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Autism: Family Life - Tactics for Getting Normal Again
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. Yelling Autism Family Life counselor CEUFCT 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.
Impact of a digital Modified Checklist for Autism in Toddlers–Revised on likelihood and age of autism diagnosis and referral for developmental evaluation
Autism, Ahead of Print.
The present study is a single-site quality improvement project within pediatric primary care involving the implementation of a digital version of the Modified Checklist for Autism in Toddlers–Revised. We evaluated the impact of the digital screener on the likelihood of physician referral for a developmental evaluation or autism diagnosis, and the age of the patients at the time of the event. Patients were children 16–30  months old seen for 18 and 24 months’ well-child visits (1279 encounters), who screened positive for risk for autism spectrum disorder on the Modified Checklist for Autism in Toddlers–Revised without a previously documented autism spectrum disorder diagnosis. Comparisons were made between a cohort of children screened with the paper and pencil version of the Modified Checklist for Autism in Toddlers–Revised before the digital version was implemented and a cohort of children screened during the intervention period. Patients were followed until 48 months and referrals were obtained from electronic health records. Patients screened with the digital Modified Checklist for Autism in Toddlers–Revised were five times more likely to be referred for a developmental evaluation. The automatic scoring, risk assessment, and referral decision support features helped to improve screening outcomes. In this clinic, process change to a digital screening method with automatic guidance for next steps improved adherence to evidence-based clinical care.Lay abstractThis was a project in primary care for young children (1–2 years old). We tested a parent questionnaire on a tablet. This tablet questionnaire asked questions to see whether the child may have autism. We compared the paper and pencil version of the questionnaire to the tablet questionnaire. We read the medical charts for the children until they were 4 years old to see whether they ended up having autism. We found that doctors were more likely to recommend an autism evaluation when a parent used the tablet questionnaire. We think that the tablet’s automatic scoring feature helped the doctors. We also think that the doctors benefited from the advice the tablet gave them.
Implementing early intensive behavioral intervention in community settings
Autism, Ahead of Print.
Although research shows early intensive behavioral intervention is efficacious when delivered in university or private intervention centers, little is known about effectiveness or feasibility of disseminating early intensive behavioral intervention to larger communities. The Michigan State University Early Learning Institute was developed to address gaps in distribution of early intensive behavioral intervention to community settings, with an emphasis of serving children and families on Medicaid. This short report describes the Early Learning Institute’s approach and preliminary utilization data among Medicaid families. Results suggest the model has potential for dissemination within community settings and promote utilization among Medicaid children.Lay abstractAlthough research shows early intensive behavioral intervention can be very beneficial for children with autism spectrum disorder when delivered in university or private intervention centers, little is known about the best way to provide early intensive behavioral intervention within the broader community. The Michigan State University Early Learning Institute was developed to address challenges with providing early intensive behavioral intervention in community settings, with an emphasis on serving children and families on Medicaid. This short report describes the approach taken by the Early Learning Institute and reports data regarding enrollment and utilization among Medicaid families. Results suggest the model has potential to be used within community settings and that children on Medicaid are likely to consistently attend their treatment sessions.
Work, living, and the pursuit of happiness: Vocational and psychosocial outcomes for young adults with autism
Autism, Ahead of Print.
Longitudinal data on the functioning of adults referred for possible autism as children are sparse and possibly different from datasets consisting of adult clinical referrals. A total of 123 young adults, mean age of 26, referred for neurodevelopmental disorders in early childhood were categorized into three outcome groups: autism spectrum disorder (ASD) diagnosis at some point and current intelligence quotient (IQ) ⩾ 70 (Ever ASD-Higher IQ), ever ASD and current IQ < 70 (Ever ASD-Lower IQ), and individuals who never received an ASD diagnosis (Never ASD). Independence and well-being were assessed through direct testing, questionnaires, and interviews. Verbal IQ, beyond intellectual disability status, accounted for group differences in employment; autistic features (Autism Diagnostic Observation Schedule Calibrated Severity Score) were uniquely related to adaptive skills and friendships. In many ways, the Never ASD group had similar outcomes compared to the ASD groups. However, lower well-being and fewer positive emotions were related to ASD diagnosis across IQ. The Ever ASD-Lower IQ group had the highest levels of irritability, hyperactivity, and medications. Families played a major role in supporting adults with and without ASD at all intellectual levels. Realistic ways of increasing independence should be developed through working with adults and their families, while acknowledging the contribution of individual differences in mental health, intelligence, and autism symptoms across neurodevelopmental disorders.Lay abstractIt is important to better understand how adults with autism are functioning in adulthood. Studies that have tracked individuals across the lifespan can help identify developmental factors influence differences in adult outcomes. The present study examines the independence, well-being, and functioning of 123 adults that have been closely followed since early childhood. Autism diagnosis and cognitive assessments were given frequently throughout childhood and during adulthood. We examined differences between adults who had received an autism diagnosis at some point with higher cognitive abilities (Ever ASD-High IQ) and lower cognitive abilities (Ever ASD-Low IQ), as well as adults who never received a diagnosis of autism in the course of the study (Never ASD). We found that autistic features specifically related to adaptive skills and friendships, and verbal intelligence related to work outcomes. In many ways, the Never ASD group had similar outcomes compared to the ASD groups. However, adults with ASD tended to have lower well-being and fewer positive emotions. Families played a major role in supporting adults with and without ASD at all intellectual levels. The findings suggest that realistic ways of increasing independence need to be developed by working with adults and their families, while acknowledging the contribution of individual differences in mental health, intelligence and autism symptoms across neurodevelopmental disorders.
