MENTAL RETARDATION AND DEVELOPMENTAL DISABILITIES RESEARCH REVIEWS 13: 16 – 25 (2007)

EARLY COMMUNICATION DEVELOPMENT AND INTERVENTION FOR CHILDREN WITH AUTISM Rebecca Landa1,2* 1

Center for Autism and Related Disorders, Kennedy Krieger Institute, Baltimore, Maryland 2

Department of Psychiatry, Johns Hopkins School of Medicine, Baltimore, Maryland

Autism is a neurodevelopmental disorder defined by impairments in social and communication development, accompanied by stereotyped patterns of behavior and interest. The focus of this paper is on the early development of communication in autism, and early intervention for impairments in communication associated with this disorder. An overview of components of communication is provided. Communication characteristics that are diagnostic of autism are summarized, with consideration of the overlap between social and communication impairment, particularly for children with autism functioning at the prelinguistic level. Early communication development and predictors of communication functioning in autism are examined, based on a review of prospective and retrospective studies. The focus of the discussion then turns to intervention. Consideration is given to the rationale for beginning intervention as early in life as possible for children with autism. Implications of motor, imitation, and play deficits for communication-based intervention are examined. Finally, issues related to the design and delivery of intervention for young children with autism are presented, along with a review of the major early intervention approaches for autism. ' 2007 Wiley-Liss, Inc. MRDD Research Reviews 2007;13:16–25.

Key Words: autism; communication; early development; early intervention

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utism is a neurodevelopmental disorder defined by impairments in social and communication development, accompanied by stereotyped patterns of behavior and interest. Along with pervasive developmental disorder-not otherwise specified (PDD-NOS) and Asperger syndrome, autism is categorized as a pervasive developmental disorder within the DSM-IV [American Psychiatric Association (APA), 1994]. In clinical practice, the term autism spectrum disorder (ASD) is often used to collectively refer to autism, PDDNOS, and Asperger syndrome. In this paper, the term autism will be used, since much of the research is based on children who met criteria for autism. When the term ASD is used, it inclusively refers to autism and PDD-NOS. Asperger syndrome is not discussed within this review. DEFINITION OF COMMUNICATION The focus of this paper is on the early development of communication in autism and early intervention for impairments in communication associated with this disorder. Communication is a broad concept, encompassing linguistic, paralinguistic, and pragmatic aspects of functioning. The linguistic

' 2007 Wiley -Liss, Inc.

domain includes phonological, morphological, syntactic, and semantic rule systems. Phonological rules establish how speech sounds (phonemes) are combined to form words and how a particular speech sound is to be pronounced given the context of the speech sounds before and after it. Morphological rules involve signaling grammatical information at the word level, as when words are inflected with past tense markers such as ‘‘-ed’’. Syntax is a rule system that guides how words are combined into sequences and hierarchical structures of phrases and sentences. The semantic system involves the mental ‘‘dictionary’’ of words and their meanings, how to combine words to form meaningful relationships such as possession (‘‘my shoe’’), abstract language processing (including literal and nonliteral meaning), and formation of a gist from a text or discourse. Paralinguistic communication includes proxemics (e.g., use of space in communication as in distance between speaker and listener), facial expression (e.g., rolling the eyes to indicate that a comment was intended as sarcasm, or smiling as criticism is given to convey tenderness and sincerity so that the listener knows that the comment was made out of concern rather than merely to criticize), intonation (e.g., using a rising intonational contour at the end of a declarative syntactic construction to signal that it is to be interpreted as a question rather than as an assertion), and gesture. Pragmatics involves discourse management (e.g., topic initiation and maintenance), communicative intentions (variety expressed and understood, as well as variety of forms used to communicate intentions), and presupposition (making judgments about the type and style of information presentation depending on characteristics of the context, ranging from listener-specific characteristics to setting).

Grant sponsor: National Institute of Mental Health; Grant numbers: MH59630, 154MH066417. *Correspondence to: Rebecca Landa, 3901 Greenspring Avenue, Baltimore, MD 21211. E-mail: [email protected] Received 29 November 2006; Accepted 11 December 2006 Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/mrdd.20134

