Comparing Spoken Language Treatments for Minimally Verbal Preschoolers with Autism Spectrum Disorders

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.

Effects of a Contingent Responses Intervention on the Quantity and Quality of Vocalizations of Preschool Children with Autism Spectrum Disorder

Multiple contemporary theories emphasize the quantity and quality of child vocalizations for promoting spoken language acquisition. Yet, empirical evidence for facilitating vocal development is strikingly lacking including for children with autism spectrum disorder (ASD) who have difficulty developing language. We evaluate use of contingent responses and vocal enhancement strategies to increase the quantity and quality of child vocalizations to which adults can respond with language-facilitating input for children with ASD. Three preschool children with ASD and minimal verbal skills participated. Using an alternating treatments design embedded within a multiple probe across participants design, we compared using contingent responses with and without vocal enhancement strategies versus a non-contingent control condition. Based on visual analysis and effect sizes, all participants showed a functional relation between both active intervention conditions and quantity of vocalizations, as predicted. For quality of vocalizations, changes under the active intervention conditions were less pronounced than those observed for quantity. Two participants showed a functional relation between at least one quality variable and the active interventions. Our hypothesis that vocal enhancement strategies would exhibit a value-added effect was partially supported for quantity and quality. Findings support using contingent responses to improve the quantity and to some degree the quality of vocalizations in young children with ASD and minimal verbal skills. Support for the added value of vocal enhancement strategies was mixed. Refining the intervention strategies is warranted to meet the needs of the understudied population of children with ASD and minimal verbal skills.

Phonemic Feature Scoring as a Tool for Progress Monitoring During Language Interventions for Children With Autism and Minimal Verbal Skills

PURPOSE

An increasing number of studies focus on verbal treatments for children with autism and minimal verbal skills. However, clinical tools for progress monitoring during interventions are lacking. The aim of this clinical focus article is to provide illustrations on the utility of a phonemic feature scoring system as a progress-monitoring tool, focusing on benefits and limitations as well as indications for use.

METHOD

Current practices for progress monitoring during language interventions with children with autism and minimal verbal skills are reviewed. A phonemic feature scoring tool is provided to aid clinicians in assessing the accuracy and consistency of expressive word productions. The authors illustrate the use of phonemic feature scoring as a progress-monitoring tool for two children with autism and minimal verbal skills, contrasting the phonemic feature scoring system to correct/incorrect, phoneme-level, and whole-word scoring.

RESULTS

Case 1 demonstrates a scenario where the child's speech intelligibility is low and clinical use of the phonemic feature scoring system captures discrete changes in speech production progress not represented by correct/incorrect, phoneme-level, and whole-word scoring. However, Case 2 represents a situation where once a child's speech intelligibility improves, the phonemic feature scoring system is no longer needed, and correct/incorrect scoring may be sufficient.

CONCLUSION

The phonemic feature scoring system allows clinicians to track phonemic feature changes in word productions and provides detailed progress monitoring information, leading to adaptations of the intervention for each individual.

Word meaning is complex: Language-related generalization differences in autistic adults

The current study marries two important observations. First, there is a growing recognition that word meanings need to be flexibly extended in new ways as new contexts arise. Second, as evidenced primarily within the perceptual domain, autistic individuals tend to find generalization more challenging while showing stronger veridical memory in comparison to their neurotypical peers. Here we report that a group of 80 autistic adults finds it more challenging to flexibly extend the meanings of familiar words in new ways than a group of 80 neurotypical peers, while the autistic individuals outperform the neurotypicals on a novel word-learning task that does not require flexible extension. Results indicate that recognized differences in generalization present an ongoing challenge for autistic adults in the domain of language, separate from social cognition, executive function, or the ability to assign single fixed meanings to new words.

Language acquisition can be truly atypical in autism: Beyond joint attention

Language profiles in autism are variable and atypical, with frequent speech onset delays, but also, in some cases, unusually steep growth of structural language skills. Joint attention is often seen as a major predictor of language in autism, even though low joint attention is a core characteristic of autism, independent of language levels. In this systematic review of 71 studies, we ask whether, in autism, joint attention predicts advanced or only early language skills, and whether it may be independent of language outcomes. We consider only conservative estimates, and flag studies that include heterogenous samples or no control for non-verbal cognition. Our review suggests that joint attention plays a pivotal role for the emergence of language, but is also consistent with the idea that some autistic children may acquire language independently of joint attention skills. We propose that language in autism should not necessarily be modelled as a quantitative or chronological deviation from typical language development, and outline directions to bring autistic individuals' atypicality within the focus of scientific inquiry.

Rule-Governed Behavior: Teaching Social Skills via Rule-Following to Children with Autism

Rule-governed behavior (RGB) is behavior that is controlled by verbal descriptions of contingencies rather than by direct contact or a history of direct contact with the contingencies. Humans rely on RGB to navigate a multitude of life experiences, and in doing so, we avoid direct contact with destructive or harmful contingencies or contingencies that would be inefficient to contact. However, individuals with autism spectrum disorders (ASDs) frequently struggle with RGB, leaving them at increased risk of contacting aversive consequences. As a result, acquiring RGB can be a valuable developmental outcome for individuals with ASD. The current study examined the effectiveness of an intervention program designed to promote acquisition and generalization of rule-governed social skills in children with ASD. Multiple exemplar training (MET) resulted in increased performance of the target behavior as well as successful discrimination.

