**6. Results**

The number of studies that were included in the review totalled 106. Of these, 39 were reviews, while the other 67 were primary studies. 46 of the studies involved children diagnosed within the autism spectrum. This means that about half the research on interventions for children with communicative disabilities have focused children with ASD. 31 of the studies were included in the report published 2011 while 14 were added in the review done 2012. 20 of the publications were reviews while 27 were primary studies. There were comparatively more primary studies, often of high research quality, to be found in the more recent search (2012). Only publications where the children were clearly described as having ASD were included in this review. There were most probably even more studies of the 106 that included children with ASD since sometimes participants were described according to type and/or severity of disability (such as severe communicative disability), and not diagnose..

#### **6.1. Indirect interventions — Education and guidance to parents**

14 primary studies were found. The evidence is moderately to strong since there are also some studies with a high level of scientific control. Many of the studies were noted as showing high validity with respect to external validity as well as social and ecological validity. In several studies the parents were involved in the evaluation procedure and measures of natural interactions were included.

In general the results of education and guidance to parents and staff are very positive al‐ though this review shows that there seems to be a lack of research when it comes to ed‐ ucation and guidance of staff. Only one study was found where pree-school teachers were educated and guided how to use the PECS-method [32]. The results of the parental interventions indicate that they are effective in that positive results can be seen very quickly with respect to different areas and with comparatively little amount of interven‐ tion. This is also probably one of the reasons behind the trend that parental education seems to be included as a part of the more recently developed intervention programs. In the second literature search in this study more interventions were found that included 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 the fairly large amount of indirect instruction in these programs.

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‐

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

The number of studies that were included in the review totalled 106. Of these, 39 were reviews, while the other 67 were primary studies. 46 of the studies involved children diagnosed within the autism spectrum. This means that about half the research on interventions for children with communicative disabilities have focused children with ASD. 31 of the studies were included in the report published 2011 while 14 were added in the review done 2012. 20 of the publications were reviews while 27 were primary studies. There were comparatively more primary studies, often of high research quality, to be found in the more recent search (2012). Only publications where the children were clearly described as having ASD were included in this review. There were most probably even more studies of the 106 that included children with ASD since sometimes participants were described according to type and/or severity of

14 primary studies were found. The evidence is moderately to strong since there are also some studies with a high level of scientific control. Many of the studies were noted as showing high validity with respect to external validity as well as social and ecological validity. In several studies the parents were involved in the evaluation procedure and measures of natural

In general the results of education and guidance to parents and staff are very positive al‐ though this review shows that there seems to be a lack of research when it comes to ed‐ ucation and guidance of staff. Only one study was found where pree-school teachers were educated and guided how to use the PECS-method [32]. The results of the parental interventions indicate that they are effective in that positive results can be seen very quickly with respect to different areas and with comparatively little amount of interven‐ tion. This is also probably one of the reasons behind the trend that parental education seems to be included as a part of the more recently developed intervention programs. In the second literature search in this study more interventions were found that included

dations in a new version of the report that was recently published [53].

730 Recent Advances in Autism Spectrum Disorders - Volume I

review published in 2011 and 16 studies from the updated version of 2012.

disability (such as severe communicative disability), and not diagnose..

**6.1. Indirect interventions — Education and guidance to parents**

**6. Results**

interactions were included.

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 questionnaires filled in blindly before-after intervention.

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 the education is complemented with direct intervention to the child.

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

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 analyses, parental questionnaires and interviews.


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

Wong & Kwang, 2010 [75] RCT (small groups) Evaluation of Autism 1-2-3-progam Schlosser: 1

ACD

communication

As mentioned in earlier paragraphs generalization and maintenance has been a big issue within the field of communication and language intervention for years. Generally the childfocused interventions show better generalization and maintenance in younger children with ASD [67, 72, 76]. These studies discuss that the use of the inborn motivation of the child and the use of natural context and natural play context make the difference – all according to current theories of development of cognition and communication. Proponents of didactic training hold that the use of learned words and phrases might be a start of a positive social spiral where the child gets more response and is treated differently. Some reviews come to the conclusion that we still do not have enough evidence to tell which type of program is best, didactic or childfocused, but that the important factors seem to be early start and intensity [66, 69]. According to the meta-analysis of six RCT studies of didactic interventions [80] these however fail in reporting better outcomes than the control groups when it comes to cognition, language and adaptive functioning. Generally the children in didactic training programs also were older [68]. Didactic training in its intensive and comprehensive form seems less effective on younger children and children at early communicative levels [77]. The involvement of the parents in recurrent didactic training activities in the home is also questioned in some studies [68]. There are indications of a high degree of stress in these parents and a comparative study showed that parental stress was lowered when the training was done by others and furthermore that the

