Eliciting Language Samples for Analysis (ELSA): A New Protocol for Assessing Expressive Language and Communication in Autism

Does Gestural Communication Influence Later Spoken Language Ability in Minimally Verbal Autistic Children?

PURPOSE

The current study examined the predictive role of gestures and gesture-speech combinations on later spoken language outcomes in minimally verbal (MV) autistic children enrolled in a blended naturalistic developmental/behavioral intervention (Joint Attention, Symbolic Play, Engagement, and Regulation [JASPER] + Enhanced Milieu Teaching [EMT]).

METHOD

Participants were 50 MV autistic children (40 boys), ages 54-105 months (M = 75.54, SD = 16.45). MV was defined as producing fewer than 20 spontaneous, unique, and socially communicative words. Autism symptom severity (Autism Diagnostic Observation Schedule-Second Edition) and nonverbal cognitive skills (Leiter-R Brief IQ) were assessed at entry. A natural language sample (NLS), a 20-min examiner-child interaction with specified toys, was collected at entry (Week 1) and exit (Week 18) from JASPER + EMT intervention. The NLS was coded for gestures (deictic, conventional, and representational) and gesture-speech combinations (reinforcing, disambiguating, supplementary, other) at entry and spoken language outcomes: speech quantity (rate of speech utterances) and speech quality (number of different words [NDW] and mean length of utterance in words [MLUw]) at exit using European Distributed Corpora Project Linguistic Annotator and Systematic Analysis of Language Transcripts.

RESULTS

Controlling for nonverbal IQ and autism symptom severity at entry, rate of gesture-speech combinations (but not gestures alone) at entry was a significant predictor of rate of speech utterances and MLUw at exit. The rate of supplementary gesture-speech combinations, in particular, significantly predicted rate of speech utterances and NDW at exit.

CONCLUSION

These findings highlight the critical importance of gestural communication, particularly gesture-speech (supplementary) combinations in supporting spoken language development in MV autistic children.

Real-time coded measures in natural language samples capture change over time in minimally verbal autistic children

Prior research supports the use of natural language sampling (NLS) to assess the rate of speech utterances (URate) and the rate of conversational turns (CTRate) in minimally verbal (MV) autistic children. Bypassing time-consuming transcription, previous work demonstrated the ability to derive URate and CTRate using real-time coding methods and provided support for their strong psychometric properties. (1) Unexplored is how URate and CTRate using real-time coding methods capture change over time and (2) whether specific child factors predict changes in URate and CTRate in 50 MV autistic children (40 males; M = 75.54, SD = 16.45 (age in months)). A NLS was collected at Time 1 (T1) and Time 2 (T2) (4.5 months between T1 and T2) and coding was conducted in ELAN Linguistic Annotator software using a real-time coding approach to derive URate and CTRate. Findings from paired samples Wilcoxon tests revealed a significant increase in child URate (not examiner URate) and child and examiner CTRate from T1 to T2. Child chronological age, Mullen expressive language age equivalent scores, and URate and CTRate at T1 were predictive of URate and CTRate at T2. Findings support using NLS-derived real-time coded measures of URate and CTRate to efficiently capture change over time in MV autistic children. Identifying child factors that predict changes in URate and CTRate can help in the tailoring of goals to children's individual needs and strengths.

Response to Music-Mediated Intervention in Autistic Children with Limited Spoken Language Ability

PURPOSE

Autistic children with limited spoken language ability (LSLA) often do not respond to traditional interventions, reducing their social inclusion. It is essential to identify effective interventions, and sensitive measures to track their intervention response.

METHODS

Using data from an RCT comparing music-mediated and play-based interventions, we investigated the impact of spoken language ability on outcomes, and measured response to intervention through natural language sample measures.

RESULTS

Children with lower verbal IQ, relative to higher verbal IQ, made some greater gains over the course of music-mediated intervention. Natural language samples were helpful in characterizing communication and tracking change.

CONCLUSION

Music-mediated interventions hold promise as effective interventions for autistic children with LSLA. Natural language samples are robust in characterizing this subgroup.

