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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 Test | 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.

Conclusions
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 Test.

 
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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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