**3. Interventions to support communication and language development in children with ASD**

#### **3.1. History and different theoretical approaches**

been estimated that between one-third [7] and one-half [8] of children and adults with autism have no speech. However, more recent research results indicate that the proportion of nonspeaking children with ASD is much smaller, approximately 14% to 20%, among those who

Two phenotypes of speaking children with ASD were identified by Tager-Flusberg and Joseph [10]: children with normal linguistic abilities (phonological skills, vocabulary, syntax, and morphology) and children with impaired language that is similar to the phenotype found in specific language impairment. Another potential subgroup may experience verbal dyspraxia or dyspraxia of speech [11; 12; 13]. Voluntary motor control is disturbed in children with dyspraxia, which also affects their ability to imitate. The new research on the role of the 'mirror neurons' in the parietal and frontal lobes may provide some answers on the relationships between motor control and imitation but also on the possible link with the development of

In spite of the heterogeneity of language abilities in children with ASD, social-communication or pragmatic impairments are universal across all ages and ability levels [14]. According to Wetherby [15], the social-communication deficits in children with ASD can be organized into two major areas: (1) the capacity for joint attention and (2) the capacity for symbol use. Since joint attention emerges before words, this deficit may be more fundamental and a number of longitudinal studies provide evidence of a relationship between joint attention and language outcomes [16, 17]. According to Wetherby [15] p. 11, 'deficits in initiating and responding to joint attention have a cascading effect on language development since language learning occurs within the context of the modelling by the caregiver of words that refer to objects and words that are jointly regarded'. Wetherby [15] states that deficits in imitation and observa‐ tional learning are other main causes of the problems with symbol use experienced by children with ASD. Learning shared meanings, imitating and using conventional behaviours, and being able to decontextualize meaning from the context constitute the symbolic deficits in children

**2.2. Development of communication and language in children with ASD**

Because autism is usually not diagnosed until age three or four, there is relatively little information about language in very young children with autism [10]. Retrospective studies using parent reports and/or videotapes collected during infancy, together with studies of children considered likely to develop autism, show severely delayed language acquisition with respect to both receptive and expressive skills [18, 19, 20]. Another typical phenomenon described by 25% of parents of children with ASD is language loss after initially developing some words [21]. Lord, Schulman, and DiLavore [22] found that this language regression is unique to autism and does not occur in other children with developmental delays. Chawarska et al. [21] hypothesize that these early-acquired speech-like productions are lost by children with ASD because the link between these expressions and a network of symbolic communi‐ cation fails. There is significant variability in the rate at which language progresses among

received very early intervention [9].

720 Recent Advances in Autism Spectrum Disorders - Volume I

intersubjectivity [11].

with ASD [13].

children with ASD who do acquire speech.

The first reports on language interventions were published in the mid-1960s. The intervention at that time built on the operant tradition developed by Skinner during the 1950s. The teaching sessions in this method, referred to as discrete trial teaching or didactic teaching, are marked by a high level of adult control and direction, massed-practice periods for preselected tasks, and precise antecedent, teaching, and reinforcement practices. The learner is in a responder role, and the teacher has a directive role [11]. The strength of the didactic behavioural approach is primarily that it has demonstrated efficacy in many studies, using a variety of treatment settings and treatment deliverers, with both single-subject and group designs [11]. Limitations on this approach as a language-training method were recognized early on, with the children's lack of generalization being a core problem [26].

**3.2. Early communication intervention**

*3.2.1. Why early communication intervention?*

intervention. The most essential of these are:

constructs or competencies, such as:

adults with autism spectrum disorders [3].

perceived level of stress in their parents [34].

intervention programs given to children with ASD.

*3.2.2. Early communication intervention methods or programs*

of young disabled children [35].

**◦** Reading and writing.

**◦** Theory of Mind [33].

Several new research findings point to the importance of an early start of communication

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**•** Difficulties in understanding and expressing communication is very closely linked to the

**•** Communication and language are pivotal for the development of several other cognitive

**•** Communication ability predicts outcome with respect to functioning and quality of life in

**•** The severity of communication difficulties in preschool-aged children is correlated to the

**•** Communication is one of the most important factors for the participation in daily activities

**•** According to several guidelines, among these NRC (National Research Council) in the United States, functional communication and social interaction should be prioritized in early

Furthermore, interactional research done on children with communicative impairments and their parents has shown that the responsive communication style that characterizes parents of typically developing children is often replaced by a more directive style in pa‐ rents of children with communicative impairments. Besides this impact on quality, quan‐ tity is also affected, in that the rate of communication occasions in these families tend to decrease. This adds a cumulative negative effect on the communication development due to less stimulation and experience [36]. Research has also shown that children with ASD whose parents used a responsive style during preschool years in general had better com‐

munication and languages skills when they were followed up as teen-agers [37].