Frequency and characteristics of echoes and self-repetitions in minimally verbal and verbally fluent autistic individuals

Background and aims

Nongenerative speech is the rote repetition of words or phrases heard from others or oneself. The most common manifestations of nongenerative speech are immediate and delayed echolalia, which are a well-attested clinical feature and a salient aspect of atypical language use in autism. However, there are no current estimates of the frequency of nongenerative speech, and the individual characteristics associated with nongenerative speech use in individuals across the autistic spectrum are poorly understood. In this study, we aim to measure and characterize spontaneous and nongenerative speech use in minimally verbal and verbally fluent autistic children and adolescents.

Methods

Participants were 50 minimally verbal and 50 verbally fluent autistic individuals aged 6 to 21 years. Spontaneous and nongenerative speech samples were derived from SALT transcripts of ADOS-2 assessments. Participants' intelligible speech utterances were categorized as spontaneous or nongenerative. Spontaneous versus nongenerative utterances were compared between language subgroups on frequency of use and linguistic structure. Associations between nongenerative speech use and a series of individual characteristics (ADOS-2 subscale scores, nonverbal IQ, receptive vocabulary, and chronological age) were investigated over the whole sample and for each language subgroup independently.

Results

Almost all participants produced some nongenerative speech. Minimally verbal individuals produced significantly more nongenerative than spontaneous utterances, and more nongenerative utterances compared to verbally fluent individuals. Verbally fluent individuals produced limited rates of nongenerative utterances, in comparison to their much higher rates of spontaneous utterances. Across the sample, nongenerative utterance rates were associated with nonverbal IQ and receptive vocabulary, but not separately for the two language subgroups. In verbally fluent individuals, only age was significantly inversely associated with nongenerative speech use such that older individuals produced fewer nongenerative utterances. In minimally verbal individuals, there were no associations between any of the individual characteristics and nongenerative speech use. In terms of linguistic structure, the lexical diversity of nongenerative and spontaneous utterances of both language subgroups was comparable. Morphosyntactic complexity was higher for spontaneous compared to nongenerative utterances in verbally fluent individuals, while no differences emerged between the two utterance types in minimally verbal individuals.

Conclusions

Nongenerative speech presents differently in minimally verbal and verbally fluent autistic individuals. Although present in verbally fluent individuals, nongenerative speech appears to be a major feature of spoken language in minimally verbal children and adolescents.

Implications

Our results advocate for more research on the expressive language profiles of autistic children and adolescents who remain minimally verbal and for further investigations of nongenerative speech, which is usually excluded from language samples. Given its prevalence in the spoken language of minimally verbal individuals, nongenerative speech could be used as a way to engage in and maintain communication with this subgroup of autistic individuals.

Predicting Language in Children with ASD Using Spontaneous Language Samples and Standardized Measures

This longitudinal study examined the degree to which standardized measures of language and natural language samples predicted later language usage in a heterogeneous sample of children with autism spectrum disorder (ASD), and how this relationship is impacted by ASD severity and interventions. Participants with a diagnosis of ASD (N = 54, 41 males) completed standardized assessments of language and social functioning; natural language samples were transcribed from play-based interactions. Findings indicated that standardized language measures, natural language measures, and ADOS severity were each unique predictors of later lexical use. Intervention types also appeared to impact later language; in particular, participation in mainstream inclusion accounted for significant amounts of variance in children's mean length of utterance at T3.

Lexical and Morphosyntactic Profiles of Autistic Youth With Minimal or Low Spoken Language Skills

PURPOSE

Autistic youth who are minimally or low verbal are underrepresented in research leaving little to no evidence base for supporting them and their families. To date, few studies have examined the types of words and word combinations these individuals use. The purpose of this study was to take a strengths-based approach to outline descriptive profiles of autistic youth who use few words and elucidate the lexical and morphosyntactic features of their spoken language.

METHOD

We analyzed language samples from 49 autistic youth ages 6-21 years who used fewer than 200 words. Systematic Analysis of Language Transcripts was used to investigate the relationship between number of different words (NDW) and proportion of nouns and verbs (vs. other word classes), mean length of utterance in morphemes (MLUm), and the frequency of early developing morphosyntactic structures. We used linear regression to quantify the relationship between NDW and lexical and morphosyntactic features.

