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Autism: Family Life - Tactics for Getting Normal Again
Autism continuing education MFT CEUs

Section 15
Intervention Strategies Useful During & After Dynamic Assessment

CEU Question 15 | CEU Answer Booklet | Table of Contents | Autism
Counselor CEUs, Psychologist CEs, Social Worker CEUs, MFT CEUs

Language and Communication Intervention for Children with Autism
Children with autism who have little or no functional speech may be taught pointing skills through modeling or physical prompting. An effective touch or point can be used to access single symbols expressing different communicative functions. Once a child has learned to use single symbols effectively, a transition from single- to multisymbol use will enable the child to express numerous semantic relationships encoded with two or more symbols. For children with autism who use AAC and have achieved single-symbol proficiency, using multisymbol combinations should enhance their communicative competence and socialization skills.

Approaches for Teaching Early Multisymbol Combinations
One of the goals of language intervention for children with autism who are using single-word or single-symbol utterances is to train them to comprehend and express, either using speech or using AAC, word combinations they have never heard or been taught before. It is not feasible to train each combination of symbols; therefore, language intervention strategies should focus on the understanding and production of novel word combinations with the least amount of training. In this section, two approaches that are useful in the instruction of early symbol combinations to children with autism are discussed. These approaches are useful during dynamic assessment to determine the potential for multisymbol productions.

Matrix Strategy
The matrix strategy employs linguistic elements (e.g., nouns, verbs, adjectives) arranged in systematic combination matrices that are designed to induce generalized, rule-like behavior. The clinician combines a limited set of words in one semantic category with another set in a related semantic category to help the child combine lexical items in unique communicative ways and to generalize these skills to new content and contexts (Nelson, 1973). The matrix strategy helps children with disabilities maximize their abilities to recombine lexical items.

The matrix strategy has been successfully used as one of the intervention procedures to teach generalized word combining skills to children with mental retardation and other developmental disabilities. Trained semantic relations using a matrix strategy include action-object (e.g., Striefiel, Wetherby, & Karlan, 1976, 1978; Karlan, Brenn-White, Lentz, Hodur, Egger, & Frankoff, 1982; Romski & Ruder, 1984), object-location or preposition-object (e.g., Bunce, Ruder, & Ruder, 1985; Ezell & Goldstein, 1989; Light, Watson, & Remington, 1990), and descriptor-object (e.g., Remington, Watson, & Light, 1990). Although attempts have been made to teach word combining skills to children with little or no functional speech using a matrix strategy with unaided systems such as Signed English (Karlan et al., 1982), speech + sign (Romski & Ruder, 1984), and manual signs (Light ct al., 1990; Remington et al., 1990), more research is needed to develop strategies for incorporating matrix training strategies into language interventions in naturalistic contexts (Goldstein, 1993).  An example of a 4 x 4 matrix with action-object combinations is shown in Figure 1. A row represents an action and a column represents an object. Each cell of the matrix represents a unique action-object combination with the possibility of 16 action-object combinations. A clinician trains a subset of symbol combinations, and once the child has learned the subset the training starts on the next subset. The stepwise progression in the matrix provides the discriminative stimuli, and the child's response to the items of the matrix that are not in training subsets determines the generalization.

The matrix strategy is clearly an effective way of teaching manual sign (Light et al., 1990; Remington et al., 1990) and graphic symbol combinations (Nigam, 1999) to children with disabilities, but there is insufficient empirical evidence to support the efficacy of the matrix strategy for teaching children with autism. To date, only Nigam (1999) has demonstrated the efficacy of matrix instruction with children with autism, and his small sample (n = 2) prevents the generalization of findings. Further systematic replication studies are needed to determine the effectiveness of the matrix strategy to teach word, manual signs, and graphic symbol combinations to children with autism. Because each child possesses different strengths and weaknesses, the case study method and single-participant design would be suitable approaches to strengthen the existing knowledge base regarding the use of the matrix strategy.

