**5. Method**

during the 1990s also increased the possibility of including personal photos in AAC systems, which, according to clinical reports, seemed to increase motivation and facilitate understand‐

There are, however, also reports of problems in teaching symbols to children with ASD, mainly in teaching them to use the pictures spontaneously and for communicative functions other than requesting [41]. It was precisely these problems that led Bondy and Frost [47] to develop the method called Picture Exchange Communication System (PECS). PECS is a systematic approach to communication training specifically developed for children with autism. The elements that make PECS different from other visual-graphic techniques are the use of the concrete hand-to-hand exchange of the picture and also the highly prescriptive user manual

Historically, the use of speech output technologies with individuals with ASD has not been a matter of course [48]. Computer technology was introduced into educational settings for children with autism late, not only in North America, but also in other countries. Professionals feared that people with ASD would become even more aloof if they were encouraged to sit in front of a computer screen. Concerning speech-generating devices (SGDs), a common view was that they would only stimulate echolalia in children with ASD, and that there would be too much noise in the classroom. By the end of the 1990s, scepticism had decreased. This was probably due to reports of some studies of successful computer-assisted instruction (CAI) carried out. The introduction of "app technology "has meant a revolution to the field of speechgenerating devices and the first studies of the effects of apps are now being published.

The term evidence-based used as a prefix and a denominator of interventions and methods comes from medicine. The term evidence based means that the choices of interventions and as‐ sessments are based on a research literature not simply professional experience or previous practice. Evidence-based practice has been important within the area of early communication intervention. The behavioural intervention tradition with its roots in the research clinic has pro‐ duced a lot of high-quality research during the years. Other types of interventions has been less researched and sometimes have used methods and produced data that are different so that com‐ parisons of effects are hard or impossible to do. This has also led to an interesting discussion of how to do EPB within the field of communication intervention. Ralph W. Schlosser, professor at NorthEastern University, USA, has been of great importance in this respect. Partly because he is spreading knowledge about evidence-based practise (EBP) and due to the many thorough com‐ pilations of research that he has done, but also in demonstrating the problems and shortcom‐ ings using EBP in relation to the field of augmentative communication intervention [49]. One of these problems concerns the use of the Randomized Controlled Trial or Study (RCT) as the gold‐ en standard, as RCTs are almost non-existent within the AAC field. There are many reasons to this but the main ones are that (1) children with communicative disabilities are so heterogene‐ ous and (2) that randomization is extremely difficult to put through due to ethical reasons.

ing of pictures, particularly for individuals with ASD [46].

with its six levels to follow in sequence.

726 Recent Advances in Autism Spectrum Disorders - Volume I

**4. Evidence-Based Practice — EBP**

#### **5.1. EBP-group**

The review of research within the field of early communication intervention that is presented in this study was initiated by the Swedish association of Habilitation directors as part of a project concerning EBP that was started 2002. Within the frames of this project several reports have been produced with respect to interventions for children and adults with disability. The author of this chapter was appointed scientific leader for a group of five speech-language pathologists and one special educator in Sweden, that applied for taking part in the project. The group has worked together during recurrent two-day-sessions and in between, work has also been done separately and in pairs.

#### **5.2. EBP-method and search question**

The group decided to use the EBP-model of Ralph Schlosser [49]. As mentioned above the hier‐ archy of evidence of Schlosser is a bit different compared to the traditional ones, in that it places the meta-analysis on top of the hierarchy beside the RCT-study. Schlosser also includes per‐ spectives of the stakeholder and the influence of environment into his model of EBP and defines EBP as follows: "The integration of best and current research evidence with clinical/educational expertise and relevant stakeholder perspectives to facilitate decisions for assessment and inter‐ vention that are deemed effective and efficient for a given stakeholder". The classical model of formulation of a evidence question shortened PICO - Problem, Intervention, Comparison, Out‐ come - has accordingly been revised into PESICO - Problem, Environment, Stakeholders, Inter‐ vention, Comparison, Outcome [49]. The question that was formulated in this review was: A young child with severe communicative disability, living with his/her parents and being placed in a pree-school group: which intervention is most effective; indirect or direct interventions.

#### **5.3. Procedure**

When the clinical question had been formulated the group identified search terms to use. These were: Early Intervention, Communication, Communication Disability/ies, Direct intervention, Indirect intervention, Early childhood, Kindergarten, Pree-school, AAC, Augmentative Com‐ munication, Alternative Communication, Early Communication, Language, Meta-analysis, Review. The terms were searched separately and in combinations using four scientific data bas‐ es: PubMed, PsycInfo, CINAHL and ERIC. It was seen that CINAHL generated significantly more results than the other three. All abstract were browsed and the studies considered as rele‐ vant were downloaded. The reference lists of these studies led to some new findings. A few studies and book chapters were found through the group's different contacts and readings of literature. The studies were read and reviewed using a protocol and a manual that was devel‐ oped. The factors that were examined in each study were: Research methods, participants, envi‐ ronment, intervention, results, evidence grading and a final category called notes. This column included judgements of (a) ICF domain/s that the study involved, (b) validity: internal, external, social and ecological, (c) importance of discussion and suggestions of future studies.

