Recommendations for Young Children/Autism/Social Communication

  • XXX should be placed in a developmental preschool program, which would provide him with more structure and a student-teacher ratio more suited to his needs.
  • Participation in a developmental preschool setting to increase XXX’s exposure to and opportunities for social communication with peers his age
  • It is recommended that XXX receive speech/language intervention. Treatment targets might include: increasing joint attention and eye contact, improving social communication (greeting, requesting, commenting), and increasing receptive and expressive language.
  • Speech/language therapy focusing on increasing XXX’s receptive language skills and social use of expressive language. Specific targets might include:
  • age-appropriate comprehension of word combinations, questions, following directions, etc.
  • increasing use of expressive language (rather than nonverbal means) to request, protest, etc.
  • increasing grammatical complexity and functionality of spontaneous utterances
  • Speech/language therapy should continue to emphasize the development of XXX’s expressive language (vocabulary, multiple word utterances, etc.).
  • Play interactions can help XXX develop symbolic play skills, which underlie symbolic communication. Rather than a directive style (e.g., “Drink from the cup”), model the target behaviors and encourage XXX to imitate (e.g., Pretend to drink from a cup, then hand the cup to XXX and say “Your turn!”). Gradually increase the complexity of play by joining more play schemes together (e.g., Pretend to pour juice into the cup before pretending to drink it.)
  • PECS and/or signing should be explored as methods that will help XXX express her communicative needs; whatever system is implemented at school should also be implemented consistently at home to minimize confusion. Also, be sure to start with a limited number of choices (either picture symbols or signs) and increase the number of choices only when XXX has mastered the ones already taught.
  • Speech/language goals should be added related to increasing social communication as a way of helping XXX understand the environment-controlling potential of language.
  • Non-verbal symbolic communication systems (such as signing or The Picture Exchange Communication System (PECS)) should be explored as initial means by which XXX can increase his initiation of requesting behaviors. Research has shown that these non-verbal systems are highly successful at giving children with autistic spectrum disorders a formal, symbolic means of communication which then enables spoken language communication to emerge.
  • Speech/language intervention for XXX should focus on expanding her functional communication skills, and on transitioning her to the use of more symbolic communication:
  • XXX should continue to receive speech and language therapy that focuses on:
  • Increasing joint attention, turn-taking, and eye contact
  • Increasing requests of objects and actions using words or PECS
  • Improving play skills (appropriate toy use and symbolic play) as a foundation for development of language content and use.
  • Improve XXX’s pragmatic skills, including appropriately initiating, maintaining, and terminating interactions; identifying and repairing communication breakdowns by requesting clarification and/or additional information.
  • Speech/language therapy should continue to emphasize the development of XXX’s expressive and receptive language (following directions, answering questions, etc.), as well as decreasing echolalia and perseverative behaviors.
  • To improve XXX’s receptive language, engage him in activities that encourage joint attention, turn-taking, eye contact, and use of social communication at home, such as:
  • Speech/language therapy should continue to emphasize the development of XXX’s expressive and receptive language, particularly in the context of social communication. Increasing XXX’s readiness to engage in joint attention will aid his aural comprehension and enable him to acquire more expressive language.
  • XXX should continue to receive intervention for language and social communication in his current classroom placement. Intervention should focus on increasing XXX’s use of single words and phrases to communicate his needs and to increase his exploration of the world around him. Based on the findings from this assessment, therapy targets would include:
  • Introduce functional phrases that are specific to particular routines. Instruction of short phrases can capitalize on XXX’s ability to learn language holistically and his use of immediate echolalia.
  • Increase XXX’s single word vocabulary (e.g., nouns, verbs) by following a developmental course of language acquisition. Phrases learned holistically can be broken down into their single word components. Single word vocabulary can be taught through use of a cloze procedure with familiar songs, rhymes, and verbal routines.