DIAGNOSTIC CRITERIA FOR AUTISM INVOLVING COMMUNICATION The DSM-IV lists four criteria for communication impairment in autism: (1) delay in, or total lack of, the development of spoken language; (2) marked impairment in the ability to initiate or sustain conversation in children with speech; (3) stereotyped and repetitive use of language; and (4) lack of varied, spontaneous make-believe play or social imitative play appropriate to developmental level. Criteria for communication impairment, which encompass the linguistic and discourse aspects of communication, are separated from the criteria for ‘‘social impairment’’. However, some of the criteria specified for social impairment are intimately involved in the pragmatic aspects of communication. For example, the criterion for social impairment involving nonverbal behaviors would encompass gaze modulation, facial expressions, body gestures, and social regulatory gestures. As described earlier, such behaviors are intimately involved in cueing others about the speakers’ communicative intention (i.e., how to interpret what is meant by the words or sentences being spoken), cueing others about the speaker’s preparation to terminate a conversational turn so that the partner will not speak prematurely (which would have interrupted the speaker), clarifying or emphasizing a point that is being made linguistically, and so forth. These same behaviors are used by listeners to communicate interest in what the speaker has to say, to signal confusion or distaste about what is being said, to create a synchrony in the communicative exchange, and so forth. Another social criterion, lack of spontaneous sharing of enjoyment, interests, or achievements, melds with communication because such sharing represents a class of social communicative intentions that are considered by speech-language pathologists to fall within pragmatics. The social criterion listed in the DSM-IV as ‘‘lack of social or emotional reciprocity’’ captures an aspect of communication that signals attention, interest, and engagement between conversational or communicative partners. In very young children, especially those in the prelinguistic stage of development, the DSM-IV criteria for social impairment are particularly conceptually linked to the communication impairment of autism. During the prelinguistic stage of development, chil-

dren rely on nonverbal behavior, such as gaze, facial expression, and body language (including gesture), to communicate their needs, wants, and social intentions. They use gaze to indicate that they are directing their behavior to someone or to ‘‘point’’ to the object of their attention/intention. They use their facial expression to indicate intention (e.g., affirmation, protest, request, greeting), urgency, and to invite the engagement of others. Gestures are used to signal communicative intent and content, to take a communicative turn, and to maintain the ‘‘topic’’ of the communicative exchange with others through, for example, matching the behavior of the partner. EARLY PREDICTORS OF LANGUAGE DEVELOPMENT IN AUTISM Early social and communication development are intimately intertwined. For example, by 9–10 months of age, infants understand that others’ direction of gaze and pointing gestures signal something important, and they shift their attention to the object being ‘‘referenced’’ by these behaviors in others, thereby establishing a state of joint attention with another. This ability is important for learning that a word refers to a particular object. In typical development, infants are heavily influenced by others’ joint attention cues, and are more likely to associate a new word to an object if the speaker is looking at that object than if his/her attention is not directed to that object [Baldwin, 1991; Baldwin and Moses, 2001; Woodward, 2003]. Children with autism are impaired in their ability to use others’ gaze cues in word learning tasks [Baron-Cohen et al., 1997]. Indeed, young children’s joint attention abilities are useful in predicting a later diagnosis of autism. Early joint attention abilities also are predictive of later language functioning in typical development [Tomasello and Todd, 1983], autism [Mundy, 1995; Mundy and Gomes, 1998; Sigman and Ruskin, 1999; Charman et al., 2003; Dawson et al., 2004] and in 14-month-old siblings of children with autism [Sullivan et al., in press; Note: the relationship between autism or milder developmental disruptions in siblings of children with autism and nonfamilial autism is not yet known]. In addition, rate of nonverbal communication in 2-year-olds with autism is a significant predictor of communication and social functioning at

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age 7 years [Charman et al., 2005]. Expressive language at age 4 years is also predicted by imitation abilities measured at 2 years of age in children with autism [Stone and Yoder, 2001]. EARLY COMMUNICATION DEVELOPMENT IN AUTISM Signs of social and communication disruption may be present in children with autism as early as the first year of life, even before spoken language is expected to emerge in typically developing children. Such disruption may be seen in the desynchronization of vocal patterns with the caregiver, early sharing of affective expression [Trevarthen and Daniel, 2005; Yirmiya et al., 2006], delayed onset of babbling [Iverson and Wozniak, in press], as well as in use of gestures and responsiveness to the communicative bids of others [Baranek, 1999]. In the second and third years of life, communication development in autism is generally characterized by reduced frequency and diversity of communicative forms, including complex babbling, gestures, consonants in syllables, words, and word combinations [Wetherby et al., 2004; Goldberg et al., 2005; Landa et al., in press; Mitchell et al., 2006; Wetherby et al., in press]. Gestures tend to be isolated acts, less often integrated with vocalization than in typically developing prelinguistic children [Wetherby et al., 1998]. Initiation of social communicative acts (e.g., showing, initiating joint attention), which requires integrated attention to social and nonsocial aspects of context, is impaired relative to requesting (a nonsocial use of communication) in twoand three-year old children with autism [Wetherby and Prutting, 1984; Loveland and Landry, 1986; Sigman et al., 1986; Baron-Cohen, 1989; Mundy et al., 1990; McEvoy et al., 1993; Stone et al., 1997; Wetherby et al., 1998]. Thus, children with autism have very restricted means by which to indicate their needs and desires to others; this is likely to dramatically reduce their effectiveness as communicators when compared to their age peers. Their range of options for contingently extending the communication of others is very limited. They are likely to exhibit decreased flexibility in adapting and responding to the dynamic, fluid context of communication, where communicative topics and nature of engagement shift frequently. The resulting attenuation of ‘‘on topic’’ engagement with others may compromise the nature and frequency of linguistic and social

