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Parent-Child Interaction and Autism Spectrum Disorder ASD
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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Challenges, priorities, barriers to care, and stigma in families of people with autism: Similarities and differences among six Latin American countries
Autism, Ahead of Print.
Lack of access to services and support is an important issue for people with autism, but in low- and middle-income countries there is a lack of data on this problem. The aims of this study were to describe the challenges and priorities, identify barriers to care, and map stigma among families of individuals with autism in Latin America. This survey was undertaken by the Red Espectro Autista Latinoamerica network, a coalition of researchers/clinicians from six Latin American countries; it comprised 2942 caregivers of children with autism from Brazil, Argentina, Chile, Uruguay, Venezuela, and the Dominican-Republic, who completed the Spanish/Portuguese version of the Caregiver Needs Survey. The survey showed that the main priorities were greater community awareness and improvements in education. The main barriers to care were waiting lists (50.2%), treatment costs (35.2%), and lack of specialized services (26.1%). Stigma experienced by families was frequent: one-third reported feeling discriminated against and helpless for having a child with autism, 48.8% reported some type of financial problem, 47.4% had to reduce work hours, and 35.5% had to stop working because of their child’s autism. This survey describes the main needs/challenges faced by individuals with autism in Latin America, helping to build data-driven strategies at a national/regional level.Lay abstractApproximately 6 million individuals with autism spectrum disorder live in Latin America. In order to strengthen autism spectrum disorder research collaborations and awareness in the region, the Latin American Autism Spectrum Network (Red Espectro Autista Latinoamerica) was constituted in 2015, comprising researchers and clinicians from the following six countries: Brazil Argentina, Chile, Uruguay, Venezuela, and the Dominican Republic. This first multisite study from the Red Espectro Autista Latinoamerica network aims to describe the challenges and priorities to identify barriers to care and to map stigma among families of individuals with autism spectrum disorder living in Latin America. A total of 2942 caregivers from these six countries completed an online survey showing that the main priorities were greater community awareness and improvements in the educational system for individuals with autism spectrum disorder. In addition to that, the main barriers to care were related to lack of structure, mainly waiting lists (50.2%), high treatment costs (35.2%), and lack of specialized services (26.1%). Stigma experienced by families was frequent: one third reported feeling discriminated against and helpless for having a child with autism spectrum disorder. Also, 48.8% of the caregivers declared financial problems, 47.4% of them had to cut down work hours, and 35.5% had to leave their jobs because of their child’s autism spectrum disorder. This is a pioneer study providing a description of the needs and challenges faced by families affected by autism spectrum disorder in Latin America, helping to build data-driven strategies at the national and regional levels.
Parents’ perceptions and concerns about physical activity participation among adolescents with autism spectrum disorder
Autism, Ahead of Print.
The parents of adolescents with autism spectrum disorder have a vital and proactive role in encouraging healthy physical activity habits, and they possess important knowledge about the adolescents’ needs when it comes to enhancing participation in physical activity. But promoting healthy physical activity habits in adolescents can be difficult. The purpose of this study was thus to describe parents’ perceptions of their adolescent child’s participation in physical activity and to describe the parental role in promoting such participation. Twenty-eight parents of adolescents aged 12–16 years with autism spectrum disorder were interviewed. The interviews were analyzed using an inductive content analysis approach. The parents described how challenging participation in physical activities could be for their adolescents. Despite this, they wanted to see their children participate more in physical activity but found the promotion of physical activity to be an overwhelming task that was difficult to cope with on their own. The results reveal a need for support and collaborative efforts among different actors to give these issues increased priority in order to promote the adolescents’ physical activity participation.Lay abstractWhat is already known about the topic? The parents of adolescents with autism spectrum disorder have a vital and proactive role in encouraging healthy physical activity habits. But promoting healthy physical activity habits in adolescents can be difficult. The purpose of this study was thus to describe the parental perceptions of their adolescent child’s participation in physical activity and to describe the parental role in promoting such participation. Twenty-eight parents of adolescents aged 12–16 years with autism spectrum disorder were interviewed.What this paper adds? The parents described how challenging participation in physical activities could be for their adolescents. Despite this, they wanted to see their children participate more in physical activity but found the promotion of physical activity to be an overwhelming task that was difficult to cope with on their own.Implications for practice, research, or policy. The results reveal a need for support and collaborative efforts among different actors to give these issues increased priority in order to promote the adolescents’ physical activity participation.
Vision care among school-aged children with autism spectrum disorder in North America: Findings from the Autism Treatment Network Registry Call-Back Study
Autism, Ahead of Print.