Evaluation of the effects of "start-kit" of 12 individual sessions teaching parents communicative strategies

Early Communication Intervention for Children with Autism Spectrum Disorders

intervention for young children at risk of

Comparison of RPMT and PECS on spoken

Schlosser: 2 Nordenström: B Golper. I

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733

Nordenström: B Golper. III

Schlosser: 4 Nordenström: C Golper. II

Schlosser: 2 Nordenström: B Golper. III

Vismara et al, 2009 [81] Group study Non-

Yoder & Stone, 2006 [73] Randomized

concurrent multiple baseline design

comparison

**Table 3.** Studies of direct interventions and comprehensive programs

Woods & Wetherby, 2003 [72] Review, clinical report Review of methods of identification and

results with respect to communication development was enhanced [68].

Several recent studies report outcomes from eclectic comprehensive interventions [30, 31, 74]. These programs are built upon current theories of cognitive, communicative and neurophy‐ siological development but also adds knowledge from the behaviourist tradition or rather Applied Behavior Analysis (ABA) in optimizing the learning situation. More concretely this means that these programs are child-focused in that it makes use of the child's motivation and interests and focus the communication between the parent and the child and are often implemented in the home setting, sometimes after some introductory sessions on a clinic. An analysis of the child's communication development forms the decision of what is going to be focused during interaction. Prelinguistic competencies such as imitation, joint attention and


**Table 3.** Studies of direct interventions and comprehensive programs

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

years

understanding and treating autism

Denver Model for toddlers with ASD

and naturalistic language interventions

Review of parent-mediated intervention/

Comparison of effects of 1) intensity and form of intervention 2) intelligence on adaptive behaviour on children with ASD

Comparison of interventions for play and joint attention in children with ASD

intervention to promote communication

interaction in young children in educational

Characterizing and Predicting Outcomes of Communication Delays in Infants and Toddlers: Implications for Clinical Practice.

communication intervention to young

Evaluation of a program aimed at stimulate language learning in disabled children

intervention to children with ASD

joint attention

settings

children with ASD

for children with ASD

training of children with ASD

Schlosser: 4 Nordenström: C Golper. I

Schlosser: 4 Nordenström: C Golper. I

Schlosser: 1 Nordenström: A Golper. III

Schlosser: 4 Nordenström: B Golper. II

Schlosser: 3 Nordenström: B Golper. III

Schlosser: 2 Nordenström: B Golper. II-III

Schlosser: 4 Nordenström: B Golper. II

Schlosser: 1 Nordenström: A Golper: III

Schlosser: 2 Nordenström: A Golper. III

Schlosser: 2 Nordenström: B Golper. III

Schlosser: 4 Nordenström: B Golper. I

Schlosser: 6 Nordenström: C Golper. I

Schlosser: 6 Nordenström: C Golper. I

Schlosser: 5 Nordenström: B Golper. III

Schlosser: 1 Nordenström: A Golper. III

Charman, 2010 [76] Review Review of developmental approaches to

Corsello, 2005 [66] Review Review and discussion of interventions 0-3

Dawson et al, 2010 [30] RCT Study of the effects of : The Early Start

Delprato, 2001 [67] Review Comparison of discrete trial interventions

Goldstein, 2002 [69] Review Review and comparison of communication

Kasari et al (2010) [31] RCT Study of the outcomes of an intervention for

McConkey et al, (2010) [74] Controlled group study Evaluation of the impact of home-based

McConnell, 2002 [71] Review Review of interventions to promote social

Rogers, 2006 [11] Review Review of and historic description of

Spreckley & Boyd, 2009 [80] Meta-analysis Meta-analysis of discrete-trial-interventions

Randomized group

Review Cochrane-report

study

study

expertise

(small groups)