Milieu Language Teaching Strategies
Intervention approaches applying naturalistic strategies have been used effectively to teach lexical forms, early semantic relational forms, and requesting as well as to increase spontaneous use of language in children with language deficits (Kaiser & Hester, 1994). Milieu language teaching is a general model of language intervention, used to teach both the content and the pragmatic use of language; it includes specific techniques such as incidental teaching (Hart & Risley, 1968), the mand-model procedure (Rogers-Warren & Warren, 1980), time-delay (Halle, Marshall, & Spradlin, 1979), focused stimulation (Leonard, 1981), and systematic commenting (Warren & Bambara, 1989). Milieu language teaching "is characterized by use of dispersed teaching 'episodes' that are embedded in ongoing activities and interactions... and an orientation toward teaching the form and content of communication and language in the context of typical use" (Warren, Gazdag, Bambara, & Jones, 1994, p. 924). Like the matrix strategy, milieu teaching appears to provide instructional options for teaching multisymbol combinations during dynamic assessment.

Milieu language teaching has been effective in teaching children with language disorders who do not speak frequently and who are learning early vocabulary and early semantic relations (Kaiser, Yoder, & Keetz, 1992). Early semantic relationships taught using specific milieu teaching approaches include agent-action, action-object, modifier-noun, and agent-action-object (Cavallaro & Bambara, 1982; Charlop, Schreibman, & Thibodeau, 1985; Hart & Risely, 1974; Warren & Gazdag, 1990; Warren et al., 1994). Specific training techniques such as incidental teaching, time delay and the mand-model procedure have been integrated into systematic approaches for early communication intervention. Strategies investigated have included the following:

  1. A combination of the mand-model procedure and incidental teaching (Warren & Bambara, 1989; Warren & Gazdag, 1990; Warren et al., 1994).
  2. A combination of incidental teaching, the mand-model procedure, and time delay (Warren, Yoder, Gazdag, Kim, & Jones, 1993).
  3. A combination of child-cued modeling, the mand-model procedure, time delay, and incidental teaching (Kaiser & Hester, 1994).

Incidental Teaching. Incidental teaching has strong empirical support to validate its effectiveness in developing generalized communication skills in children with autism (McGee, Daly, Izeman, Mann, & Risley, 1991; McGee, Krantz, Manson, & McClannahan, 1983; McGee, Krantz, & McClannahan, 1999). Incidental teaching and the mand-model procedure are similar except that incidental teaching is child initiated, whereas the mand-model procedure is adult initiated through open-ended questions (e.g., "What is this?") or mands (e.g., "Tell me what do you want?").  The incidental-teaching strategy uses the naturally arising interactions between an adult and a child (e.g., play activity), and the adult systematically provides language instruction to develop communication skills (Hart & Risley, 1975). The child controls the incidence or activity in which language teaching occurs. A single, incidental-teaching episode with a child using graphic symbols might work like this:

(Context: During snack time, a child points to the symbol for "juice." The goal is to teach the graphic symbol combination with an action [verb] and object [noun].)

Child: Gains attention of an adult by vocalization and points to the symbol for "juice."
Adult: Focuses attention on the child and asks, "What do you want?"
Child: Points to the symbol for "juice."
Adult: Points to the symbol for "want" followed by the symbol for "juice" (modeling).
Child: Imitates the adult model by pointing to the symbol for "want" followed by the symbol for "juice."
Adult: Gives the child juice and says, "Alright. You want some juice. Here it is" (verbal acknowledgement + expansion).

Mand-Model.The mand-model strategy is a variation of incidental teaching in which teaching interactions are adult or clinician controlled rather than child initiated. The adult chooses a time to approach the child and request verbal behavior by using mands (a non-yes/no question) and if the child's response is incomplete or incorrect, provides a model (imitative prompts). A typical episode using the mand-model procedure with a child using graphic symbols might work like this:

(Context: Child is washing face after a snack activity. The goal is to teach the graphic symbol combination with an action [verb] and object [noun].)