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input that children with autism elicit from others. In addition, young children with autism less often initiate communication bids to regulate the behavior of others in order to achieve a desired object or action [Charman et al., 1997; Wetherby et al., 2004; Landa et al., in press; Wetherby et al., in press]. Likewise, and perhaps even more diagnostically relevant for autism, there is a reduced frequency of initiation of and response to joint attention bids to share experiences and objects of attention [Landa et al., in press; Lord, 1995; Wetherby et al., 2004; Sullivan et al., in press; Wetherby et al., in press]. This characteristic also differentiates autism from other developmental disorders from 2 to 5 years of age [Mundy et al., 1990; Lord, 1995; Charman et al., 1997; Wetherby et al., 1998; Dawson et al., 2004], and is considered to be a core deficit in autism [Sigman et al., 2004]. Some have suggested that young children with autism have particular difficulty in play and developing symbols into language, and that these two systems, though distinct, are closely linked in development [Riguet et al., 1981; Sigman and Ungerer, 1984; Stahmer, 1995; Libby et al., 1998]. In the DSMIV, the impairment in symbolic development is represented as a diagnostic criterion for autism within the broad domain of communication impairment (encompassing primarily linguistic aspects of communication, but also aspects of pragmatics and symbol development as observed in play). The symbolic impairment in autism may be related to the early receptive and expressive language delays seen in most children with autism. Over time, however, singleword vocabulary development becomes a relative strength for most children with autism [Lord and Paul, 1997]. Children with autism tend to score higher on tests of single word vocabulary than on tests of complex language [Paul, 1987]. Symbolic skills often do emerge to some degree in autism, although they may be most apparent in highly structured contexts [Curcio and Pischeria, 1978; Ungerer and Sigman, 1981; McDonough et al., 1997; Libby et al., 1998]. Symbolic communication differentiates children with autism from those with other developmental disorders from 2 to 5 years of age [Mundy et al., 1990; Lord, 1995; Charman et al., 1997; Wetherby et al., 1998; Dawson et al., 2004], and thus, is considered to be a core deficit in autism [Sigman et al., 2004]. 18

Trajectory of Communication Development Defining the developmental trajectory of communication skills in autism will yield insights into diagnostically relevant developmental disruptions, providing information pertinent to the development of early autism interventions. Our group prospectively examined receptive and expressive language development from 6 to 24 months of age [Landa and Garrett-Mayer, 2006], and development of communicative intention and use of gaze and affect in communication, and variety of communicative forms (gesture, consonants, words, word combinations), from 14 to 24 months of age in infants at high genetic risk for autism (siblings of children with autism) who received ‘‘outcome’’ diagnostic classifications at 30 or 36 months of age [Landa et al., in press; Sullivan et al., in press]. A progressive slowing in rate of receptive and expressive language development was noted between 6 and 24 months in the group of children having outcome diagnoses of ASD, distinguishing them from language delayed and typically developing groups [Landa and Garrett-Mayer, 2006]. At the 14-month assessment, about half of the children who had an outcome classification of ASD received their first ASD diagnosis. For these children, no significant gain was observed between 14 and 24 months in any aspect of communication studied [Landa et al., in press]. For the children whose ASD diagnosis was not identified until after 14 months of age, a mix of declining and plateauing development in social aspects of communication was observed between 14 and 24 months of age. This group exhibited minimal gain in linguistic aspects of communication in this same timeframe. On the basis of retrospective studies, an atypical developmental trajectory involving regression has been reported by parents, characterized by diminishing social and/or communication skills in the second and third years of life, affecting up to 50% of children with autism [Lotter, 1966; Kurita, 1985; Hoshino et al., 1987; Tuchman and Rapin, 1997; Davidovitch et al., 2000; Goldberg et al., 2003; Luyster et al., 2005; Ozonoff et al., 2005]. Of the children retrospectively reported to have exhibited regressive patterns of early development, 20–40% lost language skills [Kurita, 1985; Rutter and Lord, 1987]. Lord et al. [2004b] concluded from their study of children with autism, nonautism developmental delay, and typical de-

