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Parent-Child Interaction and Autism Spectrum Disorder ASD
Autism continuing education MFT CEUs

Manual of Articles Sections 8 - 19
Section 8
Communication Interventions for Children with Autism

CEU Question 8 | CEU Test | Table of Contents | Autism
Counselor CEUs, Psychologist CEs, Social Worker CEUs, MFT CEUs

Functional Communication Training
The term functional communication training (FCT) has been used over the past decade to refer to a set of procedures designed to reduce problem behavior by teaching functionally equivalent communication skills. FCT requires a thorough assessment to identify the function of the behavior of concern, and systematic instruction related to teaching functionally-related alternative communicative behaviors. The growing body of empirical literature demonstrating the efficacy and mechanisms of this procedure has included a number of examples in which AAC techniques were used during intervention with individuals with autism (Mirenda, 1997). In fact, one of the first empirical demonstrations of the potential of FCT involved an 11-year-old boy with autism who had extremely limited expressive language and displayed frequent grabbing and yelling behaviors during the school day (Horner & Budd, 1985). After informal assessment of the conditions in which the behaviors occurred, a decision was made to teach him five manual signs for items that appeared to be related to the grabbing/yelling. In other words, he was taught to request the items for which he usually grabbed/yelled. The data indicated quite clearly that once he had learned to use the signs in the natural environment of the classroom, his sign use increased and his grabbing and yelling behaviors decreased dramatically.

In a review of FCT studies published between 1985 and 1996 in which one or more AAC techniques were used (Mirenda, 1997), 8 of the 52 participants (15%) had autism (Bird, Dores, Moniz, & Robinson, 1989; Campbell & Lutzker, 1993; Day, Horner, & O'Neill, 1994; Horner & Budd, 1985; Horner & Day, 1991; Sigafoos & Meikle, 1996; Wacker et al., 1990). They ranged in age from 7 to 36 (four were 8 years old or younger) and engaged in one or more problem behaviors, including self-injurious behavior, aggression, crying, screaming, property destruction, tantrums, non-compliance, and self-stimulatory behavior, as well as the aforementioned grabbing and yelling. The "messages" or functions of their behaviors included "Pay attention to me" (attention), "I want x" (tangibles), and "I don't want to do this" (escape), with the majority (63%) in the latter group. A variety of AAC techniques were taught as alternatives to the challenging behaviors, including tangible symbols (1 participant), manual signs and/or gestures (6 participants), a card with printed words (e.g., "I want a BREAK") (1 participant), and line drawing symbols (1 participant). There was an immediate and substantial reduction in the frequency of problem behavior for all 8 participants after the FCT interventions were initiated, and this reduction was maintained for as long as I year (follow-up data were not provided for all participants). Since the Mirenda (1997) review was published, additional documentation of the successful use of FCT/AAC as one component of multielement interventions for young children with autism has also appeared in the literature (e.g., Dunlap & Fox, 1999; Thompson, Fisher, Piazza, & Kuhn, 1998). In addition, a recent study provided convincing evidence for the use of VOCAs in the context of FCT/AAC interventions with 5 children, 2 of whom had autism but were over the age of 8 (Durand, 1999). FCT/ AAC interventions have the clear advantage of "killing two birds with one stone," in that they teach individuals to communicate one or more functional messages while at the same time providing positive alternatives to their problem behavior(s).

Assistive Technology for Communication and Learning
Numerous assistive technology options are currently available to support the learning and communication of students with a wide variety of disabilities. These include voice output communication aids (VOCAs) as well as computer hardware and software applications that provide writing and/or spelling assistance, support various aspects of learning, and/ or facilitate classroom participation in general. In this section, the research specifically related to the use of such technologies with individuals on the autism spectrum will be reviewed.

VOCAs are portable, computerized devices that produce synthetic or digitized speech output when activated. A variety of visual-graphic symbols are used to represent messages, which are activated when an individual uses a finger, hand, optical pointer, headstick, switch, or some other means to select a symbol from the VOCA's display.