Children with autism spectrum disorder have a high risk of vision problems yet little is known about their vision care. This cross-sectional survey study, therefore, examined vision care among 351 children with autism spectrum disorder ages 6–17 years in the United States or Canada who were enrolled in the Autism Treatment Network Registry. Vision care variables were vision tested with pictures, shapes, or letters in the past 2 years; vision tested by an eye care practitioner (e.g. ophthalmologist, optometrist) in the past 2 years; prescribed corrective eyeglasses; and wore eyeglasses as recommended. Covariates included sociodemographic, child functioning, and family functioning variables. Multivariable models were fit for each vision care variable. Though 78% of children with autism spectrum disorder had their vision tested, only 57% had an eye care practitioner test their vision in the past 2 years. Among the 30% of children with autism spectrum disorder prescribed corrective eyeglasses, 78% wore their eyeglasses as recommended. Multivariable analysis results demonstrated statistically significant differences in vision care among children with autism spectrum disorder by parent education, household income, communication abilities, intellectual functioning, and caregiver strain. Overall, study results suggest many school-aged children with autism spectrum disorder do not receive recommended vision care and highlight potentially modifiable disparities in vision care.Lay AbstractChildren with autism are at high risk for vision problems, which may compound core social and behavioral symptoms if untreated. Despite recommendations for school-aged children with autism to receive routine vision testing by an eye care practitioner (ophthalmologist or optometrist), little is known about their vision care. This study, therefore, examined vision care among 351 children with autism ages 6–17 years in the United States or Canada who were enrolled in the Autism Treatment Network Registry. Parents were surveyed using the following vision care measures: (1) child’s vision was tested with pictures, shapes, or letters in the past 2 years; (2) child’s vision was tested by an eye care practitioner in the past 2 years; (3) child was prescribed corrective eyeglasses; and (4) child wore eyeglasses as recommended. Sociodemographic characteristics such as parent education level, child functioning characteristics such as child communication abilities, and family functioning characteristics such as caregiver strain were also assessed in relationship to vision care. Although 78% of children with autism had their vision tested, only 57% had an eye care practitioner test their vision in the past 2 years. Among the 30% of children with autism prescribed corrective eyeglasses, 78% wore their eyeglasses as recommended. Differences in vision care were additionally found among children with autism by parent education, household income, communication abilities, intellectual functioning, and caregiver strain. Overall, study results suggest many school-aged children with autism do not receive recommended vision care and highlight potentially modifiable disparities in vision care.
Sex-related patterns of intrinsic functional connectivity in children and adolescents with autism spectrum disorders
Autism, Ahead of Print.
Although a growing literature highlights sex differences in autism spectrum disorder clinical presentation, less is known about female variants at the neural level. We investigated sex-related patterns of functional connectivity within and between functional networks in children and adolescents with autism spectrum disorders, compared to typically developing peers. Resting-state functional magnetic resonance imaging data for 141 children and adolescents (7–17 years) selected from an in-house sample and four sites contributing to the Autism Brain Imaging Database Exchange (ABIDE I and II) were submitted to group independent component analysis to generate resting-state functional networks. Functional connectivity was estimated by generating resting-state functional network correlation matrices, which were directly compared between males and females, and autism spectrum disorder and typically developing groups. Results revealed greater connectivity within the default mode network in typically developing girls as compared to typically developing boys, while no such sex effect was observed in the autism spectrum disorder group. Correlational analyses with clinical indices revealed a negative relationship between sensorimotor connectivity and history of early autism symptoms in girls, but not in boys with autism spectrum disorder. A lack of neurotypical sex differentiation in default mode network functional connectivity observed in boys and girls with autism spectrum disorder suggests that sex-related differences in network integration may be altered in autism spectrum disorder.Lay summaryWe investigated whether children and adolescents with autism spectrum disorders show sex-specific patterns of brain function (using functional magnetic resonance imaging) that are well documented in typically developing males and females. We found, unexpectedly, that boys and girls with autism do not differ in their brain functional connectivity, whereas typically developing boys and girls showed differences in a brain network involved in thinking about self and others (the default mode network). Results suggest that autism may be characterized by a lack of brain sex differentiation.
Facial emotion recognition in autistic adult females correlates with alexithymia, not autism
Autism, Ahead of Print.
Research on predominantly male autistic samples has indicated that impairments in facial emotion recognition typically associated with autism spectrum conditions are instead due to co-occurring alexithymia. However, whether this could be demonstrated using more realistic facial emotion recognition stimuli and applied to autistic females was unclear. In all, 83 females diagnosed with autism spectrum condition completed online self-report measures of autism spectrum condition severity and alexithymia, and afacial emotion recognition deficit that assessed their ability to identify multimodal displays of complex emotions. Higher levels of alexithymia, but not autism spectrum condition severity, were associated with less accurate facial emotion recognition. Difficulty identifying one’s own feelings and externally oriented thinking were the components of alexithymia that were specifically related to facial emotion recognition accuracy. However, alexithymia (and autism spectrum condition severity) was not associated with speed of emotion processing. The findings are primarily discussed with the theoretical view that perceiving and experiencing emotions share the same neural networks, thus being able to recognise one’s own emotions may facilitate the ability to recognise others’. This study is in line with previous similar research on autistic males and suggests impairments in facial emotion recognition in autistic females should be attributed to co-occurring alexithymia.Lay abstractResearch with autistic males has indicated that difficulties in recognising facial expressions of emotion, commonly associated with autism spectrum conditions, may instead be due to co-occurring alexithymia (a condition involving lack of emotional awareness, difficulty describing feelings and difficulty distinguishing feelings from physical bodily sensations) and not to do with autism. We wanted to explore if this would be true for autistic females, as well as to use more realistic stimuli for emotional expression. In all, 83 females diagnosed with autism spectrum condition completed self-report measures of autism spectrum condition traits and alexithymia and completed a visual test that assessed their ability to identify multimodal displays of complex emotions. Higher levels of alexithymia, but not autism spectrum condition features, were associated with less accuracy in identifying emotions. Difficulty identifying one’s own feelings and externally oriented thinking were the components of alexithymia that were specifically related to facial emotion recognition accuracy. However, alexithymia (and levels of autism spectrum condition traits) was not associated with speed of emotion processing. We discuss the findings in terms of possible underlying mechanisms and the implications for our understanding of emotion processing and recognition in autism.

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