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velopment that word loss appears to be unique to, but not universal in, autism, suggesting that word loss is a ‘‘red flag’’ for autism. A recent study examined the regression issue in autism through the analysis of first birthday videotapes of toddlers with and without parental report of regression, including a group of typically developing toddlers [Werner and Dawson, 2005]. The nonregressive autism group differed from the regressive and typically developing groups in that they exhibited fewer instances of joint attention and communication. By 24 months, however, abnormality had become observable in the children with reported regression; they exhibited fewer social or communication behaviors than typically developing children [Werner and Dawson, 2005]. Prospective research on children at high risk for autism will shed more light on the nature of regression in autism, further characterizing this phenomenon through direct, longitudinal assessment of children, avoiding the complication of recall bias and limitations in behavior sampling associated with the use of home videotapes. Most children with autism acquire at least minimal spoken language ability. Of the approximately 80% of children with autism who produce more than five spoken words [Lord et al., 2004a], about two thirds are estimated to have linguistic deficits affecting receptive and expressive language domains [Allen and Rapin, 1980, 1992]. The remaining third have pragmatic impairments without substantial linguistic impairment [Allen and Rapin, 1980, 1992]. IMPLICATIONS FOR INTERVENTION The literature indicates that autism can be detected early, and thus, intervention may begin at a young age. Early intervention for the communication impairment in autism is important, since social communication deficits in autism are a major stressor for parents [Bristol and Schopler, 1984], and since gains in communication skills are related to prevention and reduction of maladaptive behaviors [Carr and Durand, 1985; Reichle and Wacker, 1993]. Furthermore, degree of language impairment impacts clinicians’ impressions about comprehensiveness of impairment, as reflected in diagnostic classification as ‘‘autism’’ or ‘‘PDD-NOS’’ [Lord et al., 2004a]. Linguistic outcomes are affected by social ability [Bono et al., 2004]. Since social impairment is an enduring feature of autism

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[Mundy et al., 1990; Sigman and Ruskin, 1999], it should be addressed as early as possible. Through early intervention, communication and social development may be improved [e.g., Rogers et al., 1986; Smith et al., 2000; Landa and Holman, 2005; Kasari et al., 2006], hopefully leading to better outcomes for the child and family. Parents and professionals face several major challenges as they encounter the task of intervention programming for young children with autism. For example, under what circumstances should a child be enrolled in early intervention? What should the instructional content (targeted goals) of the intervention be? What instructional delivery methods should be used to teach the targeted skills? These issues are briefly addressed later. WHY EARLY INTERVENTION FOR AUTISM? The urgency of early intervention felt by many parents, clinicians, and researchers is linked to recent discoveries in the neurosciences regarding experience-dependent neuroplasticity. This literature demonstrates that experience, especially within social interactions [Kuhl et al., 2003], is related to cortical specialization [Johnson and Munakata, 2005]. Such cortical specialization involves finetuning of perceptual systems and increasing intra- and inter-regional integration or connectivity. The resulting increasingly complex brain circuitry supports more complex behaviors and integration of behaviors across developmental systems. This process appears to be enhanced by exposure to diverse and complex input [Lewis, 2004; Quinn, 2006], yielding coherent and flexible patterns of behavior. With increasing experience, children develop expertise, which leads to increased levels of flexibility and generalization of knowledge. The result is more contextually appropriate behavior in increasingly novel conditions [Bloom et al., 1976; Ross, 1982; Rutter and Durkin, 1987; Eckerman and Didow, 1989]. Although these principles have not been systematically examined in intervention studies involving children with autism, they have implications for designing interventions where diversity and complexity of stimuli within learning contexts are systematically engineered, and tailored to the child’s emerging and established abilities. These principles of typical development also highlight the importance of providing interactive experiences for young children with autism, where skills may be frequently practiced in familiar and

novel, but meaningful, contexts to stimulate flexible and generalized use of skills. In autism, a growing body of literature indicates that intervention is associated with improvements in speech, language, and social development. Intensity of intervention, defined by number of hours, received by 2-year-olds with autism was a significant predictor of language outcome at age 4 [Stone and Yoder, 2001]. Better communication skills translate into better prognosis, a reduction in maladaptive behaviors [Reichle et al., 1991], and new learning opportunities that yield additional access to information about and through others [Yoder and Warren, 1999]. DECISIONS ABOUT WHEN TO ENROLL IN INTERVENTION The signs of autism emerge, often gradually [Landa and Garrett-Mayer, 2006; Landa et al., in press], between the first year of life and the third birthday. At present, however, autism and PDD-NOS are diagnosed, on average, between 3 and 4 years of age [Mandell et al., 2005]. Autism will be detected at younger ages because of recent efforts by the Centers for Disease Control and Prevention [2006], Autism Speaks, the American Academy of Pediatrics [2006], and others, to disseminate widespread information to the public (Learn the Signs, Act Early, CDC, 2006), and the publication of new guidelines from the American Academy of Pediatrics [2006] for developmental surveillance and screening. At present, however, caregivers are usually the first to note disrupted development in children later diagnosed with autism. Parents usually express concern to their pediatricians at around 18 months of age, often because their child is a late talker [Rogers and DiLalla, 1990; Wimpory et al., 2000]. Unfortunately, unless multiple milestones are delayed or a single delay is striking, professionals often respond to parents’ concerns with a watch-and-see stance. Such a stance may be acceptable in some situations, but certain ‘‘red flags’’ signal the need for a more thorough developmental screening, or even assessment. Information about ‘‘red flags’’ of developmental disruption comes from prospective, longitudinal studies of young children with autism. Wetherby et al. [2004] identified nine red flags that differentiated autism from typical or delayed development at a mean age of 21 months. These red flags included: lack of appropriate gaze; lack of warm, joyful expressions with gaze; lack of sharing enjoy-