There are many intervention programs for children with ASD that focus on communica‐ tion. Some of these are more specifically aimed at communication whilst others include communication and language as a part of a comprehensive early intervention program. Some programs (indirect interventions) focus on the parent or partner usually by guid‐ ing and teaching parents, individually or in groups (courses). Other intervention pro‐ grams focus more on the training of the child (direct interventions). Today it is common

development of challenging behaviors in individuals with autism [2].

The pragmatic understanding of communication was fully developed after the operant teaching methods were first developed [11]. The current scientific understanding of commu‐ nication and language development stems from the 1970s and 1980s, when it was demon‐ strated that language develops from the preverbal social exchanges of infants with important others (Bates, 1976). According to Rogers [11 p. 149], 'current research, building primarily on the work of Wetherby [13, 15, 23], Prizant [13], and Mundy, Sigman and Kasari [17], has demonstrated that young children with autism lacked these early building blocks of commu‐ nication, involving social initiative, joint attention, social and emotional reciprocity, and the use of gestures to co-ordinate social exchanges.

In 1968, an important study was published by Hart and Risley [27]. Very positive results were obtained with an intervention in which the principles of operant teaching were applied in the child's natural environment. The term 'incidental teaching' was used for this approach, in which the natural environment is deliberately structured to highlight the function of the targeted language form. This intervention produced much better results with respect to maintenance and generalization and stimulated development and research in the field [11]. According to Rogers [11, p. 153], the effectiveness of this approach results from four factors: (1) child language functions to achieve child-chosen goals and child-chosen reinforcers, which strengthen their power; (2) the focus is on child communication skills that are functional in all settings; (3) the social functions of language are highlighted; (4) emphasis on child motivation and natural reinforcers adds a positive element to the interactions, which may enhance memory for learning.

The third major approach in the field of communication intervention for children with ASD is the developmental pragmatic approach. The most elaborated programme for treatment, the SCERTS (Social-Communication, Emotional Regulation, Transactional Support) model [28] focuses on functional communication. This approach bears many resemblances to the behav‐ ioural naturalistic teaching methods. More emphasis is, however, placed on developing nonverbal behaviours prior to verbal communication and on the use of Augmentative and Alternative Communication (AAC) systems to assist in the development of verbal communi‐ cation [11]. Today many models combine behavioural techniques and social-interactionist approaches, such as Enhanced Milieu Teaching, developed by Kaiser and colleagues [29], The Denver Early Start [30], Caregiver Mediated Joint Engagement Intervention for Toddlers with Autism [31], Focus parent training for toddlers with autism [32]. The strength of the develop‐ mental model is its strong basis in the science of communication development. Its weaknesses include the lack of treatment manuals and the fact that it requires considerable knowledge on the part of the therapist [11].

#### **3.2. Early communication intervention**

and precise antecedent, teaching, and reinforcement practices. The learner is in a responder role, and the teacher has a directive role [11]. The strength of the didactic behavioural approach is primarily that it has demonstrated efficacy in many studies, using a variety of treatment settings and treatment deliverers, with both single-subject and group designs [11]. Limitations on this approach as a language-training method were recognized early on, with the children's

The pragmatic understanding of communication was fully developed after the operant teaching methods were first developed [11]. The current scientific understanding of commu‐ nication and language development stems from the 1970s and 1980s, when it was demon‐ strated that language develops from the preverbal social exchanges of infants with important others (Bates, 1976). According to Rogers [11 p. 149], 'current research, building primarily on the work of Wetherby [13, 15, 23], Prizant [13], and Mundy, Sigman and Kasari [17], has demonstrated that young children with autism lacked these early building blocks of commu‐ nication, involving social initiative, joint attention, social and emotional reciprocity, and the