Fernell et al, 2011 [77] Comparative group

732 Recent Advances in Autism Spectrum Disorders - Volume I

Paul & Roth , 2011 [78] Narrative review/

Schuit et al, 2011 [79] Controlled group study

Diggle & McConachie, 2009

Kasari, Paparella & Freeman,

2008 [70]

[68]

As mentioned in earlier paragraphs generalization and maintenance has been a big issue within the field of communication and language intervention for years. Generally the childfocused interventions show better generalization and maintenance in younger children with ASD [67, 72, 76]. These studies discuss that the use of the inborn motivation of the child and the use of natural context and natural play context make the difference – all according to current theories of development of cognition and communication. Proponents of didactic training hold that the use of learned words and phrases might be a start of a positive social spiral where the child gets more response and is treated differently. Some reviews come to the conclusion that we still do not have enough evidence to tell which type of program is best, didactic or childfocused, but that the important factors seem to be early start and intensity [66, 69]. According to the meta-analysis of six RCT studies of didactic interventions [80] these however fail in reporting better outcomes than the control groups when it comes to cognition, language and adaptive functioning. Generally the children in didactic training programs also were older [68]. Didactic training in its intensive and comprehensive form seems less effective on younger children and children at early communicative levels [77]. The involvement of the parents in recurrent didactic training activities in the home is also questioned in some studies [68]. There are indications of a high degree of stress in these parents and a comparative study showed that parental stress was lowered when the training was done by others and furthermore that the results with respect to communication development was enhanced [68].

Several recent studies report outcomes from eclectic comprehensive interventions [30, 31, 74]. These programs are built upon current theories of cognitive, communicative and neurophy‐ siological development but also adds knowledge from the behaviourist tradition or rather Applied Behavior Analysis (ABA) in optimizing the learning situation. More concretely this means that these programs are child-focused in that it makes use of the child's motivation and interests and focus the communication between the parent and the child and are often implemented in the home setting, sometimes after some introductory sessions on a clinic. An analysis of the child's communication development forms the decision of what is going to be focused during interaction. Prelinguistic competencies such as imitation, joint attention and use of symbol play and symbols are seen as basic and pivotal. The behavioural techniques are used to arrange the environment and chose strategies to refine and enhance learning in the natural interaction. The trainer serve as model to the parent and then guide and coach the parent, often in the home.

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

Bopp, Brown & Mirenda, 2004 [83] Review Review of FCT and use of visual

Brady, 2000 [84] Case study Study of the impact of use of SGDs on

Branson & Demcak, 2009 [85] Meta-analysis Evaluation of AAC interventions for

SSRD – Multiple baseline

Millar, Light & Schlosser 2006 [87] Meta-analysis The impact of AAC-interventions on

Papparella & Kasari, 2004 [88] Review Study of the relationship between joint

Schlosser &, 2006 [90] Quantitative review The impact of AAC on children with

Schlosser & Wendt, 2008 [91] Meta-analysis Effects of different types of AAC on

study

Preston & Carter, 2009 [89] Meta-analysis Study of the effects of PECS Schlosser: 1

baseline

Review The impact of AAC-intervention on use

of AAC, symbolic gestures and speech

Early Communication Intervention for Children with Autism Spectrum Disorders

strategies and discussion of the role of speech-language pathologist in working with challenging behaviors

the understanding of speech

toddlers and infants with disability

Impact of PECS on requesting and

Study of the effects of a pictureexhange-intervention using milieu

attention and language – manual

developmental disabilites

speech in children with ASD

with severe communicative disabilities

Evaluation of a program using AAC (not

Review Study of the effectiveness of training of rejecting using AAC

Review Review of AAC-interventions to children

further described)

teaching in the home

speech development

speech

signing

Schlosser: 4 Nordenström: B Golper. II

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735

Schlosser: 4 Nordenström: B Golper. I

Schlosser: 5 Nordenström: C Golper. I

Schlosser: 1 Nordenström: A Golper. III

Schlosser: 2 Nordenström: B Golper. III

Schlosser: 2 Nordenström: B Golper. III

Schlosser: 1 Nordenström: B Golper. I

Schlosser:4 Nordenström: C Golper. I

Nordenström: B Golper. III

Schlosser: 4 Nordenström: B Golper. II

Schlosser: 1 Nordenström: B Golper: II

Schlosser: 4 Nordenström: B Golper. I

Schlosser: 4 Nordenström: B Golper. I

Schlosser: 5 Nordenström: B Golper. II

Binger, Berens, Kent-Walsh &Taylor,

Ganz, Simpson & Corbin-Newsome,

Sigafoos, Drasgow, Reichle, O´Reilly &

Snell, Chen, Lih-Huan & Hoover, 2006

van der Meer et al, 2011 [93] Controlled group

**Table 4.** Studies of education and guidance to parents

Tait, 2004 [92]

