Wednesday, March 6, 2019

Autism, Assistive Technology, and Augmentative Communication

 Assistive Technology
Assistive technology (AT) refers to a number of accommodations and adaptations which enable individuals with disabilities to function more independently. This includes any type of technology that provides students with disabilities greater access to the general education curriculum and increases the potential to master academic content, interact with others, and enhance functional independence and quality of life. While AT is not necessary or required for every student receiving special education services, schools are required to provide the appropriate assistive technology system when it supports the child’s access to a free and appropriate public education (FAPE). There are various types of technology ranging from "low" to "high" tech that might be incorporated into the educational setting to increase children’s independent functioning skills and reduce barriers that may prevent them from performing at a similar level as their peers. For example, students may use software with word prediction capabilities that allow them to have more success with written composition. Hardware such as portable keyboards, laptop computers, and tablets may lessen the physical demand of writing for students with weak fine motor skills or difficulty coordinating ideas with writing. Similarly, a speech-generating device or voice output communication aids may meet the needs of children with limited expressive language, by providing an effective means of verbal communication.
 Augmentative and Alternative Communication (AAC)
 Communication impairments can impact an individual’s ability to communicate with others (expressive communication) and/or receive communication from others (receptive communication). Augmentative and Alternative Communication (AAC) is a type of assistive technology that can help assist children with communication impairments to increase skills in this area and to become more competent communicators. Some students with autism spectrum disorder (ASD) who have difficulty with expressive communication may be successful in social interaction and expressing their wants and needs with a low technology AAC system such as the Picture Exchange Communication System (PECS©). PECS is considered an evidence-based practice that incorporates both behavioral and developmental-pragmatic principles to teach functional communication to children with limited verbal and/or communication skills. There are six phases of PECS instruction, with each phase building on the last. The phases are: (1) Teaching the physically assisted exchange, (2) Expanding spontaneity, (3) Simultaneous discrimination of pictures, (4) Building sentence structure, (5) Responding to, “What do you want?” and (6) Commenting in response to a question. PECS relies on the principles of applied behavior analysis (ABA) so that distinct prompting, reinforcement, and error correction strategies are specified at each training phase in order to teach spontaneous, functional communication. The research evidence suggests that PECS can be used in multiple settings, including schools, homes, and therapy settings to successfully improve functional communication, play, and behavioral skills.
It is important for educational teams to consider AAC for any student with ASD. For some students, AAC may act as the primary mode of communication. For others, it may be a secondary form. A referral to an assistive technology specialist or speech-language pathologist for an evaluation should be made for a student who may benefit from assistive technology and/or an augmentative communication system. As with all assessment and intervention procedures, a team approach is necessary to determine the child’s strengths and limitations, and the range and scope of potential assistive technology options to address his or her specific needs.
Adapted from Wilkinson, L. A. (2017). A best practice guide to assessment and intervention for autism spectrum disorder in schools. London and Philadelphia: Jessica Kingsley Publishers.
Key References and Further Reading
