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Essential Question:

What treatment strategies are effective in improving the communication skills of pre-school children with autism who do not communicate verbally?

Foundation Questions:

1.)  What is autism?
2.)  What are common characteristics of autism?
3.)  What are common characteristics of autism regarding language?

Tentative Points:

Currently, my goal is to illustrate the process of childhood autism intervention by following the development of a yet-to-be-named character.  I was hoping to subtly incorporate various subcategories of information throughout the different genres:  for instance, characteristics of onset will be described in the journal entry, the process of intervention will be delineated in the Powerpoint Presentation, etc.  This research project is created primarily to educate the audience, but also to persuade parents to watch for developmental milestones in their children--the sooner a pervasive developmental disorder is identified, the more opportunities a child will have to catch up with his/her peers. 

Genres:

Genre 1:  Webliography
Voice:  Clinician
Audience:  General Public
Rationale:  This is the equivalent to the "About the Author" flap found on bookcovers.  It probably explains my motivation in creating the project, (I'm a student), and though it doesn't particularly add anything to the content, it gives the audience a feel for *who* exactly designed this site.  It makes the process more personal. 

Genre 2:  Journal entries
Voice:  Client's mother
Audience:  She's probably writing symptoms to tell a professional. . .  
Rationale:  Hopefully this will be an interesting way to imbed information on the immediate abnormalaties that may coincide with infantile autism and may continue through the toddler years.

Genre 3:  Powerpoint presentation
Voice:  Clinician
Audience:   General Public and Client's Family
Rationale:  The Powerpoint presentation will chronicle the course of action the parents take to help their child, discussing the purpose of various professionals that may be involved in the child's remediation. 

Genre 4:  Observation report
Voice:  Student Clinician
Audience: Client's family (and for clinician's personal use.) 
Rationale:  The observation report will make note of the child's specific strengths and weaknesses regarding behavior and communication.

Genre 5:  E-mail exhange
Voice:  Client's mother and SLP (clinician)
Audience:  Client's mother and SLP (clinician)
Rationale:  Hopefully, through the mother's questions (and the SLP's answers) this email exhange will explore the child's characteristics and development.

Genre 6:  Interiew
Voice:  Client's mother and SLP (clinician)
Audience:  General public
Rationale: The SLP will be determining Allie's case history.

Genre 7:  Poem
Voice:  Client
Audience:  General Public
Rationale:  The poem will offer a perspective from the child and perhaps shed light on the unique thought patterns of autistic individuals.  

Aniticipated Integration of Genres:

With the exception of my webliography, all of my genres will revolve around a little girl (hypothetical, but I'm trying to stay in character) with autism.  I was hoping to have these different genres represent a different time in the client's life and arrange them in some kind of chronological order, from about the ages of 1 1/2 to 5.

Tentative Resources:

Bronwym, M., Durkin, K., & Mayberry, M. (2003). Weak central coherence, poor joint attention, and low verbal ability: Independent deficits in autism.  Developmental Psychology, 39(4), 646-656. Retrieved October 8, 2005, from the PsycARTICLES database.

Blanc, R., Adrien, J., & Royx, S. (2005). Dysregulation of pretend play and communication development in children with autism. Autism, 9(3), 229-245.  Retrieved September 29, 2005, from the PsycINFO database.  

Frith, U., & Happe, F. (1994). Language and communication in autistic disorders.  Philosophical Transactions of the Royal Society of London, 346(1315), 97-104.  Retrieved October 9, 2005, from the MEDLINE database (7886159).

Hale, C.M. (2005). Social communication in children: The relationship between theory and discourse. Autism, 9(2), 157-178. Retrieved October 8, 2005, from the MEDLINE database (15857860).

Harris, P.L. & Leevers, H.J. (1998). Drawing impossible entities: A measure of imagination in children with autism, children with learning disabilities, and normal 4-year-olds. Journal of Child and Psychological Psychiatry and Allied Disciplines, 39(3), 399-410. Retrieved Ocrober 8, 2005, from the MEDLINE database (9670095).

Leekham, S.R., Lopez, B., & Moore, C. (2000). Attention and joint attention in preschool children with autism. Developmental Psychology, 36(21), 261-273. Retrieved October 8, 2005, from the PsycARTICLES database.