RESULTS

Proportion of nouns and verbs produced did not increase significantly in those with higher NDW. Conversely, MLUm and the frequency of early developing morphosyntactic structures increased significantly in those with higher NDW.

CONCLUSIONS

Youth with higher NDW did not produce more nouns and verbs, suggesting lexical profiles that are not aligned with spoken vocabulary level. Youth with higher NDW had higher MLUm and more early morphosyntactic forms, suggesting that morphosyntactic profiles align with spoken vocabulary level. We discuss the implications for improving clinical services related to spoken language.

Fine motor skill and expressive language in minimally verbal and verbal school-aged autistic children

Fine motor skill is associated with expressive language outcomes in infants who have an autistic sibling and in young autistic children. Fewer studies have focused on school-aged children even though around 80% have motor impairments and 30% remain minimally verbal (MV) into their school years. Moreover, expressive language is not a unitary construct, but it is made up of components such as speech production, structural language, and social-pragmatic language use. We used natural language sampling to investigate the relationship between fine motor and speech intelligibility, mean length of utterance and conversational turns in MV and verbal autistic children between the ages of 4 and 7 while controlling for age and adaptive behavior. Fine motor skill predicted speech production, measured by percent intelligible utterances. Fine motor skill and adaptive behavior predicted structural language, measured by mean length of utterance in morphemes. Adaptive behavior, but not fine motor skill, predicted social-pragmatic language use measured by number of conversational turns. Simple linear regressions by group corrected for multiple comparisons showed that fine motor skill predicted intelligibility for MV but not verbal children. Fine motor skill and adaptive behavior predicted mean length of utterance for both MV and verbal children. These findings suggest that future studies should explore whether MV children may benefit from interventions targeting fine motor along with speech and language into their school years.

Review of methods for conducting speech research with minimally verbal individuals with autism spectrum disorder

The purpose of this paper was to review best-practice methods of collecting and analyzing speech production data from minimally verbal autistic speakers. Data on speech production data in minimally verbal individuals are valuable for a variety of purposes, including phenotyping, clinical assessment, and treatment monitoring. Both perceptual ("by ear") and acoustic analyses of speech can reveal subtle improvements as a result of therapy that may not be apparent when correct/incorrect judgments are used. Key considerations for collecting and analyzing speech production data from this population are reviewed. The definition of "minimally verbal" that is chosen will vary depending on the specific hypotheses investigated, as will the stimuli to be collected and the task(s) used to elicit them. Perceptual judgments are ecologically valid but subject to known sources of bias; therefore, training and reliability procedures for perceptual analyses are addressed, including guidelines on how to select vocalizations for inclusion or exclusion. Factors to consider when recording and acoustically analyzing speech are also briefly discussed. In summary, the tasks, stimuli, training methods, analysis type(s), and level of detail that yield the most reliable data to answer the question should be selected. It is possible to obtain rich high-quality data even from speakers with very little speech output. This information is useful not only for research but also for clinical decision-making and progress monitoring.

Exploring communicative competence in autistic children who are minimally verbal: The Low Verbal Investigatory Survey for Autism (LVIS)

LAY ABSTRACT

Approximately one in three autistic children is unable to communicate with language; this state is often described as minimally verbal. Despite the tremendous clinical implications, we cannot predict whether a minimally verbal child is simply delayed (but will eventually develop spoken language) or will continue to struggle with verbal language, and might therefore benefit from learning an alternative form of communication. This is important for clinicians to know, to be able to choose the most helpful interventions, such as alternative forms of communication. In addition, the field lacks a standard definition of "minimally verbal." Even when we do agree on what the term means (e.g. fewer than 20 words), describing a child based on their lack of words does not tell us whether that child is communicating in other ways or how they are using those 20 words. To address these concerns, we developed the Low Verbal Investigatory Survey (LVIS), a one-page parent-report measure designed to help us characterize how minimally verbal autistic children are communicating. Parents of 147 children (aged 1-8 years) completed the LVIS. Here, we ask (1) whether the survey measures what it was designed to measure, that is, communicative ability in children without much spoken language, and (2) how the LVIS relates to cognitive and language ability, and symptoms of autism. Results suggest that this survey, which takes only 5 min to complete, is a good estimate of the child's communication skills. Furthermore, LVIS survey scores are correlated with other measures of language and cognitive abilities as well as autism symptomatology. The LVIS has the potential to save time and money in both clinical and research efforts to assess communication skills in minimally verbal autistic children.