  • Teach two-word phrases such as “more + thing/action” and “no + thing/action” to enhance XXX’s control of his environment. For example, develop specific requests such as “more cookie/juice,” and “more swinging/tickling.” Expand XXX’s verbal protest to be context-specific, such as “no juice,” and “stop tickling.”
  • Reduce injurious behaviors by increasing XXX’s use of language to protest (e.g.,“stop swinging”).
  • Engage XXX in play activities that increase his socialization with others and exploration of objects.
  • Engage XXX in reciprocal routines with an adult such as brushing and feeding.
  • Provide opportunities for initiation by teaching XXX to request help by giving. For example, hand XXX a desired food item which is wrapped and teach XXX to seek assistance by saying “Help, please” and giving the package to another person to open.
  • XXX should continue to receive speech-language intervention with a focus on increasing his receptive and expressive language abilities.
  • The expressive language areas of content and form can be targeted separately to decrease the demands on XXX’s language formulation. Language goals related to content should focus on increasing XXX’s ability to describe things and events without a need to state these details in a grammatically correct form. Similarly, language goals related to form should focus on producing grammatically correct sentences in simple exercises that do not require a significant amount of independent ideation.
  • Language learning can be facilitated with frequent models of simple language at school and at home. When XXX makes a statement, the adult should expand on his production to validate its content, provide a model of grammatical completeness, and add more information to the idea. For example, if XXX says, “Maybe we swim in water,” the adult could respond, “You’re right! We will swim in the water. The water might be cold.” Maintaining a high level of enthusiasm for XXX’s attempts can help him feel more successful, thereby increasing the likelihood of his participation.
  • Storytelling activities can provide XXX with repetitive, but enjoyable, opportunities to produce language. At home, XXX’s parents can read familiar storybooks and provide model narratives that are simple and descriptive. XXX can then retell these stories with the support of pictures to help him remember to include details. Simple stories can also be developed around familiar family events. Repeated exposure to a set of familiar narratives will enhance XXX’s ability to retell these stories with sufficient detail.
  • Based on the findings of the assessment team, XXX exhibits significant delays in both speech/language development and self-help skills. It is thus recommended that XXX be enrolled in a developmental preschool in her local school district. She should receive the services of a certified speech-language pathologist as part of her academic program. She should also be assessed in the areas of fine and gross motor development, as no occupational or physical therapy assessments were carried out at today’s evaluation. XXX’s parents should be involved in her therapy programs to ensure maximal carryover of intervention procedures from the school to the home environment.
  • It is recommended that XXX return for a re-evaluation in one year. By assessing the progress she has made over this time period, a better idea of her developmental course can be determined and her intervention plan can be modified as needed.
  • Capitalize on XXX’s strong visual skills to aid in the development of age-appropriate communication and behavior.
  • The Picture Exchange Communication System (PECS) is designed to teach formal, symbolic communication to children who do not yet use words or signs. Communication using formal symbols lays a foundation for the emergence of spoken words (which are also abstract symbols).
  • Visual schedules can be prepared to cue XXX to follow the steps of a routine (e.g., getting ready for bed), to prepare him for transitions during the day, to assist him in following directions, etc.
  • Coordinate XXX’s interventions to ensure that there is consistency among the home, preschool, and individual therapy environments (e.g., the same visual schedule should be used for a handwashing routine in all contexts; if PECS is used in one environment, it should be used in the others, etc.).
  • It is recommended that XXX continue to receive speech/language therapy to improve his receptive and expressive language skills, particularly in the context of meaningful social interaction. Following are suggestions for therapy:
  • Devise therapy goals that can be addressed in naturalistic contexts (e.g., the classroom, lunchroom, playground, small group of peers, etc.) to help XXX apply his communication skills in a more functional and social manner.
  • Scripts for social interaction can be beneficial to children with autism. For example, XXX can be taught a script for interacting with his peer during snack time, recess, etc. XXX’s peers could also be taught this script to facilitate XXX’s participation. Scripts help translate the subtle and changing world of social interactions into concrete, predictable routines that allow children with autism to achieve success in social situations. Once a routine is established, begin varying it slightly (change of peers, activities, location, etc.) to increase flexibility and comfort level in a wider variety of contexts.