Schuler, A. L. (2003). Beyond echoplaylia. Autism: The International Journal of Research & Practice, 7(4), 455-469. Retrieved September 29, 2005, from Academic Search Premier database (AN 11827442).

Scott, J., & Baldwin, W. L. (2005.) The challenge of early intensive intervention. In Autism spectrum disorders: Identification, education, and treatment.   (pp.173-228). (3^rd ed). Mahwah, NJ: Lawrence Erlbaum Associates, Publishers. Retrieved September 30, 2005, from PsycINFO database.

Shwartz, I. S., Sandall, S. R., & McBride, B. J. (2004). Project DATA (developmentally appropriate treatment for autism): An inclusive school-based approach to educating young children with autism. Topics in Early Childhood Special Education, 24(3), 156-168. Retrieved September 29, 2005, from Academic Search Premier database (AN 14836765).

 Sigman, M., Dijamco, A., Gratier, M., & Rozgo, A. (2004). Early detection of core deficits in autism. Mental Retardation & Developmental Disabilities Research Reviews, 10(4), 221-233.  Retrieved September 29, 2005, from PsycINFO database.

Inside,

                 please look for

yourself,

                 my actual ability, not language,

lies

                 beneath the pictures I cannot show.

Beauty

                 locked within my soul.

May 15, 2002

I was woken up this morning by a soft purring that continued as steadily as a motor.  My thoughts immediately turned to my lovely sixteen-month-old girl, Allie.  She is such a sweet baby, a quiet baby. There are times, however, her listless and almost disinterested demeanor makes me apprehensive.  I’ve expressed concern to my friends with little ones, and they exclaim (over a large cup of coffee, I might add), “Count your blessings!”  But I would gladly trade all those nights of peaceful slumber for the reassurance of my baby’s well-being.

Allie has recently discovered the wonder of her voice and is making up for lost time.  Unfortunately, instead of using them for words, little Allie will just make. . . noise, sounds without meaning. . .on-and-off, for hours upon hours in a day.   Now I walk to her crib, pencil and notebook in hand.  She is awake.  I am standing right beside her, yet she does not stir.  She jiggles her left foot, (she favors her left side), and passively continues her grating, “Rrrrrrrrrrrrrrrrrrrrrrr.”  Laying on her backside, her beautiful brown eyes are dazed, off-center. . .can she be lost inside her own mind?   I want to help her (oh please say I can help her) but how can I when she doesn’t even see me? 

July 15, 2002

If my wish was to experience the sleepless nights of a new parent, my wish has came true.  Something is wrong with my baby.  Her tantrums are incessant.  Out of this teeny, tiny body come the most terrible, blood-curdling screams.  I run to her aid, but she cannot be consoled.  Sometimes she lets me pick her up and hold her; she’ll be calm for a little while.  Other times, hugging her makes her writhe in pain as if the mere sensation of touch is unbearable.  “She’s teething,” or, “Sometimes kids start their terrible twos early,” say my coffee-drinking friends.  “But I’ve caught her literally clutching onto the bars of her crib and banging her head against the side!  Tell me, is this normal?”  I cry.  For her unhappiness is my unhappiness, and her pain is my burden.  Sometimes, I think of her at ten months, when her eyes would meet mine and she would smile.  She used to point, to crawl around, she even babbled some. . . but now it’s just noise.

“Allie!”  I say.  (No response.)”  “Allie!”  (Still nothing.)  “ALLIE!”  She looks up, momentarily, before allowing her gaze to drift around the room.  “Allie, you can’t hear the fear in my voice, can you?”  I’m talking to myself at this point.  “All right.  I’ll. . . I’ll call the doctor.”    

ADVANCED THERAPY OBSERVATION REPORT
# 1
 
Name: Megan Thacker            Client’s Initials: A.B.

Date of Observation: October 13, 2005    Age: 3

Length of Observation: Two hours            Indiv. Yes      Group

Client Disorder: Lang./Artic./Voice/Fluency/HI/Dysphagia Other: (specify) Autism

1.) Describe 1 segment of the session you found to be effective  (What appeared to go well?  What was successful?).