**Author&year Study design Intervention Evidence grading**

the use of responsive strategies

Early Communication Intervention for Children with Autism Spectrum Disorders

ComAlong parental education; responsive strategies and AAC

Pilot RCT Focus parent training; joint attention Schlosser: 1

imitation and responsive strategies

Hanen More than Words parental education and guidance: responsive

(and also some older children)

ComAlong parental education; responsive strategies and AAC

ComAlong parental education; responsive strategies and AAC

ComAlong parental education; responsive strategies and AAC

Hanen More than Words parental education and guidance: responsive

fathers as analyzed by video

including responsive strategies

Parents and course leaders' experiences of the ComAlong augmentative and alternative communication early

Large-scale SSRD Education and guidance of fathers:

intervention course

strategies

strategies

Group study Verbal outcomes after training of

interactions

Group study Evaluation of the parental plus progam

Oosterling et al., 2010 [63] RCT Focus parent training; joint attention Schlosser: 1

RCT PECS – training of pree-school teachers

Schlosser: 1 Nordenström Golper. III

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Schlosser: 5 Nordenström: B Golper. II

Nordenström: A Golper. III

Schlosser: 2 Nordenström: B Golper. III

Schlosser: 5 Nordenström: B Golper. II

Schlosser: 5 Nordenström: C Golper. III

Schlosser: 1 Nordenström: A Golper. III

Schlosser: 5 Nordenström: B Golper. II

Schlosser: 5 Nordenström: B Golper. I

Schlosser: 5 Nordenström: B Golper. II

Schlosser: 2 Nordenström: B Golper: III

Nordenström: A Golper. III

Schlosser: 2 Nordenström: B Golper. III

Schlosser: 5 Nordenström: B Golper. II

Aldred, Green & Adams, 2004 [54] RCT Education and guidance of parents in

Group study; mixed methods

Case study, Interaction analyses

Pre-experimental group study; mixed methods

mixed methods

control group

study

**Table 2.** Studies of education and guidance to parents or staff

Controlled group

group-study

Callenberg och Ganebratt, 2009 [56] Pre-experimental

Drew, Baird, Baron-Cohen, Cox, Slonims, Wheelwright, Swettenham, Berry & Charman, 2002 [32]

2005 [57]

2007 [58]

Thunberg, 2011 [55]

Charman, 2007 [59]

Elder, Valcante, Yarandi, White & Elder,

Ferm, Andersson, Broberg, Liljegren &

Girolametto, Sussman & Weitzmann,

Howlin, Gordon, Pascoe, Wade &

Jonsson, Kristoffersson, Ferm & Thunberg, 2011 [40]

McConachie, Randle, Hammal & LeCouteur, 2005 [61]

Seung, Ashwell, Elder & Valcante, 2006

Sharry, Guerin, Griffin & Drumm, 2005

[64]

[65]

Karlsson & Melltorp, 2006 [62] Pilot group study,

Lennartsson och Sörensson, 2010 [60] Group study, small

Each study was first reviewed by two group members separately and then discussed and graded by the group altogether. The group graded the studies according to three systems: Schlosser [49], Nordenström [51] and Golper [52]. Schlosser's system was seen as the most important for this study due to the fact that it was developed for the field of communication intervention for people with disability. Nordenström represent the classical medical evidence hierarchy whilst the Golper was included for its ambition to catch or grade the level or depth of evaluation that the study represents.


**Table 1.** Systems for evidence-grading being used in this study. SSRD=Singel Subject Research Design, RCT=Randomized Controlled Study


**Table 2.** Studies of education and guidance to parents or staff

studies and book chapters were found through the group's different contacts and readings of literature. The studies were read and reviewed using a protocol and a manual that was devel‐ oped. The factors that were examined in each study were: Research methods, participants, envi‐ ronment, intervention, results, evidence grading and a final category called notes. This column included judgements of (a) ICF domain/s that the study involved, (b) validity: internal, external,

Each study was first reviewed by two group members separately and then discussed and graded by the group altogether. The group graded the studies according to three systems: Schlosser [49], Nordenström [51] and Golper [52]. Schlosser's system was seen as the most important for this study due to the fact that it was developed for the field of communication intervention for people with disability. Nordenström represent the classical medical evidence hierarchy whilst the Golper was included for its ambition to catch or grade the level or depth

social and ecological, (c) importance of discussion and suggestions of future studies.