Effects of Rhythmic Gymnastics on Joint Attention and Emotional Problems of Autistic Children: A Preliminary Investigation

The adaptive rhythmic gymnastics (ARG) course has been specially designed for children with autism spectrum disorders (ASD). The purpose of this study is to discover the influence of the course on the joint attention and emotional problems of ASD children. This study adopted A-B-A cross-subject multibaseline design in a single case research design. The joint attention behaviour of two 6-year-old ASD children was examined. The experiment process was recorded and coded, and the results were analysed. The results illustrated the following: (1) ARG is effective in promoting the development of joint attention in ASD children, but it has a better effect on increasing responding joint attention, and (2) to a certain extent, ARG can boost the classroom participation of ASD children and improve their emotional problems.

Lexical Acquisition and Phonological Development in Minimally Verbal Children With Autism Spectrum Disorders

PURPOSE

This study examines two components of lexical acquisition and phonological development that occur during the first 50-word stage of language development in neurotypical (NT) children. One component is how children learn words based on their existing speech sound inventories (i.e., in-phonology and out-of-phonology word learning). The other component is the relationship between the children's number of words and the number of phonemes in their speech sound inventories. The goal of this study is to determine if the same two components occur in children with autism spectrum disorders (ASDs) who are older than their NT peers but are in the same stage of lexical development.

METHOD

This study involved 20 minimally verbal children with ASDs, ages 28-72 months, who produced five to 50 spoken words. The children's spoken words were obtained from the MacArthur-Bates Communicative Development Inventories. The speech sound inventories were obtained from the utterances produced during assessment/play sessions with the children. The children's spoken words from the Communicative Development Inventories (CDI) were categorized as either in-phonology or out-of-phonology based on whether the words began with a phoneme in the child's existing speech sound inventory. Additionally, the children's number of spoken words on the CDI was compared to the number of phonemes in their speech sound inventories.

RESULTS

The children in this study produced in-phonology words more often than out-of-phonology words (z = -3.922; p < .001). Moreover, there was a moderate positive correlation between the children's number of spoken words and the number of phonemes in their speech sound inventories (r = .534, p = .019).

CONCLUSIONS

The relationship between lexical acquisition and phonological development appears to exist for the children in this study, who are in the first 50-word stage of development. Clinical implications for increasing the expressive language of children with ASDs were discussed.

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.

Caregiver Language Input Supports Sentence Diversity in Young Children With Autism Spectrum Disorder

PURPOSE

Sentence diversity is a measure of early language development that has yet to be applied to individuals with autism spectrum disorder (ASD). The primary aim of this study was to identify whether children with ASD show change in sentence diversity over 6 months of treatment with Naturalistic Developmental Behavioral Intervention (NDBI). The secondary aim was to examine possible predictors of changes in children's sentence diversity, including caregiver use of NDBI strategies, naturally occurring instances of caregiver Toy Talk, and child characteristics.

METHOD

Fifty children with ASD (ages 2-4 years) and their caregivers, who were receiving NDBI, engaged in two 10-min video-recorded play interactions, 6 months apart. Child speech was transcribed and coded for sentence diversity. Caregiver input was transcribed and coded for naturally occurring Toy Talk. Zero-inflated negative binomial mixed models were used to explore predictors of change in child sentence diversity.

RESULTS

Children's sentence diversity improved over time. Changes in caregiver NDBI strategy use and caregiver baseline Toy Talk were significant predictors of changes in sentence diversity, as were baseline age, nonverbal ratio IQ, and child sex. Additionally, a significant interaction of caregiver baseline Toy Talk and change in caregiver NDBI strategies emerged; the effect of caregiver baseline Toy Talk on children's sentence diversity change was stronger when NDBI strategy use improved.

CONCLUSIONS

Sentence diversity is a developmentally sensitive measure of language development in ASD. NDBI strategies that facilitate reciprocal social communication, combined with input composed of declarative sentences with noun or third-person pronoun subjects, may provide optimal support for children's sentence development.

Short-term trajectories of restricted and repetitive behaviors in minimally verbal children with autism spectrum disorder

Very little is known about the 30% of children with Autism Spectrum Disorder (ASD) who remain minimally verbal when they enter school. Restricted and repetitive behaviors (RRBs) are well-characterized in younger, preschool, and toddler samples. However, the prevalence and impact of RRBs has not been characterized in older, minimally verbal children. The goal of this study was to characterize this core diagnostic feature in minimally verbal children with ASD ages 5-8 years over a 9-month period to better understand how these behaviors manifest in this crucially understudied population. RRBs were coded from caregiver-child interactions (CCX) at four timepoints. Upon entry into the study, children demonstrated an average of 17 RRBs during a 10-min CCX. The most common category was Verbal. RRBs remained constant over 6 months; however, a slight reduction was observed at the final timepoint. Compared to prior literature on younger samples, minimally verbal children with ASD demonstrated higher rates of RRBs and higher rates of verbal RRBs. Further work is required to understand the function and impact of RRBs in minimally verbal children. LAY ABSTRACT: Approximately one-third of children with autism spectrum disorder (ASD) remain minimally verbal at the time of school entry. In this study, we sought to characterize the presence of restricted and repetitive behaviors (RRBs) in school-aged children (5-8) who were minimally verbal. Compared to prior studies, minimally verbal children with ASD had higher frequencies of RRBs and demonstrated a different profile of behaviors, including more verbal RRBs.