In 1968, an important study was published by Hart and Risley [27]. Very positive results were obtained with an intervention in which the principles of operant teaching were applied in the child's natural environment. The term 'incidental teaching' was used for this approach, in which the natural environment is deliberately structured to highlight the function of the targeted language form. This intervention produced much better results with respect to maintenance and generalization and stimulated development and research in the field [11]. According to Rogers [11, p. 153], the effectiveness of this approach results from four factors: (1) child language functions to achieve child-chosen goals and child-chosen reinforcers, which strengthen their power; (2) the focus is on child communication skills that are functional in all settings; (3) the social functions of language are highlighted; (4) emphasis on child motivation and natural reinforcers adds a positive element to the interactions, which may enhance

The third major approach in the field of communication intervention for children with ASD is the developmental pragmatic approach. The most elaborated programme for treatment, the SCERTS (Social-Communication, Emotional Regulation, Transactional Support) model [28] focuses on functional communication. This approach bears many resemblances to the behav‐ ioural naturalistic teaching methods. More emphasis is, however, placed on developing nonverbal behaviours prior to verbal communication and on the use of Augmentative and Alternative Communication (AAC) systems to assist in the development of verbal communi‐ cation [11]. Today many models combine behavioural techniques and social-interactionist approaches, such as Enhanced Milieu Teaching, developed by Kaiser and colleagues [29], The Denver Early Start [30], Caregiver Mediated Joint Engagement Intervention for Toddlers with Autism [31], Focus parent training for toddlers with autism [32]. The strength of the develop‐ mental model is its strong basis in the science of communication development. Its weaknesses include the lack of treatment manuals and the fact that it requires considerable knowledge on

lack of generalization being a core problem [26].

722 Recent Advances in Autism Spectrum Disorders - Volume I

use of gestures to co-ordinate social exchanges.

memory for learning.

the part of the therapist [11].

#### *3.2.1. Why early communication intervention?*

Several new research findings point to the importance of an early start of communication intervention. The most essential of these are:

	- **◦** Reading and writing.
	- **◦** Theory of Mind [33].

Furthermore, interactional research done on children with communicative impairments and their parents has shown that the responsive communication style that characterizes parents of typically developing children is often replaced by a more directive style in pa‐ rents of children with communicative impairments. Besides this impact on quality, quan‐ tity is also affected, in that the rate of communication occasions in these families tend to decrease. This adds a cumulative negative effect on the communication development due to less stimulation and experience [36]. Research has also shown that children with ASD whose parents used a responsive style during preschool years in general had better com‐ munication and languages skills when they were followed up as teen-agers [37].

#### *3.2.2. Early communication intervention methods or programs*

There are many intervention programs for children with ASD that focus on communica‐ tion. Some of these are more specifically aimed at communication whilst others include communication and language as a part of a comprehensive early intervention program. Some programs (indirect interventions) focus on the parent or partner usually by guid‐ ing and teaching parents, individually or in groups (courses). Other intervention pro‐ grams focus more on the training of the child (direct interventions). Today it is common that early intervention programs include both indirect and direct aspects: education and tutoring of parents and training of the child.

the home setting [39]. The parents are provided with picture boards so they can use aided

Early Communication Intervention for Children with Autism Spectrum Disorders

http://dx.doi.org/10.5772/54881

725

Training of communication, language and speech is most often an important part in the different comprehensive programs, addressing different skills and problems, that has been developed for young children within the autism spectrum. Some of these are built on behav‐ ioural theories, others on developmental pragmatic approaches. There seems to be a trend that the programs being developed and researched during the last decade, specifically for young children with autism, are more eclectic. The background theories are often described as developmental pragmatic whilst ABA (Applied Behavior Analysis) techniques are used to strengthen the teaching practices. Most often these comprehensive programs include both direct training to the child and indirect intervention parts in that parents and/or staff in the

AAC comprises different methods and modes of communication such as body communication, concrete objects, manual signs, graphic symbols or speech-generating devices. Historically, the first studies describing AAC techniques being used for individuals with autism appeared in the 1970s; they reported on the use of sign language to improve communication [41]. These studies appeared at the same time as the unsatisfactory results of spoken-language-training programmes were being published. Studies by, for example, Lovaas et al. [26] reported little change after many hours of intensive treatment, and the results were particularly poor for the children whose comprehension and vocal skills were most impaired [41]. Initially, most signing programmes were built on formal sign language systems, but it became evident that these were often too complex and abstract, and so specially adapted systems were developed and implemented. Sign-based programmes spread rapidly in schools for children with autism