Concurrent Predictors of Supplementary Sign Use in School-Aged Children With Childhood Apraxia of Speech

PURPOSE

Manual sign is a common alternative mode of communication taught to children with childhood apraxia of speech (CAS). Gesture use is positively related to later increases in vocabulary and syntactic complexity in typical development, but there is little evidence supporting the use of manual sign for children with CAS. We sought to identify the communicative functions of signs and gestures produced by children with CAS and to identify concurrent factors suggesting which children are more likely to benefit from sign-supported speech intervention.

METHOD

Measures of receptive and expressive language were gathered from 19 children (ages 3.8-11.1 years) with CAS in a school-based sign-supported speech program. Fourteen of the children produced a total of 145 manual signs, which included both gestures and signs from American Sign Language (M = 10.4 per child, SD = 11.6). Manual signs were coded according to whether they conveyed information that was semantically redundant with (complemented) or added information to (supplemented) their speech.

RESULTS

Children produced 107 complementary manual signs (75.4%) and 38 supplemental (24.6%) manual signs. Of the 38 supplemental signs, 24 (63.2%) provided additional information in the presence of unintelligible or no speech and 14 (36.8%) provided additional information in the presence of intelligible speech. Children's expressive language scores significantly predicted and accounted for 38.4% of the variance in the number of supplemental signs that children used.

CONCLUSION

Children with CAS whose oral expressive language was relatively more impaired produced the most supplementary signs, suggesting that children with oral expressive language challenges are more likely to rely on them for communicating words they cannot yet speak.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.21217814.

The importance of deep speech phenotyping for neurodevelopmental and genetic disorders: a conceptual review

Background

Speech is the most common modality through which language is communicated, and delayed, disordered, or absent speech production is a hallmark of many neurodevelopmental and genetic disorders. Yet, speech is not often carefully phenotyped in neurodevelopmental disorders. In this paper, we argue that such deep phenotyping, defined as phenotyping that is specific to speech production and not conflated with language or cognitive ability, is vital if we are to understand how genetic variations affect the brain regions that are associated with spoken language.

Speech is distinct from language, though the two are related behaviorally and share neural substrates. We present a brief taxonomy of developmental speech production disorders, with particular emphasis on the motor speech disorders childhood apraxia of speech (a disorder of motor planning) and childhood dysarthria (a set of disorders of motor execution). We review the history of discoveries concerning the KE family, in whom a hereditary form of communication impairment was identified as childhood apraxia of speech and linked to dysfunction in the FOXP2 gene. The story demonstrates how instrumental deep phenotyping of speech production was in this seminal discovery in the genetics of speech and language. There is considerable overlap between the neural substrates associated with speech production and with FOXP2 expression, suggesting that further genes associated with speech dysfunction will also be expressed in similar brain regions. We then show how a biologically accurate computational model of speech production, in combination with detailed information about speech production in children with developmental disorders, can generate testable hypotheses about the nature, genetics, and neurology of speech disorders.

Conclusions

Though speech and language are distinct, specific types of developmental speech disorder are associated with far-reaching effects on verbal communication in children with neurodevelopmental disorders. Therefore, detailed speech phenotyping, in collaboration with experts on pediatric speech development and disorders, can lead us to a new generation of discoveries about how speech development is affected in genetic disorders.