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ment or interest; lack of response to name; lack of coordination of gaze, facial expression, gesture, and sound; lack of showing; unusual prosody; repetitive movements of the body; and repetitive movements with objects. Occasionally, a child may be identified as being at risk for autism based on these red flags, but over time, these behaviors become less prominent or undetectable [Fein et al., 2005]. Early intervention providers, together with caregivers, should closely monitor the developmental trajectory of children who show signs of being at high risk for an autism diagnosis, and implement appropriate developmental stimulation (through parent training and/or direct service delivery to the child) or intervention programming at levels of intensity deemed necessary. INTERVENTION CONTENT CONSIDERATIONS: NONLINGUISTIC FACTORS Multiple developmental systems are impaired in autism, including aspects of perceptual, motor, cognitive, social, and cross-modal processing systems. Since language development represents a transactive process involving nonlinguistic aspects of development, such as imitation [Tomasello and Farrar, 1986], development within one domain is expected to affect development in other domains [Thelen, 2000]. Several aspects of development have particularly strong concurrent and predictive relationships to language development. These include motor, imitation, and play development. Below, these are briefly discussed. Direct intervention targeting two of these (imitation and play) has been documented to have enhancing effects on communication development [Play: Rogers and Lewis, 1989; Stahmer, 1995; Whalen and Schreibman, 2003; Kasari et al., 2006; Imitation: Leaf and McEachin, 1999; Ingersoll and Schreibman, 2006]. Motor Disruption in motor development has been detected in the first year of life in infant siblings of children with autism [Iverson and Wozniak, in press], in 9–12-month-olds later diagnosed with autism [Baranek, 1999], and in older children with autism [e.g., Jansiewicz et al., 2006], but is not diagnostic of autism. Motor disruptions may include, for example, delayed onset of early motor milestones, abnormalities in motor tonus, postural instability, excessive mouthing, and poor movement modulation [Vernazza-Martin et al.,

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2005]. These motor differences may impede the timing and grading of movements involved in contingent communication and imitation, resulting in desynchronized interactions and, possibly, missed opportunities for engagement and language learning. In some children, disruption in aspects of motor functioning (e.g., involving planning) may even contribute to the failure to acquire spoken language [Rogers et al., 2006]. From early in life, disruption of the motor system could have implications for communication development. For example, motor and vocal systems are tightly coupled in infancy. This coupling, or synchronicity, has been shown to be abnormal in infants at high genetic risk for autism [Iverson and Wozniak, in press]. Specifically, these infants exhibited reduced integration of rhythmic limb movement with vocalization. This disruption in the ‘‘coupling’’ between manual and oral/vocal systems early in development could have implications for the coordination of vocalization and gesture during intentional communication acts [Iverson and Thelen, 1999]. In typical development, infants’ frequent experience with rhythmic arm movements, along with the stability of this motor pattern prior to the emergence of reduplicative babbling, may facilitate vocal activity, eventually leading to babbling characterized by rhythmically organized consonant-vowel sequences [Iverson and Thelen, 1999]. Infants with autism may not be able to benefit from such natural facilitation if their motor development is disrupted and if they have difficulty integrating behaviors across developmental domains. Intervention for communication impairment in autism should take into consideration the developing motor system. Factors such as the child’s postural control and the positioning requirements of communication activities, the complexity of motor demands of intervention activities, and the complexity and familiarity of movements required for vocal, gestural, action schema in play, or imitative sequences should be considered. In early intervention, vocalization may be enhanced when communication-based activities occur within tasks having predictable limb movement, simple rhythmic patterns (e.g., song-gesture games in which the child’s arms are gently moved in a rhythmic pattern that keeps time with the production of simple, repetitive vocal patterns), ample response time, and secure physical positioning. 20

Imitation Imitation is intimately related to communication learning [Rogers, 1999]. In addition, it provides a vehicle for communicative reciprocity. For example, an imitation of another’s behavior serves to acknowledge their act, confirming attention and responsivity in a reciprocal, meaningfully contingent way. The imitation ‘‘invites’’ a response from the other person, and thus initiates an interactive exchange. A ‘‘teachable moment’’ has arisen. In children with autism, such naturally occurring teachable moments are altogether too sporadic. Despite the socially disengaged echoic behavior seen in many children with autism, children with autism rarely exhibit spontaneous, meaningful, and socially engaged imitation of others’ actions on objects, vocalizations, and body movements [Dawson et al., 1998; Smith and Bryson, 1998; Bennetto, 1999; Hobson and Lee, 1999; Aldridge et al., 2000]. Imitation is impaired by 20 months of age in autism [Charman et al., 1997]. Impaired ability to imitate others at such a young age has been shown to be related to language functioning later in the preschool years [Stone and Yoder, 2001]. Likewise, imitation ability in young children with autism is related to other aspects of development (e.g., joint attention and play) that are closely linked to language development [Loveland and Landry, 1986; Mundy et al., 1990; Baron-Cohen and Swettenham, 1997; Sigman and Ruskin, 1999; Charman et al., 2003]. Targeting imitation in intervention for autism is a longstanding practice. Since imitation is a powerful tool for communication and contingent interactions with others, the movement patterns that children are taught to imitate should incorporate the movement patterns needed for targeted communicative gestures and for actions on objects within meaningful play sequences. As skills improve, mapping language onto the production of the imitated movement (e.g., ‘‘bye bye,’’ ‘‘come,’’ ‘‘big,’’ ‘‘push’’) will strengthen the link between motor and language modalities for communicative purposes. Play Play is the platform for much of the social engagement that young children have with others [Doctoroff, 1996]. It is also a context for establishing social coordination with others within which many communication exchanges are made [Ross and Lollis, 1989]. In autism, play development is