During the 80's and the 90's a gradual change in AAC intervention for persons with autism, was seen, as visual-graphic communication was more in focus. Mirenda and Erickson [42] explain that the shift away from the use of signing to visual-graphic communication occurred as a result of research findings in three main areas: imitation, iconicity, and intelligibility. In addition to the evidence of a generalized imitation deficit in autism, there were also studies showing that some children with ASD had extremely poor sign imitation skills [43] due to difficulties with motor planning, control and execution [44]. According to Howlin [41], the shift from the use of manual signs to visual methods was also due to the fact that visual methods had proven to be effective in enhancing general skill acquisition, mainly within the TEACCH programme (Treatment of Education of Autistic and related Communicationhandicapped CHildren; [45]) developed during the 1970s. A variety of symbol systems were also developed, beginning with Blissymbolics and Rebus followed by Pictogram and Picture Communication Symbols. The improvements in computer technology made these symbol sets easily available in the form of practical software packages. The development of digital cameras

close network of the child are given education, training and/or guidance.

*3.2.2.3. Augmentative and Alternative Communication — AAC*

language modeling in their homes [39, 40].

*3.2.2.2. Comprehensive intervention programs*

in many countries.

Another dimension of great importance in early communication intervention concerns the degree of child focus. To have a child focus means that the motivation of the child and the developmental level is decisive in what is done during intervention. The adult follows the lead of the child and the place for training is where the child is, often the floor. In this way it's not necessary to use reinforcements or rewards since the child is already interested and motivated. To get the child to train and focus the intended skills or functions different behavioural techniques are often used. At the other end of this di‐ mension we find the more traditional didactic training situation where the adult trainer or therapist follows and uses a predefined set of activities and materials during a train‐ ing session. The specific behavioural techniques; prompts and reinforcements used dur‐ ing the session are often also specified or planned. The child is expected to follow the lead of the adult and it is typical that the training is held the child and the adult sitting face-to-face at a table. It is more typical that child-focused interventions are provided during daily activities in the natural environment of the child; at home and/or in preeschool, whilst didactic training is provided at a clinic, at least during the introduction of new materials and training activities.

Still another difference between programs that might be seen as a dimension is the degree to which augmentative and alternative communication (AAC) is included. In some programs these strategies, in the form of manual signs, symbols and pictures and speech-generating devices (SGDs, today often Apps used on an iPad, smartphone or other platform), are included already from the start to promote communication and build language, whilst in other pro‐ grams AAC strategies are not included, but instead seen as a last resort when training of speech has failed.

#### *3.2.2.1. Education and tutoring of parents and staff*

The most common intervention of this type is parental education. The internationally most wide-spread parental education programs most probably are the courses developed by the Canadian Hanen Centre [38]. The course being developed for children within the autism spectrum is called More Than Words and includes eight group sessions for the parents and three "home-visits" by the Speech-language pathologist. During these visits the interaction between the child and the parent is videotaped and the parents are given feed-back and further guidance how to improve communication and use of the strategies being taught during the course. The Hanen courses is a developmental approach and teaches responsive strategies to the parents adding some behavioural techniques to stimulate communication learning within the frames of child-focused natural interaction in the home [38]. A new parental course called ComAlong has been developed in Sweden and now is spreading in northern Europe [39]. ComAlong include eight group sessions focusing on responsive strategies and environmental teaching but also puts a large focus on the use of augmentative communication strategies in the home setting [39]. The parents are provided with picture boards so they can use aided language modeling in their homes [39, 40].

#### *3.2.2.2. Comprehensive intervention programs*

that early intervention programs include both indirect and direct aspects: education and

Another dimension of great importance in early communication intervention concerns the degree of child focus. To have a child focus means that the motivation of the child and the developmental level is decisive in what is done during intervention. The adult follows the lead of the child and the place for training is where the child is, often the floor. In this way it's not necessary to use reinforcements or rewards since the child is already interested and motivated. To get the child to train and focus the intended skills or functions different behavioural techniques are often used. At the other end of this di‐ mension we find the more traditional didactic training situation where the adult trainer or therapist follows and uses a predefined set of activities and materials during a train‐ ing session. The specific behavioural techniques; prompts and reinforcements used dur‐ ing the session are often also specified or planned. The child is expected to follow the lead of the adult and it is typical that the training is held the child and the adult sitting face-to-face at a table. It is more typical that child-focused interventions are provided during daily activities in the natural environment of the child; at home and/or in preeschool, whilst didactic training is provided at a clinic, at least during the introduction of