Diagnosis and Treatment of Childhood Apraxia of Speech Among Children With Autism: Narrative Review and Clinical Recommendations

PURPOSE

Treatment for children with autism spectrum disorder (ASD) and low verbal ability is a largely neglected area of study. Existing research focuses on language abilities; however, a subset of children with ASD also has speech sound disorders (SSDs). The purpose of this tutorial is to provide clinicians with evidence-based recommendations to guide speech assessment and treatment among children with ASD, low verbal ability, and suspected childhood apraxia of speech (CAS).

METHOD

Multifaceted search procedures were used to identify studies that have assessed or treated speech sound production among children with ASD. A narrative review and synthesis of the literature is followed by practical clinical recommendations based on best available evidence.

CONCLUSIONS

It is critically important to consider all possible hindrances to the development of functional communication ability for children with ASD. Speech sound production has been identified as a key predictor of expressive language outcomes, yet there are very few studies that address assessment and treatment of SSDs among children with ASD. Less is known about the presentation of CAS among children with ASD and low verbal ability. More research is needed to determine whether existing speech assessment and treatment methods are appropriate for children with ASD, if modifications are needed, or if new methods should be designed.

Spoken Language Change in Children on the Autism Spectrum Receiving Community-Based Interventions

We assessed the spoken language of 73 preschool aged children on the autism spectrum receiving community-based early intervention at two time points, approximately 7 months apart. Using the Spoken Language Benchmarks, there was a small non-significant change in the proportion of children transitioning from below, to at or above, Phase 3 (word combinations). Using binomial regression, a model comprising seven of nine clinician-proposed child-related predictors explained 64% of the variance. None of the predictors were individually significant, although a large effect size (OR = 16.71) was observed for children's baseline rate of communicative acts. The findings point to substantial unmet clinical need in children with minimal verbal language, but also the relevance of clinician-proposed predictors of their spoken language outcomes.

Providing a parent-administered outcome measure in a bilingual family of a father and a mother of two adolescents with ASD: brief report

There is a need for psychometrically sound outcome measures for treatment studies that have a low burden for families and that are available in multiple languages. We have developed a language assessment in English and Spanish that parents can administer to their children at home via telehealth-delivered procedures. The current case study presents descriptive data on a single family of two parent-child dyads. Both the mother and father from a single family were trained in their primary language (Spanish) on how to administer the Expressive Language Sampling - Narration (ELS-N) in their secondary language (English) to their two English-speaking monolingual sons with ASD through telehealth-delivered procedures. Both parents learned to administer the procedures to a predetermined level of fidelity. Extension to a larger sample of bilingual families is needed for this home-based, parent-administered test; however, the present results suggest feasibility even when the language of training and administration differ.

Using telehealth-delivered procedures to collect a parent-implemented expressive language sampling narrative task in monolingual and bilingual families with Autism Spectrum Disorder: A pilot study

Language impairments are frequent, severe, and of prognostic value in autism spectrum disorder (ASD). Unfortunately, the evaluation of the efficacy of treatments targeting the language skills of those with ASD continues to be hindered by a lack of psychometrically sound outcome measures. Expressive Language Sampling (ELS) procedures offer a promising alternative to norm-referenced standardized tests for assessing expressive language in treatment studies. Until now, however, research on the validity and utility of ELS as outcome measures has been limited to administrations by a trained professional in a clinic setting and to use with English-speaking families. These limitations are a barrier for many families accessing the benefits of participation in treatment studies. The current study examines the feasibility of teaching native English-speaking parents (NESP) and native Spanish-speaking parents (NSSP) how to administer the ELS narrative task (ELS-N) to their sons and daughters with ASD (between ages 6 and 21) at home through telehealth-delivered procedures. The parent training was provided in the primary language of the participating parent (i.e., 11 NSSP and 11 NESP) and administered by the parent to the youth in the language that the parent reported to use to communicate with the youth at home (i.e., 9 Spanish and 13 English). Families were able to choose between using their own technology or be provided with the technology needed for participation. Of the 19 parents who completed the training, 16 learned to administer the ELS-N procedures. In addition, strong test-retest reliability and no practice effects over the 4-week interval were observed for ELS-N derived youth outcome measures (i.e., talkativeness, vocabulary, syntax, dysfluency, and intelligibility) for both NSSP and NESP. Results from this pilot study suggest that the home-based parent-implemented ELS-N procedures can be learned and administered at acceptable levels of fidelity by parents, with good test-retest reliability and limited practice effects observed in terms of outcome measures for youth with ASD. Implications for treatment studies and future directions are discussed.