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disrupted. This is characterized by reduced object exploration [Pierce and Courchesne, 2001], reduced diversity of play acts on objects [Baranek et al., 2000; Stone et al., 1990; Wetherby et al., in press], fewer novel play acts [Charman and Baron-Cohen, 1997], and delay in symbolic play development [Ungerer and Sigman, 1981]. Play has been found to be concurrently associated with expressive language functioning as early as 20 months of age [Ungerer and Sigman, 1984; Charman et al., 1997]. Systematically building the capacity for representational play may facilitate the development of representational thought, which is linked to symbolic language development. At around 18 months of age, children develop strong preferences for combinatorial, constructive, and symbolic play activities. Unlike their age peers, young children with autism exhibit strong preferences for simple cause-effect activities [Losche, 1990]. To exhibit more sophisticated and symbolic play, children with autism often require highly structured contexts, within which therapists may also stimulate the coordination of play with symbolic language development. The intervention context provides enriched, scaffolded opportunities for children with autism to practice increasingly symbolic and decontextualized play and language skills, as well as the integration of these skills. Intervention programming for play can be strategically orchestrated to directly enhance the language learning process. This may be accomplished through carefully selecting the objects to be used for targeting concurrent or future linguistic concepts and combinations of such concepts into semantic relations. For example, Samuelson and Smith [2005] have shown that toddlers with typical development learn and generalize novel words best when the initial referent object has perceptually simple features. To the extent that this principle may be generalized to children with autism, the process of building categories that are represented by words (animate or inanimate) may be enhanced if the exemplar objects are at first perceptually simple, and the features that link the category members can be made salient. As concepts represented by nouns are taught to children with autism, sufficient experience with a variety of exemplars will be needed [Quinn, 2006]. Objects that afford a variety of actions have relevance to the child’s daily experience, and lend them-

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selves to being combined in thematic sequences of play will be useful in the therapeutic context. Likewise, objects should be considered that foster ‘‘teachable moments’’ because they motivate the child’s continued engagement (e.g., toys that easily generate a sensory experience, as by shaking a clear tube with plastic balls, versus a novel switch activated toy, where the action afforded by the switch may be novel and is distally related to the effect that it activates). HOW TO DESIGN AND DELIVER INTERVENTION FOR YOUNG CHILDREN WITH AUTISM? Families of children with autism are faced with a serious dilemma: how many hours of intervention are needed and what intervention method(s) should be used in their child’s intervention program? Although the literature addressing the first question is sparse, the literature supports intensive intervention for children with autism [Lovaas, 1987; Sheinkopf and Siegel, 1998; Harris and Handleman, 2000; Smith et al., 2000; Eldevik et al., 2006]. Number of hours of speech-language therapy received between ages 2 and 4 years is related to the development of spoken language in children with ASDs [Stone and Yoder, 2001]. Intervention intensity is a somewhat elusive concept, since the quality of the intervention, degree to which the child’s attention and engagement are secured and sustained during therapeutic activities, number and nature of response opportunities and other related factors are likely to contribute to the ‘‘intensity’’ (or dosage) of intervention, and to intervention response. The way that these intervention ingredients interact with hours of intervention per week and characteristics of children with autism or their parents (e.g., parents’ buyin to the intervention, or their responsivity to their child [Yoder and Warren, 2001]) has not been addressed in the empirical literature. Since autism is a heterogeneous disorder affecting multiple systems, and since children with autism have different needs at different points in their development, it is unlikely that a single intervention method will be optimally sufficient for all children with autism [Beglinger and Smith, 2005; Scherer and Schreibman, 2005]. Studies are beginning to examine the types of child characteristics that may be related to low versus high levels of improvement after exposure to a particular interven-