Charlop-Christy, M. H., Carpenter, M., H., LeBlanc, L. A., & Kellet, K. (2002). Using the Picture Exchange Communication System (PECS) with children with autism: Assessment of PECS acquisition, speech, social-communicative behavior, and problem behavior. Journal of Applied Behavior Analysis, 35, 213–231.
Frost, L., & Bondy, A. (2002). The Picture Exchange Communication System Training Manual (2nd ed.). Cherry Hill, NJ: Pyramid Educational Consultants.
Ganz, J. B., Davis, J. L., Lund, E. M., Goodwyn, F. D., & Simpson, R. L. (2012). Meta-analysis of PECS with individuals with ASD: Investigation of targeted versus non-targeted outcomes, participant characteristics, and implementation phase. Research in Developmental Disorders, 33, 406-418. doi:10.1016/j.ridd.2011.09.023.
Hart, S. L., & Banda, D. R. (2010). Picture Exchange Communication System with individuals with developmental disabilities: A meta-analysis of single subject studies. Remedial and Special Education, 31, 476-488. doi: 10.1177/0741932509338354.
Individuals with Disabilities Education Improvement Act of 2004. Pub. L. No. 108-446, 108th Congress, 2nd Session. (2004).
Kabot, S., & Reeve, C. (2014). Curriculum and Program Structure. In L. A. Wilkinson (Ed.), Autism spectrum disorder in children and adolescents:  Evidence-based assessment and intervention in schools (pp. 195-218). Washington, DC: American Psychological Association.
National Autism Center (2015). Findings and conclusions: National standards project, phase 2. Randolph, MA: Author. Available from: http://www.nationalautismcenter.org/national-standards-project/phase-2/
Sulzer-Azaroff, B., Hoffman, A. O., Horton, C. B., Bondy, A., & Frost, L. (2009).
The Picture Exchange Communication System (PECS): What do the data say? Focus on Autism and Other Developmental Disabilities, 24, 89-103.
Twachtman-Cullen, D. & Twachtman-Bassett, J. (2014). Language and Social Communication. In L. A. Wilkinson (Ed.). Autism spectrum disorder in children and adolescents:  Evidence-based assessment and intervention in schools (pp. 101-124). Washington, DC: American Psychological Association.
Wilkinson, L. A. (Ed.) (2014). Autism spectrum disorder in children and adolescents: Evidence-based assessment and intervention in schools. Washington, DC: American Psychological Association.
Wilkinson, L. A. (2014). Introduction: Evidence-Based Practice for Autism Spectrum Disorder. In L. A. Wilkinson (Ed.). Autism spectrum disorder in children and adolescents: Evidence-based assessment and intervention in schools (pp 3-13). Washington, DC: American Psychological Association.
Wilkinson, L. A. (2017). Best Practice in Special Education. In A best practice guide to assessment and intervention for autism spectrum disorder in schools (pp. 157-200). London & Philadelphia: Jessica Kingsley Publishers.
Wilkinson, L. A. (2017). A best practice guide to assessment and intervention for autism spectrum disorder in schools. London & Philadelphia: Jessica Kingsley Publishers.
Wong, C., Odom, S. L., Hume, K. A., Cox, C. W., Fettig, A., Kurcharczyk…Schultz, T. R. (2015). Evidence-based practices for children, youth, and young adults with autism spectrum disorder: A comprehensive review. Journal of Autism and Developmental Disorders, 45, 1951-66. doi: 10.1007/s10803-014-2351-z
Lee A. Wilkinson, PhD, is a nationally certified and licensed school psychologist, registered psychologist, and certified cognitive-behavioral therapist. He provides consultation services and best practice guidance to school systems, agencies, advocacy groups, and professionals on a wide variety of topics related to children and youth with autism. Dr. Wilkinson is author of the award-winning books, A Best Practice Guide to Assessment and Intervention for Autism and Asperger Syndrome in Schools and Overcoming Anxiety and Depression on the Autism Spectrum: A Self-Help Guide Using CBT. He is also editor of a best-selling text in the APA School Psychology Book Series, Autism Spectrum Disorder in Children and Adolescents: Evidence-Based Assessment and Intervention in Schools. His latest book is A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Edition).