Spoken language outcome measures for treatment studies in Down syndrome: feasibility, practice effects, test-retest reliability, and construct validity of variables generated from expressive language sampling

BACKGROUND

The purpose of this study was to evaluate expressive language sampling (ELS) as a procedure for generating spoken language outcome measures for treatment research in Down syndrome (DS). We addressed (a) feasibility, (b) practice effects across two short-term administrations, (c) test-retest reliability across two short-term administrations, (d) convergent and discriminant construct validity, and (e) considered comparisons across the conversation and narration contexts.

METHOD

Participants were 107 individuals with DS between 6 and 23 years of age who presented with intellectual disability (IQ < 70). The utility of ELS procedures designed to collect samples of spoken language in conversation and narration were evaluated separately. Variables of talkativeness, vocabulary, syntax, utterance planning, and articulation quality, derived from transcripts segmented into C-units (i.e., an independent clause and its modifiers), were considered. A 4-week interval was used to assess practice effects and test-retest reliability. Standardized direct assessments and informant report measures were collected to evaluate construct validity of the ELS variables.

RESULTS

Low rates of noncompliance were observed; youth who were under 12 years of age, had phrase-level speech or less, and had a 4-year-old developmental level or less were at particular risk for experiencing difficulty completing the ELS procedures. Minimal practice effects and strong test-retest reliability across the 4-week test-retest interval was observed. The vocabulary, syntax, and speech intelligibility variables demonstrated strong convergent and discriminant validity. Although significant correlations were found between the variables derived from both the conversation and narration contexts, some differences were noted.

CONCLUSION

The ELS procedures considered were feasible and yielded variables with adequate psychometric properties for most individuals with DS between 6 and 23 years old. That said, studies of outcome measures appropriate for individuals with DS with more limited spoken language skills are needed. Context differences were observed in ELS variables suggest that comprehensive evaluation of expressive language is likely best obtained when utilizing both contexts.

A Comparison of Natural Language Samples Collected From Minimally and Low-Verbal Children and Adolescents With Autism by Parents and Examiners

Purpose We aimed to compare the speech of parents and examiners as they elicited language samples from minimally and low-verbal (MLV) children and adolescents with autism spectrum disorder (ASD), while following the same semi-structured elicitation protocol, Eliciting Language Samples for Analysis-Adolescents (ELSA-A). We also compared the speech elicited from the MLV children/adolescents by their parents at home and by trained examiners in the lab and assessed the feasibility of parents collecting language samples at home. Method Thirty-three (five female, 28 male) MLV children and adolescents with ASD between the ages of 6;6 and 19;7 (years;months) participated. All participants were administered standardized assessments, and a trained examiner collected an ELSA-A language sample from them in the lab. The parents of 22 of the children/adolescents collected an ELSA-A sample at home. All language samples were transcribed following standard procedures, and measures of expressive language were extracted to assess the quantity of speech, its syntactic complexity, and lexical diversity. At the end of the study, parents filled out a feedback survey about their experiences collecting ELSA-A. Results On average, parents produced twice as much speech as trained examiners during ELSA-A. However, their speech did not differ in syntactic complexity or lexical diversity. When with their parents, the MLV children/adolescents also produced twice as much speech than with trained examiners. In addition, their samples were more lexically diverse. Overall, parents elicited longer language samples but administered fewer of the ELSA-A activities. Nevertheless, the majority of parents rated the experience of collecting language samples at home favorably. Conclusions When parents collect language samples at home, their older MLV children/adolescents with ASD produce more speech and engage in more back-and-forth verbal interactions than when with trained examiners. Because parent-elicited language samples allow for a richer assessment of children's expressive language abilities, future studies should focus on identifying ways to encourage parents to collect data at home.