Adult: "What are you doing?" (an open-ended question that requires more than a "yes" or "no" answer).
Child: No response
Adult: "Tell me by pointing to symbols" (mand).
Child: "Face" (points to the symbol for "face").
Adult: "Wash face" (provides a model by pointing to the symbol for "wash" followed by the symbol for "face").
Child: "Wash face" (imitates adult's model by first pointing to the symbol for "wash" followed by the symbol for "face").
Adult: "That's right, you are washing your face" (positive feedback + verbal acknowledgement + expansion).

The adult will wait for another opportunity to use the procedure if the child does not respond to the model. After an open-ended question, mand, and model, an expectant pause of 3 to 4 seconds is provided.

Each child with autism has different strengths and weaknesses and poses unique challenges for speech and language practitioners considering the use of AAC. It is this author's hope that this article will encourage readers to consider the use of dynamic assessment when evaluating children for AAC systems. Furthermore, this author encourages practitioners to try the instructional strategies reviewed in the paper both during and after dynamic assessment to determine the potential for, and facilitate, multisymbol productions in children with autism.
- Nigam, Ravi; Dynamic assessment of graphic symbol combinations by children with autism; Focus on Autism & Other Developmental Disabilities, Fall 2001, Vol. 16, Issue 3.
The article above contains foundational information. Articles below contain optional updates.

Personal Reflection Exercise #8
The preceding section contained information about intervention strategies useful during and after dynamic assessment.   Write three case study examples regarding how you might use the content of this section in your practice.

Online Continuing Education QUESTION 15
What is one of the goals of language intervention for children with autism who are using single-word or single-symbol utterances? Record the letter of the correct answer the CEU Answer Booklet.