2 Well designed non-RCT group study SSRD – one intervention SSRD – several interventions

Subgroups to/variants of the types above 3 Narrative quantitative reviews (except of meta-analyses)

6 Expertise: educational books, journals, expert opinion

studies, case studies, cohort studies)

Golper Phase I Hypotheses about treatment efficacy are being developed for later testing.

or activity of a particular treatment.

Phase II The goals are to formulate and standardize protocols, validate

Nordenström A Strong scientific evidence (meta-analysis, well-done and large RCT)

descriptive reports)

treatment comparisons.

comparisons.

**Table 1.** Systems for evidence-grading being used in this study. SSRD=Singel Subject Research Design,

5 Pre- experimental group studies (i.e. before-after) and case studies

B Moderate evidence (smaller or non-randomized studies, cross-sectional

C Week evidence (expert opinion, concensus reports, case studies and other

Often this involves experimental manipulations to test potential benefits

measurement instruments, optimise dosage of treatment, and so on. Includes case reports and small group studies with no control groups or

SSRD or group studies with controls such as control groups or treatment

D Non-existent scientific evidence (No studies of sufficient quality exists).

Phase III Treatment efficacy of a specified protocol is formally tested either with

of evaluation that the study represents.

728 Recent Advances in Autism Spectrum Disorders - Volume I

RCT=Randomized Controlled Study

**System Level Definition**

Schlosser 1 Meta-analyses of SSRD /RCT

4 Narrative reviews

The results were analysed and grouped primarily according to the formulated search question but also according to the identified areas of intervention and methods being evaluated in the studies. Building on these results, recommendations and a model for early communicative intervention was suggested. These results were documented in a report being published on the website of the Association of Swedish Habilitation directors [53]. A new literature search using the same procedure as described above led to some revision of results and recommen‐ dations in a new version of the report that was recently published [53].

guidance of parents (for example 31, 63, 74, 75, 81). Several of these interventions includ‐ ed education that was combined with home-visits when the therapist interacted with and trained the child during natural play situations. The parents observed these play activi‐ ties and the therapist's use of behavioural strategies, which were then discussed an prac‐ ticed during the sessions. The results of these comprehensive programs are included in the section of direct interventions below (table 3), but it is important to also recognize

Early Communication Intervention for Children with Autism Spectrum Disorders

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In several studies of the interventions more specifically aimed at parental education, it was seen that the parent's use of responsive strategies increased [54, 58, 60, 61, 62] and some studies showed that interaction between the parent and the child was positively af‐ fected [57, 58, 62, 65]. Some studies report that the development of communication and language in the child seems to be increased when the parents are provided with educa‐ tion and guidance [32, 54, 56, 61, 62, 64]. Several studies have tried to measure parental stress and other family related parameters that are expected to be affected, also out from parental interviews [54, 55, 56, 61, 65]. Most studies failed in proving effects in this re‐ spect, at least on a level of statistical significance. In some studies the researchers specu‐ late that the questionnaires given before and after an intervention seems to fail in catching an effect. In qualitative studies parents report that they can see the problems of the child more clearly after the course and can be more open about the family problems [55]. This means that items related to family issues even might "get worse" comparing

So far very little is known of the long-term effects of indirect intervention. The few studies with this focus show that the effects seem to fade over time. Both clinicians and researchers hypothesize that there probably is a need to do follow-ups and/or provide booster interven‐ tions to maintain the intervention effects over time. There are also indications that the effects of a parental education on the development of the child seems to be further enhanced when

19 studies were found of which 10 were reviews (1 meta-analysis) and the rest primary studies. The scientific level of evidence varies, but the recently published primary studies being of high quality certainly strengthen evidence in the area of direct communication intervention.

Direct interventions or training of the child has proved to have a positive impact on the development of the child with ASD as is stated in most, but not so sure in all, of the studies in the table. Exactly what is described to be affected differs in different studies, depending on the focus of the study, but to a large extent also on what have been measured in a particular study. It is more common that classical didactic programs report outcomes within the function- or activity-domain, often by the use of measures of intelligence (IQ) or language (different language tests). The child-directed naturalistic interventions more often describe outcomes in terms of activity or participation and use data of communication or interaction from video

the fairly large amount of indirect instruction in these programs.

questionnaires filled in blindly before-after intervention.

the education is complemented with direct intervention to the child.

**6.2. Direct interventions — Provision of training of the child**

analyses, parental questionnaires and interviews.

The results that will be shared in this book chapter concerns the studies that specifically involved children on the autism spectrum, which in total involved about half of the studies, or exactly 47 studies. The data from both literature searches was used: 30 studies from the review published in 2011 and 16 studies from the updated version of 2012.