  • Develop a social skills group within the school setting and integrate XXX’s speech and language goals in the context of the group (e.g., if a goal is working on WH questions, allow him to practice his use and understanding of them with his peers in the social group).
  • To encourage appropriate behaviors and keep XXX on task in the classroom, use visual support systems and motivational systems. Children with autism tend to respond better to visual than auditory input (consider this when giving directions), and benefit from knowing the expectations ahead of time. Using a visual schedule will prepare him at the beginning of the day for all the activities and transitions he will face that day, and it can be referred to when XXX is not compliant or on task. Tangible reinforcement systems can be set up in which XXX receives a number of small tokens (stickers, pennies, etc.) for good behavior that can later be cashed in for a larger prize. XXX also responds well to verbal praise (together with interesting intonation, smiles, clapping, high fives, etc.).
  • It is recommended that XXX return to CHDD in two years for a reevaluation to determine the progress made and recommend the next step in his intervention.
  • XXX would benefit from participation in a therapeutic preschool program targeting his social communication skills. Speech/language therapy is also recommended to increase XXX’s expressive and receptive language skills. Specific targets might include:
  • Expanding his variety of communicative intents and teaching appropriate ways to request help, request information, make comments, etc.
  • Increasing joint attention and eye-contact with others.
  • Increasing his receptive and expressive vocabulary and repertoire of linguistic concepts to include pronouns, adjectives, prepositions, etc.
  • Following one-step directions, answering simple questions.
  • Although XXX does not appear to require speech and language intervention at this point, his communication development should be monitored annually to ensure that he is progressing appropriately.
  • XXX should continue to attend his developmental preschool, increasing to four days a week if possible. The best approach for teaching XXX would be intensive, systematic, and consistent instruction that breaks tasks and skills down into component parts.
  • It is recommended that XXX continue to receive speech/language therapy, focussing on increasing his intentional communication and establishing a more consistent, symbolic means of communicating. Specific treatment targets might include:
  • Establish functional, “universal” symbols. To help XXX discover the communicative power of symbols, start by teaching a way of requesting “more” that can be used across contexts (it is simpler to make a request than to make a choice, so simplify the visual strategies being used with him currently, and focus intensively on teaching this simplest level of symbolic communication). General rather than specific symbols should be used initially. In other words, instead of teaching individual symbols for each item or activity he may encounter, teach a single symbol for “more”. The symbol could be a hand-sign (“more” or “please”) or a picture symbol. Start by establishing use of the symbol in a single context (e.g., fish crackers or bubbles), then generalize it to other items, then to activities, etc. Once XXX is using this first communicative symbol consistently in a variety of contexts, a generic “all-done” symbol can be taught as a way of ending activities or refusing objects.
  • Shape sounds to be symbols. As XXX indicated an ability to use vocalization to request “more” at today’s assessment, it might be motivating for him to learn to use a generic sound (e.g., “ba” or “ma”) together with a picture symbol or hand-sign to indicate “more”, then “all-done”.
  • Teach XXX to respect personal space as both a way of learning about the difference between people and objects in his environment, and as a way of learning appropriate behavior. XXX can be taught that when interacting in certain contexts (e.g., most classroom activities, during one-on-one therapy, etc.) he is not to sit in someone’s lap or climb onto them. In all other contexts where physical affection is appropriate (e.g., at home, possibly during free-play at school), XXX should be taught to first gain permission before sitting in someone’s lap, giving them a hug, etc. He can also be taught appropriate ways to interact physically with his peers (i.e., a gentle pat on the back instead of a bear hug).
  • To maximize XXX’ potential to develop, he needs a safe, consistent, and nurturing home environment.
  • XXX’ caregiver should receive a copy of this report so that goals can be carried over into the home environment.