     During my observation, Allie demonstrated she was acquiring knowledge of the Picture Exchange Communication system.  Allie had just completed an imitation exercise.  She remained in the chair, looking kind of restless and clicking her tongue every-so-slightly.  The special education teacher, Mrs. B., went into her filing cabinet, retrieved a bag, and sat across from Allie. Another individual, (an aid), sat beside Allie.  Mrs. B. caught my eye, smiled, and said, “I guarantee you, this will catch her attention.”  She reached into the bag and dropped a few pretzels on the table; she laid down a picture of a pretzel beside it.  (It was just a simple black-and-white pretzel outline, obviously computer-generated.)  Allie instinctively reached for the pretzels, but the aid gently grabbed her arm and re-directed it to the picture.  Allie made a few disgruntled noises and tried, in vain, to be rid of this “leech” on her arm—to no avail.  She reluctantly picked up the picture—the aid released her hand but stayed within arm’s length of the girl, I guess to ensure she didn’t dive for the pretzel again.  Allie brusquely nudged Mrs. B’s hand with the picture.  Allie had obviously been through this routine before.  Mrs. B. automatically opened up her hand, accepted the picture, and asked, “Oh, do you want the pretzels?”  She picked up three and handed them to Allie, who promptly shoved them in her mouth one-after-the-other.  I was impressed that Allie knew exactly what to do with the picture with little prompting.  I also thought that a tangible reinforcer seemed to work best in motivating Allie to accomplish a task.

 2.)  Describe 1 segment of the session you found to be less effective and/or confusing to you.  (What do you think did not produce a desirable result?  What did you not understand?)

     Sometimes Mrs. B. would lose Allie’s attention when working with her on following one-step directions.  Allie responded almost immediately to “Come here”, but when the teacher said, “Give me a high-five”, she appeared anxious and seemed increasingly withdrawn.  The teacher simply moved on with “Sit down”, and after a few moments of processing, Allie obeyed.  “Good job!” Mrs. B. said encouragingly.  Honestly, I thought “Give me a high five!” was a horrible direction to give to a three-year-old, let alone a three-year-old child with autism.  Individuals with autism interpret language extremely literally, and how would someone literally interpret, “Give me a high-five!”?  Also, I don’t understand why she skipped the direction; I figured she would go ahead and “give her a high five” so at least Allie would have been exposed to the direction.  

3.)  Discuss 1 element of the session that surprised you and/or that you found contradictory to your understanding (information you have from class, common sense, experience, or expectations).

     I didn’t think of this until I had completed my observation, but I remembered that during the use of the PECs system, as soon as Allie nudged Mrs. B’s hand with the picture, Mrs. B. accepted it. She responded immediately with, “Oh, do you want pretzels?" and then gave her the pretzels.  However, Allie was not demonstrating any form of eye contact during the exchange.  I remember reading somewhere that the exchange should not take place until the person wanting the object shares eye contact with the person giving the object.  However, I did witness Allie use eye contact periodically throughout the session (meaning the capability is there.)  And she must have developed some form of joint attention, because she could follow some instructions throughout the session.  (Meaning she has some receptive language.) 

 4.)  Write about:

• What you learned from this observation

     Before this observation, I had only heard of the PECs system.  Even though I only got to observe Phase I, I still felt like it greatened my appreciation of the process.  It provides the child with a way of communicating through interaction.  It could lay the foundation for actual language, because it teaches how things can be indirectly represented.  To express her needs, Allie will eventually be forced to distinguish between pictures on a communication board.  She will (hopefully) develop the ability to pick out the picture of, for instance, the pretzel if she wants a pretzel.  She will realize the picture is not the object (the pretzel) itself but merely a representation of the pretzel.

       I also got a better understanding of how children with autism react to various auditory / tactile / and visual stimuli. These characteristics differ individual-to-individual, however, seeing Allie’s reactions in certain situations deepened my understanding of how people with autism may have different thresholds of tolerance than people without autism.  For instance, during the session a garbage truck came around back.  It beeped loudly, and made an almost thrashing sound as the back of the truck lowered and emptied its contents.  Allie ran into the corner, curled up into a ball, and starting rocking, back and forth, back and forth.  When the truck left and Mrs. B. finally persuaded Allie out of her corner, I could easily tell from her expression it wasn’t an issue of defiance; she had experienced a level of something . . . we probably don’t have a word for.  Something like pain and over stimulation and panic, and yet not quite like any of those things.