Autism-Centered Therapy for Childhood Apraxia of Speech (ACT4CAS): A Single-Case Experimental Design Study

Purpose A subset of children with autism spectrum disorder (ASD) has speech sound disorders, including childhood apraxia of speech (CAS). To date, virtually all speech treatment studies consider ASD an exclusionary criterion, resulting in little scientific evidence for treatment of CAS for children who also have ASD. This study proposes and tests a novel approach, Autism-Centered Therapy for Childhood Apraxia of Speech (ACT4CAS), as a theoretically and clinically informed speech treatment option for this population. Method Using a multiple-baseline design within and across participants, three children with co-occurring ASD and CAS received 11-18 treatment sessions. Treatment targets were individually designed and matched with untreated control words. Probes were administered at the start of each session to assess speech production accuracy perceptually. Changes in production accuracy were examined through visual inspection and quantified with effect sizes. Results Findings were mixed, with one child showing significant gains for half of the treated targets at follow-up and two children showing no clear improvement. Conclusions Preliminary evidence suggests potentially positive treatment effects for ACT4CAS when implemented as intended, although treatment intensity and disorder severity likely influence treatment outcome. Replication and comparison of ACT4CAS to other speech treatments is needed. Supplemental Material https://doi.org/10.23641/asha.14110445.

An Evaluation of Reinforcer Magnitude and Echoic Prompts on Vocal Requesting of Individuals with Autism Spectrum Disorder

Individuals with autism spectrum disorder (ASD) often have communication support needs and many rely on augmentative and alternative communication (AAC) systems to communicate. Previous research suggests that AAC use does not preclude the acquisition of spoken language and, in some cases, may facilitate improvements in spoken communication in children with ASD. This study systematically applied echoic prompting and manipulated reinforcer magnitude in an effort to increase the spoken requests of 3 children with ASD, ages 10-12 years, who used iPad-based speech generating devices (SGDs). The spoken language (vocal requests) of all 3 participants increased in frequency and 1 participant began using spoken language exclusively, even when the SGD was an option. Implications for practitioners and directions for future research in this area are discussed.

Looking back and moving forward: A scoping review of research on preschool autism interventions in the field of speech-language pathology

BACKGROUND & AIMS

Speech-language pathology services are frequently accessed by families of children who have suspected or diagnosed autism. This is expected given that social communication differences are a core feature of autism. This review looked broadly at the state of research in the field of speech-language pathology and preschool autism interventions in order to identify the types of studies that could be used to inform the practices of speech-language pathologists (SLPs), and to identify gaps in the field so they can be addressed in future research. Specifically, we examined the extent of research conducted on interventions delivered (at least in part) by SLPs to preschool children with suspected or diagnosed autism, identified the range of skill development areas targeted within the studies, and explored the characteristics of the interventions (i.e., theoretical models underlying the programs, service delivery models, treatment dosage).

METHODS

A scoping review of articles published between 1980 and 2019 was conducted using the five phases outlined by the Arksey and O'Malley framework: (a) articulating the research question; (b) identifying relevant studies; (c) selecting studies; (d) charting the data; and (e) collating, summarizing, and reporting the results.

MAIN CONTRIBUTION/RESULTS

A total of 114 studies met inclusion criteria with most published since 2010 and conducted within North America. Case study or single-subject study designs were the most frequently used. Interventions delivered solely by SLPs and by multiprofessional teams that included SLPs were relatively equally represented. Across the included studies, nine skill development areas were targeted, but interventions targeting social communication, language, and augmentative communication skills made up the vast majority of studies. There was relatively even distribution of interventions informed by child-centered, clinician-directed, and hybrid models. Explicit information detailing intervention characteristics (e.g., treatment dosage, professional training of clinicians delivering the intervention) was poorly reported in many studies. For those studies providing details, there was a great deal of variability in the nature of interventions (e.g., service delivery models, SLPs' role, dosage).

CONCLUSIONS

This review revealed that research in the area of autism interventions delivered, at least in part, by SLPs has markedly increased over the past 10 years. Still, there remains a need for more research, and greater transparency detailing the nature of the interventions being investigated. The research conducted to date captures the versatility of the SLP's role within preschool autism intervention. Improved reporting and studies with strong methodological rigor focused on capturing the complex and individualized nature of interventions are needed, as are intervention studies aligned with real-world community practice.

IMPLICATIONS

This review provides a comprehensive examination of the status of research on preschool interventions delivered to children with suspected or diagnosed autism within the field of speech-language pathology. Several directions for future research are provided, as are suggestions for improving the clinical applicability of results to further the development of effective, evidence-informed policy and practice in speech-language pathology.

Feasibility of an app-based parent-mediated speech production intervention for minimally verbal autistic children: development and pilot testing of a new intervention

BACKGROUND

Training speech production skills may be a valid intervention target for minimally verbal autistic children. Intervention studies have explored various approaches albeit on a small scale and with limited experimental control or power. We therefore designed a novel app-based parent-mediated intervention based on insights from the video modelling and cued articulation literature and tested its acceptability and usage.

METHODS

Consultation with the autism community refined the initial design and culminated in a pilot trial (n = 19) lasting 16 weeks. Participants were randomly allocated an intervention duration in an AB phase design and undertook weekly probes during baseline and intervention via the app. We evaluated the acceptability of the intervention via feedback questionnaires and examined the usability variables such as adherence to the testing and intervention schedule, time spent on the app and trials completed during the intervention phase.

RESULTS

High acceptability scores indicated that families liked the overall goals and features of the app. Ten participants engaged meaningfully with the app, completing 82% of the test trials and uploading data in 61% of intervention weeks; however, of these, only three met the targeted 12.5 min of intervention per week.

CONCLUSION

We discuss the possible reasons for variability in usage data and how barriers to participation could be surmounted in the future development of this intervention.