Only one published research study has investigated the relative effectiveness of VOCA versus non-VOCA output in persons with autism. In this study, a 10-year-old boy was taught to spell words under three feedback conditions (Schlosser, Blischak, Belfiore, Bartley, & Barnett, 1998). In the auditory-visual condition, the participant received both synthetic speech (via the VOCA) and orthographic feedback. In the visual condition, he received only orthographic feedback; and in the auditory condition, he received only synthetic speech feedback. The participant reached criterion and maintained performance in all three conditions, but his performance was slightly more efficient in the auditory and auditory-visual conditions. It is important to note that this study did not include a condition in which natural speech (as opposed to synthetic speech) feedback was provided. Thus, although it appears that the provision of some type of auditory (i.e., spoken) feedback enhanced learning efficiency with regard to spelling, it is not clear whether ,synthetic speech feedback via a VOCA was essential in this regard.

An additional advantage of VOCAs is that because they provide speech output, they have the potential to be easily integrated into everyday environments with unfamiliar people. This was demonstrated in the aforementioned FCT/ AAC study by Durand (1999), in which 5 children (2 with autism) learned to use VOCAs to produce alternative communicative behaviors that served the same functions as their problem behaviors (e.g., "I need help," "I want more"). The study included empirical evidence that following initial instruction, all of the participants were able to use their VOCAs without prompting in novel community settings with untrained community members.

Finally, a third potential advantage of VOCAs is their ability to facilitate natural interpersonal interactions and socialization by virtue of the speech output they provide. Schepis, Reid, Behrmann, and Sutton (1998) investigated this issue in a study of 4 young children with autism (3-5years old) who had little or no functional speech and attended a self-contained classroom with 4 other children with autism. The participants were taught to use individual VOCAs with line drawing symbols to represent messages such as "I want a snack, please," "more," and" I need help." Each of the messages was activated by touching a single symbol on the display. Naturalistic teaching procedures, including child-preferred stimuli, natural cues such as expectant delay and questioning looks to elicit communication, and non-intrusive prompting techniques were used to teach the children to interact with classroom staff through their VOCAs. Over a 1- to 3-month period, all 4 children learned to use their VOCAs to request items, respond to questions, and make social comments (e.g., "thank you") during natural play and/or snack routines in the classroom. By the end of formal training, the majority of interactions by the children were spontaneous (i.e., unprompted) and contextually appropriate. In addition, classroom staff engaged in a higher frequency of communicative interactions with the children following naturalistic teaching with the VOCA; however, no such effects were seen with regard to child-child interactions (see Note 2). This study provides the first empirical demonstration of the potential of VOCA use for supporting the communicative interactions of children with autism.

Computer-Assisted Instruction
In the 1970s and 1980s, several "concept papers" that presented various rationales for the use of computers with individuals with autism began to appear in the literature. Most were accompanied by anecdotal reports of positive outcomes with regard to, for example, increased peer interactions, motivation, and communication (e.g., Colby, 1973; Frost, 1984, Hedbring, 1985; Panyan, 1984). The first study to compare human instruction and CAI in this population involved 17 children, 6 of whom had autism (4 were 8 years old or younger) (Pleinis & Romanczyk, 1985). Results indicated that although there was no overall difference in participants' learning performance between conditions on a progressively more difficult 2-choice discrimination task, the participants as a group exhibited fewer disruptive behaviors and higher rates of compliance to instruction in the CAI condition. Separate analyses were not conducted for the participants with autism vs. the other participants in this study. However, Romanczyk, Weiner, Lockshin, and Ekdahl (1999) described three unpublished follow-up studies that investigated various aspects of CAI effectiveness specifically with students with autism (ages unknown). Although these three studies did not meet the criteria for inclusion in this article, they seem to provide additional evidence that relationships between behavior and performance during CAI are quite child-specific and interact with the modality, method of instruction, and type of reinforcement or corrective feedback available. In a related study that involved 4 young children with autism in Singapore (Chen & Bernard-Opitz, 1993), 3 showed evidence of more motivation and fewer problem behaviors with CAI, although this did not affect their overall learning rates. In fact, one child's rate of learning was considerably better with human instruction, and one child's was better with CAI. This study supports the conclusions of Romanczyk and his colleagues with regard to the child-specific nature of the effects of CAI.

