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Autism Spectrum Disorder: Promoting Communication & Socialization Skills
Autism: Teaching Parents How to Prompt Communication & Socialization

Section 19
Augmentative and Alternative Communication for
Persons with Autism

CEU Question 19 | CEU Test | Table of Contents | Autism
Social Worker CEUs, Psychologist CEs, Counselor CEUs, MFT CEUs, Nurse CEUs

Lloyd, Fuller, and Arvidson (1997) define augmentative and alternative communication (AAC) as an area of inquiry and practice emphasizing "the supplementation or replacement of natural speech and/or writing using aided and/or unaided symbols..." (p. 524). Zangari, Lloyd, and Vicker (1994) noted that recognition of AAC as an independent field dates only to the 1970s. Since that time, however, AAC has enjoyed unbounded growth due to scientific, technological, and social changes (Arvidson & Lloyd, 1997). Today, individuals of all ages with severe communication impairments and various disability types are receiving AAC assessment and intervention services. One population clearly recognized by its needs in the area of communication is persons with autism.

Severe communication deficits have long been associated with the syndrome of autism (Kanner, 1943, 1946). Reported impairments have ranged from atypical nonverbal and nonsymbolic communication (Baron-Cohen, 1989; Curcio, 1978; Ogletree, 1992; Prizant & Duchan, 1981; Prizant & Rydell, 1984; Wetherby, 1986; Wetherby & Prutting, 1984) to oral language that differs from the norm both quantitatively and qualitatively (Baltaxe, 1977; Fay & Schuler, 1980; Rutter, 1979; Tager-Flusberg, 1996, 1997; Twachtman, 1995). Deficits have been pervasive across all domains of communication and language but have been thought to be most notable in the areas of semantics (i.e., meaning) and pragmatics (i.e., use). In fact, the disruption of communication is so common in people with autism that communication and language impairment has become widely accepted as a central feature of the syndrome (Rutter, 1979).

Since the 1970s, the communicative deficits of individuals with autism have been addressed, in part, through the application of AAC. Mirenda and Erickson (2000), in a comprehensive yet brief historical review, note that early AAC efforts focused upon the use of tangible symbols, lexograms, and manual signs. Traditional orthographic symbols were also used throughout the 1970s and 1980s, with applications specific to facilitated communication extending well into the 1990s. In the 1980s and beyond, visuospatial symbols such as photographs and line drawings emerged as the symbol choice of many practitioners. Finally, Mirenda and Erickson note that voice-output communication aids and computer software programs became prominent communication options for many persons with autism by the 1980s and 1990s. They also reported that AAC became a method of choice to facilitate language comprehension (augmented input) and to address challenging behavior (functional communication training).

Although AAC has found its way into various communication interventions for persons with autism, the dearth of literature specific to this application and its efficacy is astounding. In 1989, Mirenda and Schuler reported limited and mixed evidence supporting AAC use with persons with autism and suggested that no firm conclusions regarding efficacy could be made. In a subsequent writing Mirenda and Erickson (2000) expressed surprise that since 1989 "no summary or review article has appeared in any journal indexed by Psychological Abstracts--certainly, though both the fields of AAC and autism have changed dramatically!" (p. 333).

In her contribution, "Autism, Augmentative Communication, and Assistive Technology: What Do We Really Know?," Pat Mirenda offers a comprehensive and critical review of empirical investigations pertaining to AAC and autism that have been published across the last two decades. By conducting a broad search and imposing rigorous criteria for including published reports, she has produced an authoritative review of the current state of the art in AAC intervention for individuals with autism.

In the next article, Jeff Sigafoos and Erik Drasgow classify AAC systems as either aided or unaided systems, and they describe the conditional use of each type of system with individuals with autism. In addition to providing a comprehensive review of extant literature, the authors offer a clinical case demonstration that consolidates and underscores the primary points raised in the earlier sections of the article.

Koul, Schlosser, and Sancibrian extend the discussion of aided and unaided AAC systems by critically examining the variables that appear to operate in symbol acquisition by individuals with autism spectrum disorders. Through a series of anecdotal vignettes, they place the variables under discussion into real-world contexts.

In their contribution, Schlosser and Blischak provide a comprehensive examination of state-of-the-art speech output intervention with individuals with autism. When discussing synthetic speech, the authors note that its monotonic, limited-affect quality may be preferable in speech output AAC systems for children with autism. This is an intriguing finding, particularly in light of Fay and Schuler's (1980) report that the natural speech of children with autism is characteristically monotone and lacks affective expression. Emerging from the Sohlosser & Blischak review are directions for future investigations involving speech output.