Differences in Language Ability and Emotional-Behavioral Problems according to Symptom Severity in Children with Autism Spectrum Disorder

PURPOSE

The aim of this study was to investigate differences in language ability and emotional-behavioral problems according to the severity of social communication impairments (SCI) and restricted and repetitive behaviors (RRB) in children with autism spectrum disorders (ASD).

MATERIALS AND METHODS

We grouped 113 children with ASD aged 3-12 years according to the severity of SCI and RRB, and investigated language differences and emotional-behavioral problems among the severity groups. If differences in language abilities between the groups were observed, they were further subdivided to examine possible predictors of both receptive and expressive language abilities.

RESULTS

In cluster analyses using subdomains of the Autism Diagnostic Interview-revised, severe SCI individuals showed lower language ability than their milder counterparts, while RRB showed no differences. Receptive and expressive language in the severe SCI group was negatively predicted by social communication and social motivation, respectively. The severe RRB group showed significantly higher levels of anxiety/distress, somatic complaints, thought problems, attention problems, and aggressive behavior, while the severe SCI group was reported to be more withdrawn.

CONCLUSION

The results of this study suggest that the severity of SCI greatly affects language ability. In children with severe SCI, social communication and social motivation negatively predicted receptive language and expressive language, respectively. Children with severe RRB may have more emotional-behavioral problems that require active intervention.

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

Expressive language and communication are among the key targets of interventions for individuals with autism spectrum disorder (ASD), and natural language samples provide an optimal approach for their assessment. Currently, there are no protocols for collecting such samples that cover a wide range of ages or language abilities, particularly for children/adolescents who have very limited spoken language. We introduce a new protocol for collecting language samples, eliciting language samples for analysis (ELSA), and a novel approach for deriving basic measures of verbal communicative competence from it that bypasses the need for time-consuming transcription. Study 1 presents ELSA-adolescents (ELSA-A), designed for minimally and low-verbal older children/adolescents with ASD. The protocol successfully engaged and elicited speech from 46 participants across a wide range of ages (6;6-19;7) with samples averaging 20-25 min. The collected samples were segmented into speaker utterances (examiner and participant) using real-time coding as one is listening to the audio recording and two measures were derived: frequency of utterances and conversational turns per minute. These measures were shown to be reliable and valid. For Study 2, ELSA was adapted for younger children (ELSA-Toddler [ELSA-T]) with samples averaging 29 min from 19 toddlers (2;8-4;10 years) with ASD. Again, measures of frequency of utterances and conversational turns derived from ELSA-T were shown to have strong psychometric properties. In Study 3, we found that ELSA-A and ELSA-T were equivalent in eliciting language from 17 children with ASD (ages: 4;0-6;8), demonstrating their suitability for deriving robust objective assessments of expressive language that could be used to track change in ability over time. We introduce a new protocol for collecting expressive language samples, ELSA, that can be used with a wide age range, from toddlers (ELSA-T) to older adolescents (ELSA-A) with ASD who have minimal or low-verbal abilities. The measures of language and communication derived from them, frequency of utterances, and conversational turns per minute, using real-time coding methods, can be used to characterize ability and chart change in intervention research. LAY SUMMARY: We introduce a new protocol for collecting expressive language samples, ELSA, that can be used with a wide age range, from toddlers (ELSA-T) to older adolescents (ELSA-A) with autism spectrum disorder who have minimal or low-verbal abilities. The measures of language and communication derived from them, frequency of utterances and conversational turns per minute, using real-time coding methods, can be used to characterize ability and chart change in intervention research.

Examining Useful Spoken Language in a Minimally Verbal Child With Autism Spectrum Disorder: A Descriptive Clinical Single-Case Study

Purpose This was a companion study to a previous one (Biller & Johnson, 2019). The purpose was to develop a detailed descriptive profile of a minimally verbal child with a unique medical history and autism spectrum disorder (ASD). The present report describes his social-cognitive and speech sound production abilities in relation to his potentially burgeoning spoken language. Method This in-depth, descriptive, clinical single-case study focused on a 3-year-old boy who was diagnosed with a chromosomal abnormality and ASD. The size of his spoken vocabulary fell at the upper limit for classifying a child as minimally verbal. His demographic information was obtained, in addition to general information from his mother. Four social-cognitive and three speech sound production abilities were assessed, as well as his overall performance in both domains. The study included a parent interview and two child assessment sessions. Results The child exhibited low social-cognitive and speech sound production abilities for his age, with social-cognitive abilities higher than speech sound production abilities. Comparison with the previous study revealed substantial gaps in social cognition and speech sound production between this child and five other minimally verbal children with ASD. His higher abilities in these two domains co-occurred with his larger spoken vocabulary size. Conclusions Although the child's social-cognitive abilities were low for his age, with his speech sound production abilities even lower, both domains were perhaps high enough to support spoken vocabulary at the upper limit for minimally verbal children. Indeed, there appeared to be quantitative and qualitative differences between him and other minimally verbal children in the previous study. The possibility was explored that there is a point or threshold along the developmental continua for social cognition and speech sound production that allows for expansion into useful language.

Language Growth in Young Children with Autism: Interactions Between Language Production and Social Communication

Young children with autism spectrum disorder (ASD) present with a broad range of spoken language abilities, as well as delays in precursor skills such as gesture production and joint attention skills. While standardized assessments describe language strengths, the Communication and Symbolic Behavior Scales (CSBS-DP) is a particularly robust measure as it additionally characterizes precise aspects of social communication. This study provides a unique contribution by assessing the interactional effects of CSBS-DP Social Composite performance with early language samples on later language outcomes. Our results indicate that multiple social communication elements significantly interact with early spoken language to predict later language. Our findings also highlight the transactional relationship between early spoken vocabulary and social communication skills that bolster language development growth.