Does implementing a new intervention disrupt use of existing evidence-based autism interventions?
Autism, Ahead of Print.
This study examines how the introduction of TeachTown:Basics, a computer-assisted intervention for students with autism spectrum disorder, influenced teachers’ use of other evidence-based practices. In a randomized controlled trial that enrolled 73 teachers nested within 58 schools, we used three-level hierarchical linear models to evaluate changes in teachers’ use of evidence-based practices across the school year for those who received TeachTown:Basics versus those assigned to control. Both groups received training and implementation support to deliver three well-established evidence-based practices for autism spectrum disorder. Qualitative interviews were conducted with 25 teachers who used TeachTown:Basics to better understand their experience. Compared with teachers in the control group, teachers in the TeachTown:Basics group reported significantly less growth over the 9-month period in their use of evidence-based practices that require one-to-one instruction (ps < 0.05), but no difference in their reported use of evidence-based practices that do not involve one-to-one instruction (p = 0.637). Qualitative interviews indicated that teachers viewed TeachTown:Basics as an effective substitute for one-to-one instruction because it was less burdensome, despite the lack of support for TeachTown:Basics’ effectiveness. Before introducing new practices, education leaders should carefully consider both evidence of effectiveness and the potential impact on the use of other evidence-based practices.Lay abstractInterventions for children with autism spectrum disorder are complex and often are not implemented successfully within schools. When new practices are introduced in schools, they often are layered on top of existing practices, with little attention paid to how introducing new practices affects the use of existing practices. This study evaluated how introducing a computer-assisted intervention, called TeachTown:Basics, affected the use of other evidence-based practices in autism support classrooms. We compared how often teachers reported using a set of evidence-based practices in classrooms that either had access to TeachTown:Basics or did not have the program. We found that teachers who had access to the computer-assisted intervention reported using the other evidence-based practices less often as the school year progressed. Teachers also reported that they liked the computer-assisted intervention, found it easy to use, and that it helped overcome challenges to implementing other evidence-based practices. This is important because the computer-assisted intervention did not improve child outcomes in a previous study and indicates that teachers may use interventions that are appealing and easier to implement, even when they do not have evidence to support their effectiveness. These findings support the idea of interventions’ complexity and how well the intervention fits within the classroom affect how teachers use it and highlight the need to develop school-based interventions that both appeal to the practitioner and improve child outcomes.
Autistic peer-to-peer information transfer is highly effective
Autism, Ahead of Print.
Effective information transfer requires social communication skills. As autism is clinically defined by social communication deficits, it may be expected that information transfer between autistic people would be particularly deficient. However, the Double Empathy theory would suggest that communication difficulties arise from a mismatch in neurotype; and thus information transfer between autistic people may be more successful than information transfer between an autistic and a non-autistic person. We investigate this by examining information transfer between autistic adults, non-autistic adults and mixed autistic-with-non-autistic pairs. Initial participants were told a story which they recounted to a second participant, who recounted the story to a third participant and so on, along a ‘diffusion chain’ of eight participants (n = 72). We found a significantly steeper decline in detail retention in the mixed chains, while autistic chains did not significantly differ from non-autistic chains. Participant rapport ratings revealed significantly lower scores for mixed chains. These results challenge the diagnostic criterion that autistic people lack the skills to interact successfully. Rather, autistic people effectively share information with each other. Information transfer selectively degrades more quickly in mixed pairs, in parallel with a reduction in rapport.Lay abstractSharing information with other people relies on the ability to communicate well. Autism is defined clinically by deficits in social communication. It may therefore be expected that autistic people find it difficult to share information with other people. We wanted to find out whether this was the case, and whether it was different when autistic people were sharing information with other autistic people or with non-autistic people. We recruited nine groups, each with eight people. In three of the groups, everyone was autistic; in three of the groups, everyone was non-autistic; and three of the groups were mixed groups where half the group was autistic and half the group was non-autistic. We told one person in each group a story and asked them to share it with another person, and for that person to share it again and so on, until everyone in the group had heard the story. We then looked at how many details of the story had been shared at each stage. We found that autistic people share information with other autistic people as well as non-autistic people do with other non-autistic people. However, when there are mixed groups of autistic and non-autistic people, much less information is shared. Participants were also asked how they felt they had got on with the other person in the interaction. The people in the mixed groups also experienced lower rapport with the person they were sharing the story with. This finding is important as it shows that autistic people have the skills to share information well with one another and experience good rapport, and that there are selective problems when autistic and non-autistic people are interacting.

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