tion approach. The most commonly studied predictor is pretreatment intelligence quotient (IQ) [Bibby et al., 2002; Eikeseth et al., 2002; Goldstein, 2002]. Younger age at onset of intervention [Bibby et al., 2002; Goldstein, 2002; Harris and Handleman, 2000) and rapid learning, particularly involving imitation and receptive language, during the first 3–4 months of intervention [Newsom and Rincover, 1989; Weiss, 1999] have been reported as predictors of positive outcome. Recently, pretreatment social behavior has been identified as a predictor of outcome. For example, Beglinger and Smith [2005] examined the relationship between social subtype of autism and IQ change in early intensive behavioral intervention, where children received 30–40 hr of 1:1 intervention involving discrete trial teaching, usually within the home. They found that children with autism who were categorized as ‘aloof’ according to Wing and Gould’s (1979) subtyping guidelines showed the smallest gain in IQ (7.6 points) when compared to IQ gains of 19.25, 27.17, and 36.75 points for children in the autism subtype categories of Passive, Active-but-odd, and Typically developing based on parent report on the Wing Subgroups Questionnaire [Castelloe and Dawson, 1993]. In a similar vein, Sallows and Graupner [2005] reported that outcome for children enrolled in an intensive behavioral intervention (ABA) was predicted by pretreatment imitation, language, and social responsiveness. Studies have not yet examined the impact of changing intervention approach for children showing no or slow response to a certain instructional method. Thus, there are no prescriptive formulas to help providers select which intervention method(s) to use for children with particular behavioral profiles. At Kennedy Krieger’s Center for Autism and Related Disorders, early intervention is guided by ‘‘feature match’’ design, where the instructional features are selected to address individual children’s patterns of relative strength and impairment. Evidence to support this approach has been reported [Rogers et al., 1986; Rogers, 1996; Stahmer and Ingersoll, 2004; Landa and Holman, 2005]. A feature match design cannot be equated with what the literature refers to as an ‘‘eclectic’’ approach [e.g., Eldevik et al., 2006], where a variety of educational settings and instructional approaches are represented in a child’s intervention repertoire, but without evidence that therapists have mastered the intervention techniques.

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Below, major intervention approaches to autism are summarized. They are conceptually grouped into: traditional applied behavior analysis (ABA), contemporary ABA, transactional, and complementary approaches. To greater or lesser degrees, these approaches achieve the guidelines presented by the National Research Council [2001] on Educating Children with Autism. TRADITIONAL ABA INTERVENTIONS Traditional ABA, often referred to as Discrete Trial Teaching or Early Intensive Behavioral Intervention, is an established and extensively studied intervention method [Smith, 2001; Goldstein, 2002]. It is based on principles of operant conditioning [Newsom, 1998] where skills are dissected into discrete intervention targets based on task analysis and the child’s task performance. Intervention targets are addressed through massed trials of antecedent–behavior– consequence chains, initiated by the adult, using adult-selected materials and tasks, and presented in massed trials to promote success. The therapist maintains tight control over antecedent stimuli, prompt hierarchy, and reinforcers, which are usually not specifically related to the content of the child’s behavior. Teaching occurs within a nondistracting environment, disembedding behavior from meaningful activities during initial skill acquisition. After initial skill acquisition, the emphasis is on systematically generalizing skills to activities typical of the child’s daily life. Curriculum manuals provide step-by-step guidelines for teaching component skills, usually within the domains of language, nonverbal cognitive, and preacademic skills [Partington and Sundberg, 1998; Lovaas, 2003]. Studies of the effects of traditional behavior analytic intervention delivered for a period of 1–4 years, with 30–40 hr per week of 1:1 intervention, report an average IQ gain of 20 points for preschoolers with autism [Lovaas, 1987; Sallows and Graupner, 2005], with greater improvement being associated with greater intensity (e.g., 40 hr per week versus 10 hr per week) (e.g., McEachin et al., 1993; Smith et al., 2000; Howard et al., 2005; Cohen et al., 2006]. The number of children attaining age-appropriate IQ (usually defined as 85) by the end of the study ranges from 0 to about 50%. Short-term discrete trial teaching has been successful in teaching 4- to 6-year-olds with autism to combine gesture with simple verbal responses [Buffington et al., 1998]. More research is needed to assess the impact of this intervention approach on social func-