Intervention Effects on Language in Children With Autism: A Project AIM Meta-Analysis

Purpose This study synthesized effects of interventions on language outcomes of young children (ages 0-8 years) with autism and evaluated the extent to which summary effects varied by intervention, participant, and outcome characteristics. Method A subset of effect sizes gathered for a larger meta-analysis (the Autism Intervention Meta-analysis or Project AIM) examining the effects of interventions for young children with autism, which were specific to language outcomes, was analyzed. Robust variance estimation and metaregression were used to calculate summary and moderated effects while controlling for intercorrelation among outcomes within studies. Results A total of 221 outcomes were gathered from 60 studies. The summary effect of intervention on language outcomes was small but significant. Summary effects were larger for expressive and composite language outcomes compared to receptive language outcomes. Interventions implemented by clinicians, or by clinicians and caregivers together, had summary effects that were significantly larger than interventions implemented by caregivers alone. Participants' pretreatment language age equivalent scores positively and significantly moderated intervention effects, such that effects were significantly larger on average when samples of children had higher pretreatment language levels. Effects were not moderated by cumulative intervention intensity, intervention type, autism symptomatology, chronological age, or the proximity or boundedness of outcomes. Study quality concerns were apparent for a majority of included outcomes. Conclusions We found evidence that intervention can facilitate improvements in language outcomes for young children with autism. Effects were largest for expressive and composite language outcomes, for children with initially higher language abilities, and for interventions implemented by clinicians or by caregivers and clinicians combined. However, quality concerns of included studies and borderline significance of some results temper our conclusions regarding intervention effectiveness and corresponding moderators.

Identifying prognostic markers in autism spectrum disorder using eye tracking

While many children with autism spectrum disorder are now detected at young ages given the rise in screening and general awareness, little is known regarding the prognosis of early detected children. The brain is shaped by experience-dependent mechanisms; thus, what a child pays attention to plays a pivotal role in shaping brain development. Eye tracking can provide an index of a child's visual attention and, as such, holds promise as a technology for revealing prognostic markers. In this, 49 children aged 1-3 years with autism spectrum disorder participated in an eye-tracking test, the GeoPref Test, that revealed preference for social versus nonsocial images. Next, children participated in a comprehensive test battery 5-9 years following the initial GeoPref Test. Statistical tests examined whether early age eye tracking predicted later school-age outcomes in symptom severity, social functioning, adaptive behavior, joint attention, and IQ. Results indicated that toddlers with higher preference for geometric images demonstrated greater symptom severity and fewer gaze shifts at school age. This relationship was not found in relation to IQ or adaptive behavior. Overall, the GeoPref Test holds promise as a symptom severity prognostic tool; further development of eye-tracking paradigms may enhance prognostic power and prove valuable in validating treatment progress.

Social-Cognitive and Speech Sound Production Abilities of Minimally Verbal Children With Autism Spectrum Disorders

Purpose To date, there has been a dearth of systematic research that examines both social-cognitive (SC) and speech sound production (SSP) abilities simultaneously in minimally verbal (MV) children with autism spectrum disorders (ASDs). Such an analysis would allow a unified and comprehensive view of the children's communication abilities. The purpose of this study was to develop detailed descriptive profiles of MV children with ASD and uncover patterns in their SC and SSP abilities that may pertain to spoken language. Method This study was a descriptive, multiple clinical case study that examined 5 MV children with ASD, 4 boys and 1 girl, aged 3-6 years. The case studies consisted of demographic information, parent report, and formal and informal assessment of the children. Four SC abilities and 3 SSP abilities were assessed. Results The 5 children's SC score, SSP score, and number of spoken words were converted to z scores. This analysis revealed 2 different patterns of development: 3 of the children had lower SC than SSP abilities, and 2 of the children had the reverse pattern. Conclusions The 5 children were low in both SC and SSP abilities. Although both domains were low, the measure that coincided most with spoken vocabulary among the 5 children was their SSP abilities. Specifically, the children had difficulty in demonstrating emerging control of the onset of voicing for specific speech sounds and verbal imitation of single speech sounds and syllables. Clinical implications of simultaneously assessing and treating SC and SSP abilities in MV children are discussed.

Predictors and growth in receptive vocabulary from 4 to 8 years in children with and without autism spectrum disorder: A population-based study

Few studies have examined growth and predictors of receptive vocabulary in children with autism spectrum disorder. Here we aimed to compare receptive vocabulary from 4 to 8 years and identify predictors of receptive vocabulary, at 8 years, in children with and without autism spectrum disorder. Participants were drawn from a nationally representative population-based study with two cohorts recruited at birth (N = 4983) and kindergarten (N = 5107). Receptive vocabulary growth was compared for children with and without autism spectrum disorder at 4 (n = 188, n = 7136), 6 (n = 215, n = 7297) and 8 (n = 216, n = 7408) years. Predictors of receptive vocabulary were analysed. Estimated mean receptive vocabulary scores for children without autism spectrum disorder were 2.3 units higher than the autism spectrum disorder group across three time points. This difference was significant (p = 0.004; 95% confidence interval 0.769-3.927). Children with and without autism spectrum disorder progressed at a similar pace. There was no significant difference between the proportions of children with and without autism spectrum disorder who had stable, improving and declining trajectories. Age was the only significant predictor of greater receptive vocabulary growth in children with autism spectrum disorder. Baseline receptive language and nonverbal IQ were significant predictors of receptive vocabulary ability at 8 years. These findings inform prognostic advice given to families on language outcomes.