• Your feelings/reactions of the impact of the therapist’s intervention on the client

     I thought the special educator did a terrific job interacting with Allie.  She seemed to have developed a genuine relationship with her; there was a sort of unspoken, mutual trust between the two of them.  I do admit the possibility that I’m just interpreting what I want to interpret out of the situation, but I stand by my hypothesis.  Even if Allie’s demeanor appeared somewhat disinterested, I noticed she usually responded in some way to Mrs. B.  (Even if she didn’t exactly do as told.)  Mrs. B told me I caught Allie on a good day, and at the beginning of the year she quickly became infamous for her screeching tantrums.  However, she also said, “Allie has so much personality, she’s such a determined young girl. . . we just have to unlock that door so she can express what she’s thinking and feeling.”  Mrs. B also said Allie’s mom was elated because Allie was finally taking to affection (e.g. she wouldn’t immediately squirm when hugged, patted, etc.) 

•  Your feelings/reactions of the impact of the client on you as an observer           

          Observing Allie only deepened my desire to work with children.  I think it would be incredibly rewarding to have a positive impact on the life of a child, particularly a child with special needs.  The odds are really against them—it makes all the difference in the world if someone is actually rooting for them.  I realize a two-hour observation focused on one individual doesn’t give me a concrete idea of what a job of this magnitude entails.  I left with more questions than answers.  However, I also left more intrigued by the disorder, the treatment of the disorder, and curious to how a little girl like Allie could fall into an SLP’s scope of practice.

Sheila Clark:  Hi, my name is Sheila Clark.  I'm a speech-language pathologist, and over the next few days, I'm going to be assessing how Allie communicates.  You must be Ms. Jones, Allie’s mother.

Jessica Jones:  Yes. 

Clark [shuffles through papers]:  The worst of the interrogation is over.  I know you had to go through quite a lengthy interview with your pediatrician before he diagnosed Allie with Autism Spectrum Disorder—

Jones: It doesn’t even compare to what I’ve answered for you guys!

Clark [smiles]:  Before any child is admitted into our program, we obtain extremely, extremely detailed case histories.  We leave no stone unturned.  I’ve already studied Allie’s medical history, developmental history, behavioral history, and so forth—I've reviewed any information that could possibly be beneficial in her treatment regime. 

This is going to be a pretty informal interview.  I’ve briefly met with Allie and I was hoping we could discuss some of my first impressions.  I also wanted to answer any questions you might regarding my role in treating Allie--though you’re welcome to contact me anytime.  I’m sure we’ll be meeting frequently to discuss Allie’s progress.

Jones:  That’s fine, I’ll answer any questions I can. 

Clark:  Let me start out, Ms. Jones, by telling you what a beautiful little three-year-old you have.  She's determined and very strong-spirited.

Jones [brightens]:  I’ve told people that!  I’ve always told people that.  Since the day she was born, my Allie has known exactly what she wanted.  She gets that from my side of the family. 

I’ll have bring in my neice some time to watch Allie in session.  Megan’s a budding speech-language pathologist; she’s a junior at Marshall University. It's all she talks about. (Rolls eyes.)  Her program requires that she view a session of some type of speech therapy, and then write an observation report.     

Clark :  Well. . .because Allie is nonverbal, my focus in therapy will be language development.   How does Allie express herself?

Jones [after slight hesitation]:  Allie's prone to tantrums, and she'll scream whenever she's upset.   Whenever she sees the Teletubbies, for example.  As soon as they come on and start socializing with that floating sun-baby, she screams and cries like there's no tomorrow.

Clark:  Is this intentional communication?  Is she crying because she's upset, or because she wants you to do something?

Jones:  Oh, I feel certain she expects me to turn off the T.V. in response to her crying.   Because if the crying doesn't get my attention, she'll kick the television set.  And I think she realizes this "kicking" behavior forces me to drop whatever I'm doing to run to her aid . . .

Clark:   It is important for us to understand how the child communicates,  so we can “. . . formulate goals to make communication conventional.  For example. . . [we] can teach a child to shake his head 'no' instead of screaming and throwing”  (Maurice, p. 299, 1996). 