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Table of Contents

Anxiety in 3- to 7-year-old children with autism spectrum disorder seeking treatment for disruptive behavior
Autism, Ahead of Print.
Anxiety is a common and impairing problem in children with autism spectrum disorder, but little is known about it in preschool children with autism spectrum disorder. This article reports on the characteristics of anxiety symptoms in young children with autism spectrum disorder using a parent-completed rating scale. One hundred and eighty children (age 3–7 years) participated in a clinical trial of parent training for disruptive behaviors. Anxiety was measured as part of pre-treatment subject characterization with 16 items from the Early Childhood Inventory, a parent-completed scale on child psychiatric symptoms. Parents also completed other measures of behavioral problems. Sixty-seven percent of children were rated by their parents as having two or more clinically significant symptoms of anxiety. There were no differences in the Early Childhood Inventory anxiety severity scores of children with IQ < 70 and those with ⩾70. Higher levels of anxiety were associated with severity of oppositional defiant behavior and social disability. Anxiety symptoms are common in preschoolers with autism spectrum disorder. These findings are consistent with earlier work in school-age children with autism spectrum disorder. There were no differences in anxiety between children with IQ below 70 and those with IQ of 70 and above. Social withdrawal and oppositional behavior were associated with anxiety in young children with autism spectrum disorder.
Obesity, physical activity, and sedentary behaviors in adolescents with autism spectrum disorder compared with typically developing peers
Autism, Ahead of Print.
Decreased engagement in beneficial physical activity and increased levels of sedentary behavior and unhealthy weight are a continued public health concern in adolescents. Adolescents with autism spectrum disorder may be at an increased risk compared with their typically developing peers. Weekly physical activity, sedentary behavior, and body mass index classification were compared among adolescents with and without autism spectrum disorder. Analyses included 33,865 adolescents (autism spectrum disorder, n = 1036) from the 2016–2017 National Survey of Children’s Health (United States). After adjustment for covariates, adolescents with autism spectrum disorder were found to engage in less physical activity and were more likely to be overweight and obese compared with their typically developing peers (p’s < 0.05). As parent-reported autism spectrum disorder severity increased, the adjusted odds of being overweight and obese significantly increased and physical activity participation decreased (p-for-trends < 0.001). The findings suggest there is a need for targeted programs to decrease unhealthy weight status and support physical activity opportunities for adolescents with autism spectrum disorder across the severity spectrum.
Scanpath similarity measure reveals not only a decreased social preference, but also an increased nonsocial preference in individuals with autism
Autism, Ahead of Print.
We compared scanpath similarity in response to repeated presentations of social and nonsocial images representing natural scenes in a sample of 30 participants with autism spectrum disorder and 32 matched typically developing individuals. We used scanpath similarity (calculated using ScanMatch) as a novel measure of attentional bias or preference, which constrains eye-movement patterns by directing attention to specific visual or semantic features of the image. We found that, compared with the control group, scanpath similarity of participants with autism was significantly higher in response to nonsocial images, and significantly lower in response to social images. Moreover, scanpaths of participants with autism were more similar to scanpaths of other participants with autism in response to nonsocial images, and less similar in response to social images. Finally, we also found that in response to nonsocial images, scanpath similarity of participants with autism did not decline with stimulus repetition to the same extent as in the control group, which suggests more perseverative attention in the autism spectrum disorder group. These results show a preferential fixation on certain elements of social stimuli in typically developing individuals compared with individuals with autism, and on certain elements of nonsocial stimuli in the autism spectrum disorder group, compared with the typically developing group.
Psychosocial deficits across autism and schizotypal spectra are interactively modulated by excitatory and inhibitory neurotransmission
Autism, Ahead of Print.
Continued human and animal research has strengthened evidence for aberrant excitatory–inhibitory neural processes underlying autism and schizophrenia spectrum disorder psychopathology, particularly psychosocial functioning, in clinical and nonclinical populations. We investigated the extent to which autistic traits and schizotypal dimensions were modulated by the interactive relationship between excitatory glutamate and inhibitory GABA neurotransmitter concentrations in the social processing area of the superior temporal cortex using proton magnetic resonance spectroscopy. In total, 38 non-clinical participants (20 females; age range = 18–35 years, mean (standard deviation) = 23.22 (5.52)) completed the autism spectrum quotient and schizotypal personality questionnaire, and underwent proton magnetic resonance spectroscopy to quantify glutamate and GABA concentrations in the right and left superior temporal cortex. Regression analyses revealed that glutamate and GABA interactively modulated autistic social skills and schizotypal interpersonal features (pcorr < 0.05), such that those with high right superior temporal cortex glutamate but low GABA concentrations exhibited poorer social and interpersonal skills. These findings evidence an excitation–inhibition imbalance that is specific to psychosocial features across the autism and schizophrenia spectra.
Gender differences in self-reported camouflaging in autistic and non-autistic adults
Autism, Ahead of Print.
Social camouflaging describes the use of strategies to compensate for and mask autistic characteristics during social interactions. A newly developed self-reported measure of camouflaging (Camouflaging Autistic Traits Questionnaire) was used in an online survey to measure gender differences in autistic (n = 306) and non-autistic adults (n = 472) without intellectual disability for the first time. Controlling for age and autistic-like traits, an interaction between gender and diagnostic status was found: autistic females demonstrated higher total camouflaging scores than autistic males (partial η2 = 0.08), but there was no camouflaging gender difference for non-autistic people. Autistic females scored higher than males on two of three Camouflaging Autistic Traits Questionnaire subscales: Masking (partial η2 = 0.05) and Assimilation (partial η2 = 0.06), but not on the Compensation subscale. No differences were found between non-autistic males and females on any subscale. No differences were found between non-binary individuals and other genders in either autistic or non-autistic groups, although samples were underpowered. These findings support previous observations of greater camouflaging in autistic females than males and demonstrate for the first time no self-reported gender difference in non-autistic adults.

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