Communication interventions for autism spectrum disorder in minimally verbal children

BACKGROUND

Autism spectrum disorder (ASD) has an estimated prevalence of around 1.7% of the population. People with ASD often also have language difficulties, and about 25% to 30% of children with ASD either fail to develop functional language or are minimally verbal. The ability to communicate effectively is an essential life skill, and difficulties with communication can have a range of adverse outcomes, including poorer academic achievement, behavioural difficulties and reduced quality of life. Historically, most studies have investigated communication interventions for ASD in verbal children. We cannot assume the same interventions will work for minimally verbal children with ASD.

OBJECTIVES

To assess the effects of communication interventions for ASD in minimally verbal children.

SEARCH METHODS

We searched CENTRAL, MEDLINE and Embase as well as 12 other databases and three trials registers in November 2017. We also checked the reference lists of all included studies and relevant reviews, contacting experts in the field as well as authors of identified studies about other potentially relevant ongoing and unpublished studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of communication-focused interventions for children (under 12 years of age) diagnosed with ASD and who are minimally verbal (fewer than 30 functional words or unable to use speech alone to communicate), compared with no treatment, wait-list control or treatment as usual.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodological procedures.

MAIN RESULTS

This review includes two RCTs (154 children aged 32 months to 11 years) of communication interventions for ASD in minimally verbal children compared with a control group (treatment as usual). One RCT used a verbally based intervention (focused playtime intervention; FPI) administered by parents in the home, whereas the other used an alternative and augmentative communication (AAC) intervention (Picture Exchange Communication System; PECS) administered by teachers in a school setting.The FPI study took place in the USA and included 70 participants (64 boys) aged 32 to 82 months who were minimally verbal and had received a diagnosis of ASD. This intervention focused on developing coordinated toy play between child and parent. Participants received 12 in-home parent training sessions for 90 minutes per session for 12 weeks, and they were also invited to attend parent advocacy coaching sessions. This study was funded by the National Institute of Child Health and Human Development, the MIND Institute Research Program and a Professional Staff Congress-City University of New York grant. The PECS study included 84 minimally verbal participants (73 boys) aged 4 to 11 years who had a formal diagnosis of ASD and who were not using PECS beyond phase 1 at baseline. All children attended autism-specific classes or units, and most classes had a child to adult ratio of 2:1. Teachers and parents received PECS training (two-day workshop). PECS consultants also conducted six half-day consultations with each class once per month over five months. This study took place in the UK and was funded by the Three Guineas Trust.Both included studies had high or unclear risk of bias in at least four of the seven 'Risk of bias' categories, with a lack of blinding for participants and personnel being the most problematic area. Using the GRADE approach, we rated the overall quality of the evidence as very low due to risk of bias, imprecision (small sample sizes and wide confidence intervals) and because there was only one trial identified per type of intervention (i.e. verbally based or AAC).Both studies focused primarily on communication outcomes (verbal and non-verbal). One of the studies also collected information on social communication. The FPI study found no significant improvement in spoken communication, measured using the expressive language domain of the Mullen Scale of Early Learning expressive language, at postintervention. However, this study found that children with lower expressive language at baseline (less than 11.3 months age-equivalent) improved more than children with better expressive language and that the intervention produced expressive language gains in some children. The PECS study found that children enrolled in the AAC intervention were significantly more likely to use verbal initiations and PECS symbols immediately postintervention; however, gains were not maintained 10 months later. There was no evidence that AAC improved frequency of speech, verbal expressive vocabulary or children's social communication or pragmatic language immediately postintervention. Overall, neither of the interventions (PECS or FPI) resulted in maintained improvements in spoken or non-verbal communication in most children.Neither study collected information on adverse events, other communication skills, quality of life or behavioural outcomes.

AUTHORS' CONCLUSIONS

There is limited evidence that verbally based and ACC interventions improve spoken and non-verbal communication in minimally verbal children with ASD. A substantial number of studies have investigated communication interventions for minimally verbal children with ASD, yet only two studies met inclusion criteria for this review, and we considered the overall quality of the evidence to be very low. In the study that used an AAC intervention, there were significant gains in frequency of PECS use and verbal and non-verbal initiations, but not in expressive vocabulary or social communication immediately postintervention. In the study that investigated a verbally based intervention, there were no significant gains in expressive language postintervention, but children with lower expressive language at the beginning of the study improved more than those with better expressive language at baseline. Neither study investigated adverse events, other communication skills, quality of life or behavioural outcomes. Future RCTs that compare two interventions and include a control group will allow us to better understand treatment effects in the context of spontaneous maturation and will allow further comparison of different interventions as well as the investigation of moderating factors.