Two more recent studies provided some evidence of the efficacy of CAI with regard to learning, although neither assessed the comparative effects of CAI versus human instruction. The first study, conducted by a Swedish research team (Heimann, Nelson, Tjus, & Gillberg, 1995), investigated the use of a Swedish version of Alpha (Nelson & Prinz, 1991), an interactive multimedia software program that has been used successfully to teach reading and language skills to children with severe hearing impairments. The study compared the use of Alpha with 11 children with autism (ages 6-14, mean = 9-4 years), 9 children with mental retardation and at least one motor or sensory impairment, and 10 typical preschoolers. Results indicated that children in ail three groups made significant gains in reading, phonological awareness, verbal behavior, and motivation over the course of the study (approximately 5 months). In the second study, an adult with mental retardation, a profound hearing impairment, and autism was exposed to a software program designed to teach basic spelling skills (Stromer, Mackay, Howell, McVay, & Flusser, 1996). The participant's spelling skills for 12 target words (3 letters each) improved both on the computer and during a written generalization task.

A related issue of interest is the use of computers with synthesized speech to facilitate speech development or production. Only one study has investigated this application of CAI to date; it involved six verbal children with autism, ages 4-8 to 6-8 (Parsons & La Sorte, 1993). The children were exposed to a computer with simple software programs for learning in two conditions: synthesized speech ON and synthesized speech OFF. The children's spontaneous verbal utterances were counted during teaching sessions under both conditions. The results indicated marked increases in their spontaneous utterances in all of the ON conditions, compared to both baseline (no computer) and OFF conditions. These results suggest that CAI with synthesized speech may have a facilitative effect on speech production for children with autism, although additional research is clearly needed in this area.
- Mirenda, Pat; Autism, augmentative communication, and assistive technology: what do we really know?; Focus on Autism & Other Developmental Disabilities, Oct. 2000, Vol. 30.
The article above contains foundational information. Articles below contain optional updates.

Personal Reflection Exercise Explanation
The Goal of this Home Study Course is to create a learning experience that enhances your clinical skills. We encourage you to discuss the Personal Reflection Journaling Activities, found at the end of each Section, with your colleagues. Thus, you are provided with an opportunity for a Group Discussion experience. Case Study examples might include: family background, socio-economic status, education, occupation, social/emotional issues, legal/financial issues, death/dying/health, home management, parenting, etc. as you deem appropriate. A Case Study is to be approximately 150 words in length. However, since the content of these “Personal Reflection” Journaling Exercises is intended for your future reference, they may contain confidential information and are to be applied as a “work in progress.” You will not be required to provide us with these Journaling Activities.

Personal Reflection Exercise #1
The preceding section contained information about interventions to facilitate communication in autism.  Write three case study examples regarding how you might use the content of this section in your practice.

Online Continuing Education QUESTION 8
What are the three advantages to VOCAs? Record the letter of the correct answer the CEU Test.

