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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 Answer Booklet | 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
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.

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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 Answer Booklet.

 
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The article above contains foundational information. Articles below contain optional updates.
What are we targeting when we treat autism spectrum disorder? A systematic review of 406 clinical trials
Autism, Ahead of Print.
The number of trials aimed at evaluating treatments for autism spectrum disorder has been increasing progressively. However, it is not clear which outcome measures should be used to assess their efficacy, especially for treatments which target core symptoms. The present review aimed to provide a comprehensive overview regarding the outcome measures used in clinical trials for people with autism spectrum disorder. We systematically searched the Web of KnowledgeSM database between 1980 and 2016 to identify published controlled trials investigating the efficacy of interventions in autism spectrum disorder. We included 406 trials in the final database, from which a total of 327 outcome measures were identified. Only seven scales were used in more than 5% of the studies, among which only three measured core symptoms (Autism Diagnostic Observation Schedule, Childhood Autism Rating Scale, and Social Responsiveness Scale). Of note, 69% of the tools were used in the literature only once. Our systematic review has shown that the evaluation of efficacy in intervention trials for autism spectrum disorder relies on heterogeneous and often non-specific tools for this condition. The fragmentation of tools may significantly hamper the comparisons between studies and thus the discovery of effective treatments for autism spectrum disorder. Greater consensus regarding the choice of these measures should be reached.
Self-reported motivations for offending by autistic sexual offenders
Autism, Ahead of Print.
Autism spectrum disorder is a neurodevelopmental disorder estimated to have elevated prevalence in forensic populations (approximately 4.5%). It has been suggested that offenders with autism spectrum disorder engage more frequently in crimes against the person and sexual offences than other types of offences such as property, driving and drug offences. To date little is empirically known about the reasons why autistic individuals engage in sexual offences, yet understanding the motivation(s) for offending are key to developing and implementing effective interventions to help reduce both initial offending and also re-offending. In this study, semi-structured interviews were conducted with nine autistic sexual offenders in prisons and probation services across England and Wales. Thematic analyses revealed five main themes (social difficulties, misunderstanding, sex and relationship deficits, inadequate control and disequilibrium). Analyses indicated that social skills difficulties, lack of perspective/weak central coherence, misunderstanding the seriousness of their behaviours and a lack of appropriate relationships were the main reasons for offending reported by this group of autistic sexual offenders. Findings highlight a need to develop sex and relationship education interventions which are tailored to the needs of autistic individuals, to address both their reported reasons for offending and their reported lack of sexual knowledge and awareness.
Acting on observed social exclusion and pro-social behaviour in autism spectrum disorder
Autism, Ahead of Print.
Humans are commonly motivated towards cooperation and prosociality. In this study, we examined this motivational predisposition in autistic individuals. Using an adaptation of the Cyberball paradigm, we investigated subsequent pro-social behaviour after witnessing social exclusion. Participants witnessed and played a series of Cyberball games, rated their affective state and valued emotional faces with respect to their approachability. Results showed that participants from both groups were aware of the social exclusion. However, while neurotypically developing participants engaged in pro-social behaviour in reaction to the exclusion, autistic participants showed less alterations, in terms of either behaviour or affective state. The current findings suggest a distinct motivational drive and processing of social reward stimuli in autism, which may result in behavioural responses divergent from typical development when engaging in the social world.
Self-reported social impairments predict depressive disorder in adults with autism spectrum disorder
Autism, Ahead of Print.
In adults with autism spectrum disorder, co-occurring psychiatric conditions are prevalent, and depression is one of the most common co-occurring disorders. This study examined the relationship between depression and cognitive ability, autism symptom severity, and self-reported social impairments in autism spectrum disorder. A total of 33 adults with autism spectrum disorder and 28 adults with typical development completed a standardized psychiatric interview, cognitive test, measure of clinician-rated autism symptom severity, and self-report of social impairments. Nine participants with autism spectrum disorder (27%) met the criteria for a depressive disorder (autism spectrum disorder + depressive disorder). Relatively more females with autism spectrum disorder had a co-occurring depressive disorder. The typical development group had a higher intelligence quotient than the autism spectrum disorder group, but the autism spectrum disorder + depressive disorder group did not differ from the typical development or autism spectrum disorder group. While the autism spectrum disorder + depressive disorder group had lower clinician-rated autism symptom severity than the autism spectrum disorder group, the autism spectrum disorder + depressive disorder group reported more social impairments than the autism spectrum disorder group. Self-reported social impairments predicted depression in adults with autism spectrum disorder when accounting for symptom severity and cognitive ability. These findings suggest that more self-perceived social impairments are related to depressive disorders in autism spectrum disorder, and may help clinicians identify individuals who are vulnerable in developing a co-occurring depressive disorder. Future directions include follow-up studies with larger cohorts and longitudinal designs to support inferences regarding directionality of these relationships.
Complex facial emotion recognition and atypical gaze patterns in autistic adults
Autism, Ahead of Print.
While altered gaze behaviour during facial emotion recognition has been observed in autistic individuals, there remains marked inconsistency in findings, with the majority of previous research focused towards the processing of basic emotional expressions. There is a need to examine whether atypical gaze during facial emotion recognition extends to more complex emotional expressions, which are experienced as part of everyday social functioning. The eye gaze of 20 autistic and 20 IQ-matched neurotypical adults was examined during a facial emotion recognition task of complex, dynamic emotion displays. Autistic adults fixated longer on the mouth region when viewing complex emotions compared to neurotypical adults, indicating that altered prioritization of visual information may contribute to facial emotion recognition impairment. Results confirm the need for more ecologically valid stimuli for the elucidation of the mechanisms underlying facial emotion recognition difficulty in autistic individuals.

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