Sunday, February 17, 2019

Pragmatic Language Skills and the Autism Spectrum


Pragmatic Language Skills

The diagnostic criteria for autism spectrum disorder (ASD) include persistent deficits in social communication and social interaction across multiple contexts. Problems with the pragmatic/social use of language or impairment in the ability to understand and use language in social-communicative contexts is a core feature of ASD. Pragmatic skills involve: (a) using language for different purposes; (b) changing language according to the needs of a listener or situation; (c) understanding non-literal language; and (d) following rules for conversations.  

There are many unwritten rules in society that govern our behavior. While most of us intuitively understand these rules, individuals with ASD have not automatically learned the conventions and nuances that make up their social environment. These unspoken or “hidden” social standards can make the world a confusing place and result in life-long challenges. For example, social expectations such as “it is not polite to interrupt others while they are talking,” “take turns in conversation” and “discuss other topics besides only those you are interested in” are not taught and are assumed to be known and understood. We seem to have an “unconscious” navigator that allows us to make intuitive sense of the unspoken rules in society and adjust to the social demands of our everyday lives.
Unspoken Rules

The unspoken rules of social engagement involve the use of the pragmatic, social communicative functions of language (e.g., turn taking, understanding of inferences and figurative expressions) as well as nonverbal skills needed to communicate and regulate interaction (e.g., eye contact, gesture, facial expression). This includes body language and idioms, metaphors, or slang – phrases and meanings that we intuitively assimilate or learn through observation or subtle cues. Individuals with ASD tend to interpret language literally and may be puzzled by the common everyday expressions used by a typical peer or adult. They may fail to use appropriate nonverbal communication skills, such as eye contact and have impairments in comprehension, or generally have difficulty communicating with others. As a result, peers often feel ineffective when engaged in social exchanges with a child on the autism spectrum and may avoid that person and/or react in a negative way (e.g., teasing or bullying), further impacting the development of appropriate social skills. 
Consider how idioms or figurative speech such as “how the cookie crumbles,” “curiosity killed the cat,” "kill two birds with one stone," "everything but the kitchen sink," and “when it rains, it pours” will have a totally different meaning and result in confusion if taken literally. In order to understand language, we must understand what the idioms in that language mean (there are well over 3,000 idioms in the English language). If you try to figure out the meaning of an idiom literally (word by word), you will be bewildered. While the typical individual might understand that the phrase “that’s the way the cookie crumbles,” and accompanying body language (e.g., voice, body) communicates to the listener that something unfortunate has happened, to someone with a pragmatic social-communication problem, this idiom will have a completely different meaning and be confusing.

Assessment

Because social communication deficits are among the core challenges of ASD, a best practice student assessment should include an evaluation of pragmatic competence and not be limited to the formal, structural aspects of language (i.e., articulation and receptive/ expressive language functioning). As a group, more capable students with ASD tend to demonstrate strength in formal language, but a weakness is pragmatic and social skills. As a result, they often fail to qualify for speech-language services because they present strong verbal skills and large vocabularies, and score well on formal language assessments. 
A variety of assessment strategies should be used, including direct assessment, naturalistic observation and interviewing significant others, including parents and educators, who are valuable sources of information. 

Assessments to identify pragmatic language deficits tend to be less well developed than tests of language fundamentals. There are fewer standard measures available to assess these skills in children with ASD. Valid norms for pragmatic development and objective criteria for pragmatic performance are also limited. Among the standardized instruments that focus on the social communicative functions of language are the Comprehensive Assessment of Spoken Language (CASL; Carrow-Woolfolk, 1999), Test of Pragmatic Language, 2nd Edition (TOPL-2; Phelps-Terasaki & Phelps-Gunn, 2007), Social Language Development Test-Elementary (SLDT-E; Bowers, Huisingh, & LoGiudice, 2008), Children's Communication Checklist, Second Edition (CCC-2; Bishop, 2006) and Pragmatic Language Skills Inventory (PLSI; Gilliam & Miller, 2006). 

It is imperative that speech/language services for children with ASD include particular attention to the pragmatic, social communicative functions of language (e.g., turn taking, understanding of inferences and figurative expressions) as well as to the nonverbal skills needed to communicate and regulate interaction (e.g., eye contact, gesture, facial expression, and body language). Significant and severe deficits in the ability to communicate and interact with others can limit participation in mainstream academic settings and community activities. Moreover, pragmatic deficits tend to become even more obvious and problematic as social and educational demands increase with age. Students with pragmatic language deficits who do not meet the DSM-5 ASD criteria for restricted, repetitive patterns of behavior should be evaluated for social (pragmatic) communication disorder (SCD).  

Adapted from Wilkinson, L. A. (2017). A best practice guide to assessment and intervention for autism spectrum disorder in schools. London and Philadelphia: Jessica Kingsley Publishers.

Lee A. Wilkinson, PhD, NCSP is a licensed and nationally certified school psychologist, registered psychologist, and certified cognitive-behavioral therapist. He provides consultation services and best practice guidance to school systems, agencies, advocacy groups, and professionals on a wide variety of topics related to children and youth with autism spectrum disorders. Dr. Wilkinson is author of the award-winning books,  A Best Practice Guide to Assessment and Intervention for Autism and Asperger Syndrome in Schools and Overcoming Anxiety and Depression on the Autism Spectrum: A Self-Help Guide Using CBTHe is also editor of a best-selling text in the APA School Psychology Book Series,  Autism Spectrum Disorder in Children and Adolescents: Evidence-Based Assessment and Intervention in Schools. His latest book is A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Edition).

© 2017 Lee A. Wilkinson, PhD

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