs up and down the
rooms screaming.

Two weeks later, 23/01/03, he has started using the first phase of PECS.
He still hesitates to initiate interaction with staff but he seems to have
grasped the concept of picture exchanging. When he is interested and
motivated by the activity he spontaneously uses PECS. When however he
is not interested in the activity, he refuses to use PECS even with
prompts.

On the 18/02/03, he seems familiar with the environment and the routines.
He uses the third phase of PECS-he discriminates between different
pictures for different objects and activities. He is able to follow the visual
timetable, but still needs prompt to start an activity even though he knows
what he has to do.

On the 16/05/03, Andy has moved to the fourth phase of PECS. He starts
combining a picture for ''I want'' with the picture of the requested item or
activity. He also seems to tolerate staff and children around him for a
significant amount of time, in snack time or singing time as well as in the
multi-sensory room.
APPENDIX 3
IEP OF STEWART
January 2003
Communication development targets:

To continue to develop use of PECS, functionally and independently.
Although Stewart could use the PECS he seemed to have a preference to
certain members of staff. Thus, staff prompted him to use it with different people.

To identify and use his own timetable without prompts from adults.
Language development targets:

To develop language skills through labelling 10 familiar objects.

To encourage use of animal noises.
Social interaction targets:

Develop ability to play cooperatively with adults and to share toy with one
other child for 3 minutes.

To join in group singing sessions for 5 minutes.
April 2003
.
Communication development targets:

To introduce “I hear”, using animal and transport noises.

To encourage Stewart to build more sentences with “I want”.
Language development targets:

To develop language skills through labelling action words.

To continue to encourage imitation of animal noises.
Social interaction targets:

To develop ability to play cooperatively with other children for longer
periods (5 minutes).

To share toy or simple turn taking activity with another child for 3-5
minutes.
IEP FOR ANDY
January 2003
Communication development targets:

To develop the use of PECS to make choices between two snacks or toys.

To introduce Andy to some visual structure to help him begin to follow the
routine of the group.
Language development targets:

To develop Andy’s tolerance of adults in his play.

To develop some imitation skills through gross motor actions e.g. clap
hands.
Social interaction targets:

To increase Andy’s use of eye contact with adults during one-to-one
sessions and at group or snack time.
April 2003
Communication development targets:

Introduction of the fourth phase of PECS. Introduction of the “I want” strip
to make choices for activities and toys.

To get Andy to travel further for PECS.
Language development targets:

To continue to develop Andy’s tolerance of adults and children in his play.
Social interaction targets:

Andy to join in group sessions for 5 minutes