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tioning, particularly in core deficits of autism such as joint attention and affective relatedness. Contemporary ABA Approaches to intervention modify the execution of ABA principles such that intervention is centered around the child’s interests and activities. This variation in technique was largely a response to children’s difficulties in generalizing skills from the highly structured, adult-led therapy activities that were disembedded from meaningful contexts in the traditional ABA approach. Contemporary applications of ABA are seen in approaches known as Incidental Teaching [McGee et al., 1999], Natural Language Paradigm [Koegel et al., 1987], Pivotal Response Training [Koegel and Koegel, 1995; Schreibman and Pierce, 1993], and the Milieu Teaching approach [Warren and Bambara, 1989]. They emphasize increasing children’s ‘‘motivation’’ to communicate, and are based on the literature on development, pragmatics, and ABA. Contemporary ABA approaches employ strategies aimed at facilitating spontaneous language and communication development and focusing on the child’s role as an active communication partner (motivation), using natural rewards, embedding teaching activities within natural environments (including group contexts), identifying topics for communicative exchange that involve child-preferred and child-selected activities, where interactions are more natural and fluidly structured to encourage child-initiated communication. These approaches are also designed to easily capitalize on spontaneity, but strategically infuse the teaching context with opportunities to increase frequency and duration of responses and engagement. Empirical support for these programs with children with autism is also available [Koegel et al., 1987; Warren et al., 1994; Pierce and Schreibman, 1995; Fey et al., 2006], with evidence that generalization of some communication skills is increased when teaching trials are embedded throughout the day in meaningful communicative contexts [e.g., Neef et al., 1984]. Furthermore, preliminary evidence has been reported by Stahmer and Ingersoll [2004] that early intervention based on contemporary ABA [specifically, McGee’s Walden program; McGee et al., 1999] may benefit early communication development in young children with autism when other intervention strategies are incorporated [e.g., Picture Exchange Communication System; Bondy and Frost, 2003] within a classroom setting where 22

typically developing peers are included. Stahmer and Ingersoll’s (2004) intervention study did not employ an experimental design, so more research is needed to evaluate the benefit of such a program for communication, cognitive, adaptive, and social functioning of young children with autism. Another approach based on principles of ABA is the Picture Exchange Communication System [PECS; Bondy and Frost, 2003], providing a visually based alternative/augmentative communication system for children with limited speech. Children are taught to exchange a single picture for a desired item and eventually to construct picture-based sentences using planned generalization behavioral principles. Evidence is emerging that PECs is a useful system for developing aspects of communication development for some children with autism [Ganz and Simpson, 2004; Rogers et al., 2006]. Transactional, developmental, and social-pragmatic approaches view language learning as a co-created process shared by child and other. Perhaps the most distinguishing features of the transactional/developmental approaches pertain to the emphasis on reciprocal, affective, self-regulatory, relationship-building, and discovery processes. Through interactions with others, such as joint action routines, shared experiences and meanings are developed. The intervention context is the natural environment, with instruction embedded within dayto-day natural routines. An emphasis, as in other approaches, is on building from concrete to abstract concepts, with particular focus on integration of these language- and socially based concepts into a variety of meaningful experiences, thus promoting generalization. The anticipated result is the development of a well-rounded communication system where a variety of communicative intentions are initiated using a variety of linguistic and nonlinguistic forms across a variety of contexts. Transactional/developmental intervention methods are often characterized by multi-modal integration of sensory stimulating, motor planning, and visual input augmentation, as well as family involvement. Approaches falling into this category include Floortime [Greenspan and Weider, 2003], Social Communication, Emotional Regulation and Transactional Support (SCERTS; Prizant et al., 2006], the Denver Model [Rogers et al., 1986], and the Miller Method [Miller and EllerMiller, 2000]. There have been no experimental studies that support the efficacy of

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these methods, but quasi-experimental evidence indicates that a well-executed and defined developmentally based approach, such as the Denver model, is associated with developmental gains for children with autism [Rogers et al., 1986]. Complementary approaches to those described earlier may include environmental engineering, augmentative communication systems, sensory-motor interventions, and more. One of the most widely used approaches for engineering the learning environment is the Treatment and Education of Autistic and related Communication-handicapped Children (TEACCH) program [Schopler and Mesibov, 1984; Ozonoff and Cathcart, 1998]. The features of this approach include physical organization of the teaching environment, schedules of activity that increase organization and predictability, individual work stations to promote independent goaldirected activity, and learning task organization using visually guided cues to successful task completion. Another approach provides guidelines and strategies for facilitating children’s ability to automatically process complex sensory information, improve motor coordination, reduce over-or under-reactivity, and improve emotional adjustment as well as social functioning. These approaches, referred to as Sensory Integration [Ayres and Mailloux, 1981] or Sensory Registration, provide systematic and individualized ‘‘doses’’ and types of sensory experience, coordinating sensation with motor planning, using a variety of equipment and sensory-enhancing materials tailored to a child’s interests. These principles are incorporated into some of the Developmental approaches (such as Floortime, SCERTS, and the Miller Method), but their efficacy has not been examined in autism. SUMMARY AND CONCLUSIONS The communication impairment in autism is universal, appears early, and affects multiple aspects of development. Fortunately, autism diagnostic indicators for young children are being revealed by research, so earlier identification of autism is becoming a reality. Communication intervention for children with autism will envelop many aspects of development, including social engagement, social reciprocity, joint attention, imitation, play, vocal-manual coordination, language, flexible communicative contingencies, and social communicative abilities. A variety of instructional approaches are available for use in targeting communication and related goals,

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some of which are evidence-based. Now, more than ever before, clinicians have resources from which to draw in the design and delivery of individualized communication interventions for children with autism. n ACKNOWLEDGMENTS Appreciation is expressed to Allison O’Neill for her administrative assistance in the preparation of this manuscript.

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