Jones :  There was a pamphlet on autism in the waiting room.  It. . . it talks about these problems that happen within the first year.  I swear, Allie was fine until she turned sixteen months.  I know. . .[lowers voice]. . I realize that she has problems, but are you sure she is autistic? 

Clark:  Ms. Jones, I haven’t spent enough time with your daughter to even  give you an educated opinion regarding her diagnosis.  However, autism isn’t necessarily identifiable at birth.  Sometimes children with autism regress; they lose previously acquired skills.  (Corsello, 2005).  Other times, the symptoms become more overt when the child is older. We notice their language skills aren't developing as they should be.  Or that they aren’t interested in people—

Jones :   And are abnormally interested in . . . things. . .  right?   I wrote some of Allie’s odd behaviors in my journal.  I’ll have to read over again when I get home.

Clark:  Yes, children with autism can become almost obsessive over certain objects.  Their play can be very restricted.

Jones:  Do you think she can understand me?

Clark:   Again, I really haven’t spent enough time with Allie to say.   Children -- with and without autism, for that matter -- usually have more receptive language than expressive language.  They understand more than they can express.       

Jones:  She knows her name, but sometimes she won’t look up until the second or third time I say it. 

Clark:  That doesn’t surprise me.  Just know that Allie is not being defiant.  “It takes a long time for. . . children [with autism] to process, understand, and organize information they hear . .  .”  (Janzen 1999). “Sometimes this delay is as long as 30 to 45 seconds”  (Janzen 1999).  “These children also have difficulty maintaining attention on verbal information.  Their attention fades in and out as it is diverted or overwhelmed by background noises”  (Janzen 1999).      

Jones:  Allie’s much less responsive when any kind of noise is in the background.  Even the sound of the running dishwasher distracts her.

Clark:  It’s impossible for us to understand exactly how a child with autism perceives the world.  What we do know is that autism is a sensory disorder.  Someone with autism may receive sensory information—whether it be tactile, visual, or auditory—“at either too high or too low a level” (Janzen 1999).  At times, Allie might not be able to make out your voice at all.  But the sound of the running dishwasher rages like a bulldozer.

Jones:  I know you were supposed to be the one interviewing me. . . but can I ask you one more thing?

Clark:  Of course!

Jones:  Will Allie ever be able to talk?

Clark:  Ms. Jones, I assure you, all will be done.  If I cannot get Allie to communicate orally, I'll teach her some form of augmentative communication.  The Picture Exchange Communication System has been effective with many of my clients.  It provides them a mode of self-expression, allowing them to visually convey their needs and desires.  And sometimes augmentative communication sets the stage for verbal communication.  [pauses]  Allie is two, right?

Jones:  She just turned two and a half yesterday.

Clark:  “The available evidence from a variety of programs and studies suggests that early intervention leads to better outcomes”  (Corsello 2005).  And the sooner the problem is identified, the earlier intervention can begin.  Fortunately, “The preschool years are still considered ‘early’ when it comes to early intervention”  (Corsello 2005). 

Jones:  I pray for her every day.  I pray that she will be happy and healthy and . . . and, that one day, everyone will see Allie as I see her.   

References: 

Corsello, Christina M.  (2005).  Early intervention in autism.  Infants & young children:  An interdisciplinary journal of special care practices, 18(2), 74-85.  Retrieved October 2, 2005, from the Academic Search Premier database.

Janzen, J. (1999). Autism: Facts and strategies for parents. United States : Therapy Skill Builders.

Maurice, C.  (Ed).  (1996).  Behavior intervention for young children with autism:  A manual for parents and professionals.  Austin, TX : PRO-ED, Inc. 

What is autism?

Autism is a lifelong, neurological disorder.  Autism is a spectrum disorder, meaning its symptoms range from mild to severe, depending on the individual.  However, according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, a diagnosis of autism entails:

• Impairments in social interaction
• Impairments in communication
• Onset before three years of age 
• Stereotyped (ritualized) behaviors

(Richard, 1997)

A child with autism may also have impairments regarding:

• Sensory integration
• Fine and / or Gross Motor Skills
• Play
• Behavior
• Cognition 

 How do I know if my child has autism?  (This list should not serve as a substitution for a diagnostic evaluation.  These are simply indicating factors.  If your child demonstrates several of these characteristics, contact your pediatrician.)    