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Table of Contents

The article above contains foundational information. Articles below contain optional updates.
To reduce the average age of autism diagnosis, screen preschoolers in primary care
Autism, Ahead of Print.
The American Academy of Pediatrics recommends autism spectrum disorder screening at the 18- and 24-month well-child visits. However, despite widespread toddler screening, many children are not diagnosed until school age, and delayed diagnosis is more common among low-income and minority children. Offering autism spectrum disorder screening at preschool well-child checks might reduce disparities and lower the overall age of diagnosis and service initiation. However, screening tools that span the preschool ages and are tailored for primary care are needed.Lay abstractPediatric primary care providers check for autism signs, usually using a standard checklist, at 18- and 24-month well-child visits. When the checklist shows possible autism, children should be referred for additional treatment and evaluation with an autism specialist. However, many children with autism spectrum disorder are not detected as toddlers. Low-income and minority children are particularly likely to have a late autism spectrum disorder diagnosis. Checking for autism at preschool-aged well-child visits might be one way to identify autism spectrum disorder earlier, especially for low-income and minority children.
The role of loneliness as a mediator between autism features and mental health among autistic young adults
Autism, Ahead of Print.
Autistic adults commonly experience anxiety and depression. These mental health concerns are often tied to social experiences, such that mental well-being can be supported by social connection and deteriorated by loneliness. The mediating role of social and emotional loneliness (i.e. social isolation and lack of emotional attachment, respectively) between autism features and mental health has yet to be empirically tested among autistic adults. Here, 69 autistic young adults completed self-report questionnaires assessing social contact (Friendship Questionnaire), autism features (Autism Quotient), mental health (Liebowitz Social Anxiety Scale, Social Phobia Inventory, Beck Depression Inventory), and loneliness (Social and Emotional Loneliness Scale for Adults). Positive associations emerged between autism features, social loneliness, family loneliness, social anxiety, and depression. In addition, more social contact was related to less social and family loneliness and less social anxiety but was not related to depression. Mediation analyses indicated significant indirect effects of social contact and autism features on mental health through social loneliness. Indirect effects partially held substituting family loneliness for social loneliness and did not hold using romantic loneliness. In light of these results, the scientific and clinical implications of the role of loneliness for autistic young adults are discussed and recommendations provided.Lay abstractAutistic adults commonly experience mental health concerns including social anxiety and depression, which can have negative effects on their quality of life. It is not completely clear, however, why rates of mental health concerns are so high. Some evidence suggests that social connectedness might play a key role. The goal of this study was to explore links between loneliness, mental health concerns, autism features, and social contact among autistic adults and test whether the links between mental health with autism features and social contact can be explained by loneliness. Researchers in this study collected data using questionnaires completed by 69 autistic young adults. Autistic adults who reported more autism features also reported more social and family loneliness, higher levels of social anxiety and depression, and fewer initiated social contacts. In addition, adults with more social contact initiations were likely to report lower levels of social and family loneliness and social anxiety but not depression. Results showed that the link from social engagement and autism features to social anxiety and depression symptoms could be mostly explained by loneliness. The results of this study expand previous findings by illustrating one factor (loneliness) that might be responsible for the high rates of mental health concerns among adults on the autism spectrum. These findings highlight the importance of studying factors related to mental health concerns among autistic adults and ways to best support social connectedness for the mental well-being of autistic young adults.
Insomnia subtypes and clinical impairment in hospitalized children with autism spectrum disorder
Autism, Ahead of Print.
Insomnia subtypes have not been characterized in severely affected youth with autism spectrum disorder. We examined indices of clinical impairment (i.e. length of hospital stay, autism severity, nonverbal intelligence quotient, and adaptive and maladaptive behaviors) across insomnia subtypes in 427 psychiatrically hospitalized children with autism spectrum disorder (mean age = 12.8 ± 3.4; 81.3% male). Multivariate analysis with Bonferroni adjustment tested for differences in clinical impairment across insomnia subtypes adjusting for age and sex. Per parent report, 60% (n = 257) of children had at least one form of insomnia. The distribution of subtypes was sleep onset (26.1%, n = 67), sleep maintenance (24.9%, n = 64), early morning waking (4.3%, n = 11), and combined (44.7%, n = 115). There was a significant multivariate effect of insomnia subtypes on clinical impairment (Pillai’s Trace = 0.25, F = 2.78, p < 0.001). Sleep maintenance and early morning waking were associated with longer hospital stays. Early morning waking was also associated with greater autism symptom severity. In general, children with sleep-maintenance or combined insomnias scored lower on adaptive behaviors and higher on maladaptive behaviors. Sleep-maintenance and combined insomnias appear to be more indicative of or consequential for impaired behavioral