  • It is recommended that XXX continue in his birth-to-three program and with speech/language therapy to increase his social communication skills (e.g., joint attention, eye contact, communicative intents).
  • Non-verbal symbolic communication systems (such as signing or Picture Exchange Communication System (PECS)) should continue to be explored as methods for XXX to increase the frequency and diversity of his communicative intents.
  • Visually-supported communication is recommended in all contexts to assist XXX in comprehending what is expected of him. As many children with autism respond better to visual than to auditory stimuli, it is recommended that spoken language addressed to XXX is paired with picture supports (e.g., Show XXX a picture of the place he is about to visit (e.g., the store, school, car, park, etc.) in addition to naming it; Use a picture schedule of the activities involved in routines such as bedtime, mealtime, etc. to assist XXX is comprehending and following the sequence).
  • It is recommended that XXX continue to receive speech/language therapy to improve her expressive language skills and comfort level with social communication. Following are suggestions for therapy:
  • Develop a form of script therapy to implement in the natural context of XXX’s classroom (e.g., during circle time, songs or rhymes could be taught in which there are individual refrains for each child, or pair of children, to contribute to the activity; during free choice time, XXX could be prompted to participate in a predictable and repetitive dramatic play sequence with a peer, such as going grocery shopping, ordering a pizza by phone, taking care of a baby, etc. By giving XXX specific utterances to use over and over in certain social situations, the demands on her language formulation will be reduced and she may learn to feel more comfortable speaking with others.
  • Help XXX participate in role-playing activities (e.g., using a puppet or doll to do the talking). Speaking through a character (especially if she has some scripted language to use) is another way to reduce the social anxiety around language production. Eventually, XXX can transition from using a prop as a character, to acting out the roles of various characters herself in dramatic play sessions with peers.
  • Consider training a preferred peer to participate in these scripted activities with XXX. Once XXX is comfortable with the task, begin to vary it by bringing another peer into the group, recreating the activity with another peer, or trying out a new but similar activity with the same peer.
  • Continue using PECS, but with two guiding principles:
  • There must be consistency between how PECS are used at school and home.
  • PECS should be used as a springboard for verbal communication (e.g., pair the exchange of pictures with single words, then phrases: “juice”, then “I want juice”).
  • Establishing consistent routines at both home and school (e.g., a mealtime routine, a bus routine, etc.). Once a routine is established and followed consistently, it provides a less stressful context for introducing new skills for XXX, increasing the likelihood that he will be able to pay attention and learn:
  • Introduce communication into the routine. Start with picture schedules that break the routine down into its parts (e.g., put the plates on the table, then silverware, etc.), then have XXX spontaneously move each picture to the “finished” part of the schedule. Eventually, you can introduce a single word for each step (e.g., “plate”, “fork”, etc.).
  • Try out the routine in new contexts. (E.g., establish a routine for how to order at McDonald’s, then start generalizing the behaviors to select other restaurants).
  • The following books are recommended for further ideas on using visually-supported communication, and on encouraging social communication in children with autism:
  • Visual Strategies for Improving Communication: Practical Supports for School and Home by Linda A. Hodgdon (Quirk Roberts Publishing, 2002).
  • Do-Watch-Listen-Say: Social and Communication Intervention for Children with Autism by Kathleen Ann Quill (Paul H. Brookes Publishing Company, 2000).
  • A Picture’s Worth: PECS and Other Visual Communication Strategies in Autism by Andy Bondy and Lori Frost, (Woodbine House, 2001)
  • Activity Schedules for Children with Autism: Teaching Independent Behavior by Lynn E. McClannahan and Patrician J. Krantz (Woodbine House, 1999).
  • Behavioral Intervention for Young Children with Autism: A Manual for Parents and Professionalsby Catherine Maurice (Ed.), (Pro-Ed, 1996)
  • Reaching Out, Joining In: Teaching Social Skills to Young Children with Autism by Mary Jane Weiss and Sandra Harris (Woodbine)
  • Teaching Children with Autism by Kathleen Ann Quill

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