Cafiero presents a practical discussion of a "total immersion augmentative communication intervention." Using a case study approach, she demonstrates the efficacy of presenting visual and verbal stimuli throughout all activities in the day of an adolescent with developmental disabilities. She reports desirable outcomes, including increases in receptive vocabulary, expressive vocabulary, and positive behaviors.

In the final article in this issue, Nigam makes the case for applying a dynamic assessment model in evaluating the potential of individuals with autism to acquire and use multiple graphic symbol combinations for communicative purposes. After defining dynamic assessment as an emerging concept, he illustrates its application through case study descriptions. He also discusses two categories of intervention strategies that coherently follow from a dynamic assessment model. Throughout the article, he draws upon published studies, including his own empirical investigations involving individuals with autism.

Unanswered Questions
Even a cursory review of the bibliographic references in this issue makes it clear that AAC systems have been employed with individuals with autism across several decades. However, as in other domains of behavioral intervention, relatively few studies of treatment efficacy have been performed. In the majority of published investigations, the number of participants has been small, and the treatment group has typically comprised individuals with severe disabilities, only some of whom fall within the diagnostic category of autism. In her review of treatment studies, Mirenda (this issue) observed that in a number of studies the inclusion of participants with autism was incidental to the study. This common methodology across several studies raises a number of intriguing questions. Does it reflect a tacit assumption that results obtained from samples of the larger population of individuals with developmental disabilities can be extended to individuals with autism? Are there aspects of the diagnostic category of autism that specifically inform the clinician regarding specific ways to design and implement AAC systems for individuals with autism?

In their contribution to this issue, Sigafoos and Drasgow note that most individuals with autism do not have any associated physical or sensory impairment that would preclude the use of certain types of AAC systems. Also in this issue, Koul, Schlosser, and Sancibrian highlight the relatively stronger visual-spatial abilities among individuals with autism, a finding consistent with Cafiero's (1998,this issue) observation that "children with autism have demonstrated interests and abilities in activities involving visual stimuli" (Cafiero, 1998, p. 113). In light of these findings, it is not surprising that interventionists have employed an array of visual-based communication systems with children with autism. However, the relative strength of children with autism in visual-spatial abilities may be at least partly mitigated by a profound disturbance of joint attention skill development (Loveland & Landry, 1986; Mundy, Sigman, & Kasari, 1990). It has long been reported by interventionists that children with autism look less at other people's faces than do typically-developing, children (Kanner, 1943). What are the consequences of a child's profound impairment in joint attention for an interventionist attempting to introduce a visual-based AAC system? How can one facilitate acquisition of visual symbols in children who do not typically follow an interventionist's line of regard? The well-documented finding of impaired joint attention in children with autism has received little mention in AAC literature pertaining to autism. One exception is Cafiero's (1998) discussion of a program aimed at teaching picture symbols, where she makes the following observation: "Children who are able to establish joint attention and are able to point can handle as many as SO symbols on a language board. Children who have not as yet established joint attention can use two- to six-symbol language boards" (p. 114). Clearly much remains to be done to measure the impact of impaired joint attention on children's use of AAC systems.

In conclusion, as editors we hope that readers will find the contributions of this issue to be both informative and applied. Clearly, questions remain unanswered. Accordingly, we encourage researchers and practitioners to continue to promote, document, and report effective AAC practices for persons with autism.
- Ogletree, Billy & William Harn, Augmentative and alternative communications for persons with autism: history, issues, and unanswered questions, Focus on Autism & Other Developmental Disabilities, Fall 2001, Vol. 16, Issue 3.

Personal Reflection Exercise #5
The preceding section contained information about augmentative and alternative communications for persons with autism.  Write three case study examples regarding how you might use the content of this section in your practice.

Peer-Reviewed Journal Article References:
Blackman, A. L., Jimenez-Gomez, C., & Shvarts, S. (2020). Comparison of the efficacy of online versus in-vivo behavior analytic training for parents of children with autism spectrum disorder. Behavior Analysis: Research and Practice, 20(1), 13–23.

Guest, J. D., & Ohrt, J. H. (2018). Utilizing child-centered play therapy with children diagnosed with autism spectrum disorder and endured trauma: A case example. International Journal of Play Therapy, 27(3), 157–165.

Harris, B., McClain, M. B., Haverkamp, C. R., Cruz, R. A., Benallie, K. J., & Benney, C. M. (2019). School-based assessment of autism spectrum disorder among culturally and linguistically diverse children. Professional Psychology: Research and Practice, 50(5), 323–332.

Online Continuing Education QUESTION 19
According to Ogletree, what areas of communication and language do persons with autism have the most difficulty? Record the letter of the correct answer the CEU Test.

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