functioning.Lay abstractInsomnia subtypes are not well understood in the most severely affected children with autism spectrum disorder. We examined length of hospital stay, autism severity, nonverbal intelligence quotient, and behavioral functioning across insomnia subtypes in 427 psychiatrically hospitalized children with autism spectrum disorder (mean age = 12.8 ± 3.4; 81.3% male). Per parent report, 60% (n = 257) of children had at least one type of insomnia. The distribution of subtypes was difficulty falling asleep (26.1%, n = 67), difficulty staying asleep (24.9%, n = 64), early morning awakening (4.3%, n = 11), and multiple insomnia symptoms (44.7%, n = 115). Difficulty staying asleep and early morning awakenings were associated with longer hospital stays. Early morning awakening was also associated with higher autism symptom severity. In general, children with difficulty staying asleep or multiple insomnia symptoms scored lower on adaptive behaviors (e.g. communication, self-care, socialization) and higher on maladaptive behaviors (e.g. irritability, hyperactivity, emotional reactivity, and emotional dysphoria). Difficulty staying asleep or having multiple insomnia symptoms appears to be most strongly related to impaired behavioral functioning. Conversely, early morning awakenings may be more closely tied with autism spectrum disorder itself. Further research is needed regarding insomnia subtypes at the severe end of the autism spectrum.
Self-compassion as a mediator of the association between autistic traits and depressive/anxious symptomatology
Autism, Ahead of Print.
Self-compassion refers to the extension of kindness to oneself when faced with inadequacies, shortcomings or failures. This study examined the mediating role of self-compassion in the relationship between autistic traits and depressive/anxious symptomatology in the general population. Participants included 164 university students (69 males and 95 females) ranging in age from 18 to 51 years (mean = 23.16, standard deviation = 7.81). Participants completed the Autism Spectrum Quotient, the Self-Compassion Scale, and the Hospital Anxiety and Depression Scale. A series of multiple mediation analyses was conducted using the bootstrapping method, and it was found that Total Self-Compassion and the two subscales of Compassionate Self-Responding and Uncompassionate Self-Responding partially mediated the relationship between autistic traits and anxious/depressive symptoms. The indirect effect of self-compassion accounted for 41.9% of the variance in the relationship between autistic traits and depressive symptoms and 50% of the variance in the relationship between autistic traits and anxiety symptoms. It was also further found that the correlation between autistic traits and self-compassion was significantly stronger in males than females. Although preliminary, the current findings suggest that self-compassion could potentially serve as a target for clinical intervention in individuals with elevated autistic traits who experience anxiety and/or depression.Lay AbstractIn this study, we asked 164 undergraduate students to complete an online questionnaire. The questionnaire measured the students’ levels of autistic traits, self-compassion, and experience of anxiety and depression. We were interested in knowing if self-compassion (defined as the extension of kindness to oneself when faced with challenges) had any influence on the relationship between autistic traits and experiences of anxiety and depression. The results of the study indicated that self-compassion may be an important factor influencing the relationship between autistic traits and mental health, with higher levels of self-compassion being related to more positive mental health outcomes. Although the findings should be considered preliminary in nature, they do suggest that self-compassion could potentially be a target for clinical intervention in people with elevated autistic traits and experience anxiety and/or depression.
Satisfaction with informal supports predicts resilience in families of children with autism spectrum disorder
Autism, Ahead of Print.
The current study examined the role of informal supports in predicting resilience among families of children with autism spectrum disorder. Participants included 153 caregivers of children with autism spectrum disorder, who were between the ages of 2 and 18 years (M = 10.45; SD = 4.32). Caregivers completed a measure of satisfaction with informal supports as well as the Family Resilience Assessment Scale-autism spectrum disorder. After controlling for demographic factors and child behavioural problems, regression analyses revealed that satisfaction with informal supports significantly predicted family resilience. The findings highlight the importance of specifically strengthening informal support networks when providing services and interventions to families of children with autism spectrum disorder to foster the family’s resilience.Lay abstractThe study of resilience among individuals with disabilities and their families represents a paradigmatic shift from a deficits orientation towards a more holistic and contextualized approach focused on strength and adaptation. The current study investigated whether informal supports could help improve families’ capacity for resilience. We recruited 153 caregivers of children aged between 2 and 18 years who all had a diagnosis of autism. Participants were asked to complete surveys assessing resilience in their families as well as their satisfaction with informal supports (e.g. friends and family). Families more likely to report higher satisfaction with their informal support networks demonstrate greater resilience. The results suggest that informal social supports are a valuable resource for families in strengthening their capacity for resilience. The findings may help inform the development of interventions and services that work collaboratively and innovatively with families and their social networks to provide assistance and support in meaningful and effective ways.

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