Behavioral predictors of improved speech output in minimally verbal children with autism

We investigated the relationship between eight theoretically motivated behavioral variables and a spoken-language-related outcome measure, after 25 sessions of treatment for speech production in 38 minimally verbal children with autism. After removing potential predictors that were uncorrelated with the outcome variable, two remained. We used both complete-case and multiple-imputation analyses to address missing predictor data and performed linear regressions to identify significant predictors of change in percent syllables approximately correct after treatment. Baseline phonetic inventory (the number of English phonemes repeated correctly) was the most robust predictor of improvement. In the group of 17 participants with complete data, ADOS score also significantly predicted the outcome. In contrast to some earlier studies, nonverbal IQ, baseline levels of expressive language, and younger age did not significantly predict improvement. The present results are not only consistent with previous studies showing that verbal imitation and autism severity significantly predict spoken language outcomes in preschool-aged minimally verbal children with autism, but also extend these findings to older minimally verbal children with autism. Autism Res 2018, 11: 1356-1365. © 2018 International Society for Autism Research, Wiley Periodicals, Inc. LAY SUMMARY: We wished to understand what baseline factors predicted whether minimally verbal children with autism would improve after treatment for spoken language. The outcome measure was change in percentage (%) syllables approximately correct on a set of 30 two-syllable words or phrases. Fifteen were both practiced in treatment and tested; the remainder were not practiced in treatment, but only tested, to assess how well children were able to generalize their new skills to an untrained set of words. Potential predictors tested were sex, age, expressive language, phonetic inventory (the number of English speech sounds repeated correctly), autism severity, and nonverbal IQ. Phonetic inventory and (for some children) autism severity predicted children's posttreatment improvement. Nonverbal IQ and expressive language ability did not predict improvement, nor did younger age, suggesting that some older children with autism may be candidates for speech therapy.

Parent-Mediated Intervention for One-Year-Olds Screened as At-Risk for Autism Spectrum Disorder: A Randomized Controlled Trial

Theoretically, interventions initiated with at-risk infants prior to the point in time a definitive autism spectrum disorder (ASD) diagnosis can be made will improve outcomes. Pursuing this idea, we tested the efficacy of a parent-mediated early intervention called Adapted Responsive Teaching (ART) via a randomized controlled trial with 87 one-year-olds identified by community screening with the First Year Inventory as at-risk of later ASD diagnoses. We found minimal evidence for main effects of ART on child outcomes. However, ART group parents showed significantly greater increases in responsiveness to their infants than control group parents. Further, significant indirect (mediation) effects of assignment group on multiple child outcomes through changes in parent responsiveness supported our theory of change.

Naturalistic language sampling to characterize the language abilities of 3-year-olds with autism spectrum disorder

Characterization of language in naturalistic settings in autism spectrum disorder has been lacking, particularly at young ages, but such information is important for parents, teachers, and clinicians to better support language development in real-world settings. Factors contributing to this lack of clarity include conflicting definitions of language abilities, use of non-naturalistic standardized assessments, and restricted samples. The current study examined one of the largest datasets of naturalistic language samples in toddlers with autism spectrum disorder, and language delay and typically developing contrast groups at age 3. A range of indices including length of phrase, grammatical markings, and social use of language was assayed during a naturalistic observation of a parent-child play session. In contrast to historical estimates, results indicated only 3.7% of children with autism spectrum disorder used no words, and 34% were minimally verbal. Children with autism spectrum disorder and language delay exhibited similar usage of grammatical markings, although both were reduced compared to typically developing children. The greatest difference between autism spectrum disorder and language delay groups was the quantity of social language. Overall, findings highlight a range of language deficits in autism spectrum disorder, but also illustrate that the most severe level of impairments is not as common in naturalistic settings as previously estimated by standardized assessments.

From intuition to intervention: developing an intonation-based treatment for autism

Autism affects ∼1.5% of children under age 8; its core symptoms include impairment in social-communicative functioning and repetitive behaviors/restricted interests. Music-based interventions have been considered one modality through which to treat autism. This report discusses considerations to take into account when developing a music-based intervention for a core symptom of autism. Treatment modality must be matched to symptom both clinically and theoretically, the behavior to be treated must be carefully defined and assessed, and outcome measures must be capable of showing improvement in that behavior over the course of the study. Fidelity assessment and rater blinding reduce experimenter bias. High inter-rater reliability for perceptually determined outcome measures helps obtain accurate estimates of treatment response. Later stages of testing compare the experimental intervention to matched control treatments or other validated therapies, isolating the intervention's "active ingredients." Such systematic investigation of a new music-based intervention can provide information of different types, ranging from an assessment of whether the intervention has any effect at all to an assessment of its outcomes and risks in uncontrolled community settings. Findings ultimately compose the evidence base that clinicians and families can use to decide the most effective way of addressing symptoms of autism for particular children.

Semantic richness and word learning in children with autism spectrum disorder

Semantically rich learning contexts facilitate semantic, phonological, and articulatory aspects of word learning in children with typical development (TD). However, because children with autism spectrum disorder (ASD) show differences at each of these processing levels, it is unclear whether they will benefit from semantic cues in the same manner as their typical peers. The goal of this study was to track how the inclusion of rich, sparse, or no semantic cues influences semantic, phonological, and articulatory aspects of word learning in children with ASD and TD over time. Twenty-four school-aged children (12 in each group), matched on expressive vocabulary, participated in an extended word learning paradigm. Performance on five measures of learning (referent identification, confrontation naming, defining, phonetic accuracy, and speech motor stability) were tracked across three sessions approximately one week apart to assess the influence of semantic richness on extended learning. Results indicate that children with ASD benefit from semantically rich learning contexts similarly to their peers with TD; however, one key difference between the two groups emerged - the children with ASD showed heightened shifts in speech motor stability. These findings offer insights into common learning mechanisms in children with ASD and TD, as well as pointing to a potentially distinct speech motor learning trajectory in children with ASD, providing a window into the emergence of stereotypic vocalizations in these children.

Word Processing in Children With Autism Spectrum Disorders: Evidence From Event-Related Potentials

PURPOSE

This investigation was conducted to determine whether young children with autism spectrum disorders exhibited a canonical neural response to word stimuli and whether putative event-related potential (ERP) measures of word processing were correlated with a concurrent measure of receptive language. Additional exploratory analyses were used to examine whether the magnitude of the association between ERP measures of word processing and receptive language varied as a function of the number of word stimuli the participants reportedly understood.