[94]

Mancil et al(2009) [95] SSRD – multiple

2008 [82]

2008 [86]

The majority of the primary studies in the table above report excellent outcomes [30, 31 70, 73, 74, 75, 81]. In general the research quality of evaluations of these interventions were high since many were of RCT type or Randomized Group studies. External, social and ecological validity was also considered as generally high partly due to the use of more interactional data and information from the stakeholders. The studies show that these interventions seem to be very effective in proving positive outcomes with respect to interaction, parental communication style and child development. Some of these intervention programs are of comparatively low intensity and short, which is interesting and important, as high intensity traditionally have been said to be essential to success in children with autism

Some articles compare interventions and discuss recommendations with respect to different needs of the child or family. A comparison of the AAC-method PECS and RPMT (a compre‐ henesive program containing parental education in the use of responsive strategies and training of the child and guidance to parents in their home) showed interesting results with respect to communication outcomes in the children [73]. The children at the earliest commu‐ nicative stage, not yet being interested in objects, seem to develop more with RPMT. At the next communicative stage when the children has an interest of objects, an understanding of cause and effect and some emergent understanding of joint attention PECS is more effective. When joint attention is more established the Prelinguistic Mileu Teching strategies (behavioral techniques implemented in natural interaction) in the RPMT seems to be more operant. It was also seen that the PMT-training had better effect for those children whose mothers used a responsive communication style. The focus on development of joint attention is emphasized as the primary goal in this study with a successive introduction of symbol play as joint attention is being established [73].

Finally, one review studies the effect of different types of interventions to promote social interaction in pree-school settings and conclude that there is good evidence that it is important to work both with the child with disability as well as with his/her friends in the school environment [71].

#### **6.3. AAC intervention**

The field of AAC is a fairly new field of knowledge that has gradually grown as there is a increasing interest in functional communication and in ensuring the communicative rights of individuals with disability. There has also been an explosion of available communication technologies and methods that can support and improve communication for individuals with autism. We have probably and hopefully only seen the dawn of these new options. It is also possible to see that we are moving from using one technique or approach at the time to working with multimodal techniques or approaches where different tools and methods combined with an understanding of communication and use of interactional strategies build a total system of communication.


**Table 4.** Studies of education and guidance to parents

use of symbol play and symbols are seen as basic and pivotal. The behavioural techniques are used to arrange the environment and chose strategies to refine and enhance learning in the natural interaction. The trainer serve as model to the parent and then guide and coach the

The majority of the primary studies in the table above report excellent outcomes [30, 31 70, 73, 74, 75, 81]. In general the research quality of evaluations of these interventions were high since many were of RCT type or Randomized Group studies. External, social and ecological validity was also considered as generally high partly due to the use of more interactional data and information from the stakeholders. The studies show that these interventions seem to be very effective in proving positive outcomes with respect to interaction, parental communication style and child development. Some of these intervention programs are of comparatively low intensity and short, which is interesting and important, as high intensity traditionally have

Some articles compare interventions and discuss recommendations with respect to different needs of the child or family. A comparison of the AAC-method PECS and RPMT (a compre‐ henesive program containing parental education in the use of responsive strategies and training of the child and guidance to parents in their home) showed interesting results with respect to communication outcomes in the children [73]. The children at the earliest commu‐ nicative stage, not yet being interested in objects, seem to develop more with RPMT. At the next communicative stage when the children has an interest of objects, an understanding of cause and effect and some emergent understanding of joint attention PECS is more effective. When joint attention is more established the Prelinguistic Mileu Teching strategies (behavioral techniques implemented in natural interaction) in the RPMT seems to be more operant. It was also seen that the PMT-training had better effect for those children whose mothers used a responsive communication style. The focus on development of joint attention is emphasized as the primary goal in this study with a successive introduction of symbol play as joint attention

Finally, one review studies the effect of different types of interventions to promote social interaction in pree-school settings and conclude that there is good evidence that it is important to work both with the child with disability as well as with his/her friends in the school

The field of AAC is a fairly new field of knowledge that has gradually grown as there is a increasing interest in functional communication and in ensuring the communicative rights of individuals with disability. There has also been an explosion of available communication technologies and methods that can support and improve communication for individuals with autism. We have probably and hopefully only seen the dawn of these new options. It is also possible to see that we are moving from using one technique or approach at the time to working with multimodal techniques or approaches where different tools and methods combined with an understanding of communication and use of interactional strategies build a total system of

been said to be essential to success in children with autism

parent, often in the home.