Still another difference between programs that might be seen as a dimension is the degree to which augmentative and alternative communication (AAC) is included. In some programs these strategies, in the form of manual signs, symbols and pictures and speech-generating devices (SGDs, today often Apps used on an iPad, smartphone or other platform), are included already from the start to promote communication and build language, whilst in other pro‐ grams AAC strategies are not included, but instead seen as a last resort when training of speech

The most common intervention of this type is parental education. The internationally most wide-spread parental education programs most probably are the courses developed by the Canadian Hanen Centre [38]. The course being developed for children within the autism spectrum is called More Than Words and includes eight group sessions for the parents and three "home-visits" by the Speech-language pathologist. During these visits the interaction between the child and the parent is videotaped and the parents are given feed-back and further guidance how to improve communication and use of the strategies being taught during the course. The Hanen courses is a developmental approach and teaches responsive strategies to the parents adding some behavioural techniques to stimulate communication learning within the frames of child-focused natural interaction in the home [38]. A new parental course called ComAlong has been developed in Sweden and now is spreading in northern Europe [39]. ComAlong include eight group sessions focusing on responsive strategies and environmental teaching but also puts a large focus on the use of augmentative communication strategies in

tutoring of parents and training of the child.

724 Recent Advances in Autism Spectrum Disorders - Volume I

new materials and training activities.

*3.2.2.1. Education and tutoring of parents and staff*

has failed.

Training of communication, language and speech is most often an important part in the different comprehensive programs, addressing different skills and problems, that has been developed for young children within the autism spectrum. Some of these are built on behav‐ ioural theories, others on developmental pragmatic approaches. There seems to be a trend that the programs being developed and researched during the last decade, specifically for young children with autism, are more eclectic. The background theories are often described as developmental pragmatic whilst ABA (Applied Behavior Analysis) techniques are used to strengthen the teaching practices. Most often these comprehensive programs include both direct training to the child and indirect intervention parts in that parents and/or staff in the close network of the child are given education, training and/or guidance.

#### *3.2.2.3. Augmentative and Alternative Communication — AAC*

AAC comprises different methods and modes of communication such as body communication, concrete objects, manual signs, graphic symbols or speech-generating devices. Historically, the first studies describing AAC techniques being used for individuals with autism appeared in the 1970s; they reported on the use of sign language to improve communication [41]. These studies appeared at the same time as the unsatisfactory results of spoken-language-training programmes were being published. Studies by, for example, Lovaas et al. [26] reported little change after many hours of intensive treatment, and the results were particularly poor for the children whose comprehension and vocal skills were most impaired [41]. Initially, most signing programmes were built on formal sign language systems, but it became evident that these were often too complex and abstract, and so specially adapted systems were developed and implemented. Sign-based programmes spread rapidly in schools for children with autism in many countries.

During the 80's and the 90's a gradual change in AAC intervention for persons with autism, was seen, as visual-graphic communication was more in focus. Mirenda and Erickson [42] explain that the shift away from the use of signing to visual-graphic communication occurred as a result of research findings in three main areas: imitation, iconicity, and intelligibility. In addition to the evidence of a generalized imitation deficit in autism, there were also studies showing that some children with ASD had extremely poor sign imitation skills [43] due to difficulties with motor planning, control and execution [44]. According to Howlin [41], the shift from the use of manual signs to visual methods was also due to the fact that visual methods had proven to be effective in enhancing general skill acquisition, mainly within the TEACCH programme (Treatment of Education of Autistic and related Communicationhandicapped CHildren; [45]) developed during the 1970s. A variety of symbol systems were also developed, beginning with Blissymbolics and Rebus followed by Pictogram and Picture Communication Symbols. The improvements in computer technology made these symbol sets easily available in the form of practical software packages. The development of digital cameras 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‐ ing of pictures, particularly for individuals with ASD [46].

Schlosser has therefore suggested an alternative evidence hierarchy placing the meta-analysis on top [49, 50]. Schlosser and several other prominent authors within the field of communica‐ tion intervention research designs recommend the use of well-controlled single-subject re‐

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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

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.

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

search designs that can form the base for systematic meta-analyses.

**5. Method**

**5.1. EBP-group**

**5.3. Procedure**

also been done separately and in pairs.

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

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 with its six levels to follow in sequence.

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.