Does your child. . .  exhibit unusual play behavior?  Children with autism usually engage in repetitive self-stimulatory behavior; they may appear as if ran by a motor.  They show little to no interest in pretend play.      

Is your child . . .  socially aloof? By the first year, your child should be exhibiting a social smile, and showing particular interest in the human face.  By the first year, he/she should be babbling and using simple gestures; by the second year, he/she should have developed some sort of gesture system, and should utilize speech communication.  (Including some two-word utterances.)   Children with autism prefer to be alone.

Does your child. . . appear withdrawn from reality?  Many children with autism have what is called an “empty gaze” and lack emotional expression.  Others appear indifferent to auditory stimuli, which is why some parents first suspect a child with autism is deaf. 

Does your child. . . display odd visual fascinations? Does your child appear more intrigued by an airborne speck of dust than his/her toys, or the people around him/her?

Also contact your pediatrician if. . .

Your child is not meeting the appropriate developmental milestones.  (Go to www.firstsigns.com for more information)      

At * any * loss of skills 

Why is an early diagnosis so important ?

The sooner a child is diagnosed, the sooner treatment can begin—and time is of the essence.  While there is no cure for autism, research shows early intervention is the key to giving these children a better quality of life.  “Since it is imperative to intervene early with these children to achieve optimum improvements, it is essential that parents and providers be aware of these early signs.”  (Beuauchesne, Kelley, 2004, p. 58.)

What kinds of early intervention are available?  Many programs utilize. . .

Developmental intervention :

Developmental intervention refers to child-directed approaches, as used in the Greenspan model.  “The adults’ role . . . is to follow the child’s lead and play at whatever captures the child’s interest while building on his actions in increasingly complex ways that literally compel the child to want to continue the interaction.”  (Janzen, 1999, p. 84)   An adult (trained to effectively respond to a child with autism) will enage in interactive play activies with the child several times a day, gradually enhancing the child’s ability to imitate, to take turns, and to hold attention.  However, this model’s emphasis is on interpersonal relations, which hopefully “lead to the mastery of cognitive and developmental skills”  (Corsello, 2005, p.82).  

Applied Behavior Analysis :

ABA “includes a number of . . . intervention strategies based on behavioral principles and programs based on behavioral principles.”  (Corsello, 2005, p.79).  The discrete trial format, like all ABA formats, is very structured.  The discrete trial format involves the following sequence:  cue, response, consequence (Janzen, 1999).  The instructor might say “Do this”, and touch her head.  The child will touch his/her head, and the teacher will offers some sort of reward, either a tangible reinforcer (e.g. food, toy)  or a social reinforcer (e.g. hug, praise.)  Incidental teaching is another form of ABA.  It involves “taking advantage of teachable moments”  (Janzen, 1999, p. 75).  For example, something the child wants is out of reach.  The child stretches his/her arms out for a stuffed dog.   The instructor may say, “You want the dog.  Here is the dog.”  Or she may say, “You want the dog.  Say ‘dog.’” Before providing the dog as a reinforcer, the teacher will expect some sort of of response, even if just the first sound of the word.  "Over the past three decades, consistent and systematic research projects have demonstrated the utility of the behavioral approach, and many recent, larger-scale outcome studies have consistently demonstrated that this approach yields significant benefits for children with autism" (Maurice, 1996, p.195).

References:   

Beauchesne, M., & Kelley, B.  Evidence to support parental concerns as an early indicator of autism in children.  Pediatric Nursing, 30(1), 57-67.  Retrieved October 2, 2005, from the Academic Search Premier database.

Corsello, Christina M.  (2005).  Early intervention in autism.  Infants & young children:  An interdisciplinary journal of special care practices, 18(2), 74-85.  Retrieved October 2, 2005, from the Academic Search Premier database.

Richard, G.  (1997).  The source for autism.  East Moline, IL : Linguisystems.

Janzen, J. (1999). Autism: Facts and strategies for parents. United States : Therapy Skill Builders.

Maurice, C.  (Ed).  (1996).  Behavioral intervention for young children with autism:  A manual for parents and professionals.  Austin, TX : PRO-ED, Inc.