734 Recent Advances in Autism Spectrum Disorders - Volume I

is being established [73].

environment [71].

communication.

**6.3. AAC intervention**

The research base with respect to AAC used by young children with autism has grown in recent years. This research mostly consists of singe-subject-design studies and case studies, with very few controlled group studies being done. On the other hand there are some welldone meta-analyses published that compile results from singe-subject research studies. Due to the difficulties of conducting RCT studies within the field of AAC-intervention the metaanlyses are important and can be seen as the golden standard. In total 14 studies were identified as focusing the use of AAC and of these 10 were reviews or meta-analyses.

**7. Conclusion**

training is low.

might be an important success factor.

**most effective; indirect or direct interventions?"**

The conclusion of this chapter is presented in the form of eight recommendations and of a model for early communication intervention answering the question that was initially formulated in this study: **"A young child with autism and severe communicative disability, living with his/her parents and being placed in a pree-school group: which intervention is**

Early Communication Intervention for Children with Autism Spectrum Disorders

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737

**1. A combination of indirect and direct interventions.** There is strong evidence that the combination of education and guidance to the parents and direct child-focused interven‐ tion to the child in a naturalistic context leads to good outcomes with respect to several parameters such as: development of communication and language, interaction between the parent and the child where the parent uses a responsive communication pattern,

**2. Parental education should include knowledge of and training in the use of responsive strategies and behavioural/environmental teaching techniques within the frames of natural interaction in the home.** Several studies show that parents change their commu‐ nicative style after a few education sessions and that this positively affect the interaction pattern with the child and enhance language development in the child. **Guidance or coaching of the parents in natural interactions in the home environment** is included in

most of the recently presented studies and show very good results in short time.

**3. Direct interventions provided to children on early communicative stage should be child-focused and implemented in daily natural interactions. The intervention should focus imitation, joint attention and symbol use** (speech, symbols, manual signs). Didactic intervention is not effective for young children since maintenance and generalization of

**4. Interventions need to be continuous and include follow-ups and possibilities of booster-intervention.** The few long-term follow up-studies all show that interventions (of different type) tend to wear off by time. The recent published studies show that lowintensity interventions also could yield good results. The engagement of the parent also

**5. Children at early communicative stages should be provided with AAC as early as possible.** There is no age-limit or prerequisites that need to met before AAC is introduced. There is strong evidence that AAC decreases challenging behaviour. There is moderate

**6. AAC-intervention should ideally be multimodal.** All modes of AAC are effective. There is some evidence that symbols (specifically combined with speech output) are learned

**7. PECS (Picture Exchange Communication System) is an effective AAC-method for children at early communicative stages.** There is strong evidence that PECS has a positive effect on interaction and behaviour and that functional communication is increased.

to strong evidence that AAC facilitates development of speech.

faster than manual signs and that iconic symbols are learned faster.

In conclusion, meta-analyses and other studies show that AAC-interventions are cost-effective and give fast results and furthermore tend to stimulate speech development [82, 84, 85, 86, 87, 91]. The best results seem to be reached when the social network surrounding a child is given support and resources, to be able to use responsive strategies and provide communication opportunities and direct training using AAC in natural daily interactions. AAC intervention should be started as soon as communication difficulties are displayed or suspected since AAC promotes communication, language and speech. AAC-intervention has also been proved to effectively decrease challenging behaviour [83]. There is today no mode of AAC that is known to be better than any other for young children with autism. Instead multimodal approaches seem to be the most effective [93]. However, graphic AAC seem to be acquired at a faster rate and also easier to generalize to other situations [90]. PECS has been proved to be an effective AAC method, specifically at early stages of communication and with respect to the first three phases of the method [89].

**Figure 1.** Model for early communication intervention