METHOD

Auditory ERPs were recorded in response to spoken words and nonwords presented with equal probability in 34 children aged 2-5 years with a diagnosis of autism spectrum disorder who were in the early stages of language acquisition. Average amplitudes and amplitude differences between word and nonword stimuli within 200-500 ms were examined at left temporal (T3) and parietal (P3) electrode clusters. Receptive vocabulary size and the number of experimental stimuli understood were concurrently measured using the MacArthur-Bates Communicative Development Inventories.

RESULTS

Across the entire participant group, word-nonword amplitude differences were diminished. The average word-nonword amplitude difference at T3 was related to receptive vocabulary only if 5 or more word stimuli were understood.

CONCLUSIONS

If ERPs are to ever have clinical utility, their construct validity must be established by investigations that confirm their associations with predictably related constructs. These results contribute to accruing evidence, suggesting that a valid measure of auditory word processing can be derived from the left temporal response to words and nonwords. In addition, this measure can be useful even for participants who do not reportedly understand all of the words presented as experimental stimuli, though it will be important for researchers to track familiarity with word stimuli in future investigations.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.5614840.

A systematic review and evaluation of procedures for the induction of speech among persons with developmental disabilities

OBJECTIVE

Deficits in vocal speech are common among those with developmental disabilities. This review examines interventions for teaching speech to individuals who presented as nonspeaking, or with low levels of vocalizations at baseline, and assesses evidence-based practice in this area.

METHODS

Systematic searches identified 78 studies suitable for inclusion. These studies were evaluated in terms of (a) participants, (b) intervention, (c) intervention setting, (d) intervention agent, (e) treatment efficacy, (f) generalization and maintenance of treatment effects, and (g) research rigor.

RESULTS

A variety of interventions, primarily behavioral, intended to induce vocal speech were delivered to participants with developmental disabilities aged between six months and 57 years. Treatment efficacy was variable (PND M = 52.9%; range 0%-100%); however, results indicated that behavioral interventions constituted evidence-based practice. Non-behavioral strategies were shown to have received insufficient research evaluation to date.

CONCLUSION

Results indicate that a number of procedures can induce speech among individuals with developmental disabilities.

White Matter Integrity and Treatment-Based Change in Speech Performance in Minimally Verbal Children with Autism Spectrum Disorder

We investigated the relationship between imaging variables for two language/speech-motor tracts and speech fluency variables in 10 minimally verbal (MV) children with autism. Specifically, we tested whether measures of white matter integrity—fractional anisotropy (FA) of the arcuate fasciculus (AF) and frontal aslant tract (FAT)—were related to change in percent syllable-initial consonants correct, percent items responded to, and percent syllable insertion errors (from best baseline to post 25 treatment sessions). Twenty-three MV children with autism spectrum disorder (ASD) received Auditory-Motor Mapping Training (AMMT), an intonation-based treatment to improve fluency in spoken output, and we report on seven who received a matched control treatment. Ten of the AMMT participants were able to undergo a magnetic resonance imaging study at baseline; their performance on baseline speech production measures is compared to that of the other two groups. No baseline differences were found between groups. A canonical correlation analysis (CCA) relating FA values for left- and right-hemisphere AF and FAT to speech production measures showed that FA of the left AF and right FAT were the largest contributors to the synthetic independent imaging-related variable. Change in percent syllable-initial consonants correct and percent syllable-insertion errors were the largest contributors to the synthetic dependent fluency-related variable. Regression analyses showed that FA values in left AF significantly predicted change in percent syllable-initial consonants correct, no FA variables significantly predicted change in percent items responded to, and FA of right FAT significantly predicted change in percent syllable-insertion errors. Results are consistent with previously identified roles for the AF in mediating bidirectional mapping between articulation and acoustics, and the FAT in its relationship to speech initiation and fluency. They further suggest a division of labor between the hemispheres, implicating the left hemisphere in accuracy of speech production and the right hemisphere in fluency in this population. Changes in response rate are interpreted as stemming from factors other than the integrity of these two fiber tracts. This study is the first to document the existence of a subgroup of MV children who experience increases in syllable- insertion errors as their speech develops in response to therapy.

Auditory-Motor Mapping Training: Comparing the Effects of a Novel Speech Treatment to a Control Treatment for Minimally Verbal Children with Autism

This study compared Auditory-Motor Mapping Training (AMMT), an intonation-based treatment for facilitating spoken language in minimally verbal children with autism spectrum disorder (ASD), to a matched control treatment, Speech Repetition Therapy (SRT). 23 minimally verbal children with ASD (20 male, mean age 6;5) received at least 25 sessions of AMMT. Seven (all male) were matched on age and verbal ability to seven participants (five male) who received SRT. Outcome measures were Percent Syllables Approximated, Percent Consonants Correct (of 86), and Percent Vowels Correct (of 61) produced on two sets of 15 bisyllabic stimuli. All subjects were assessed on these measures several times at baseline and after 10, 15, 20, and 25 sessions. The post-25 session assessment timepoint, common to all participants, was compared to Best Baseline performance. Overall, after 25 sessions, AMMT participants increased by 19.4% Syllables Approximated, 13.8% Consonants Correct, and19.1% Vowels Correct, compared to Best Baseline. In the matched AMMT-SRT group, after 25 sessions, AMMT participants produced 29.0% more Syllables Approximated (SRT 3.6%);17.9% more Consonants Correct (SRT 0.5); and 17.6% more Vowels Correct (SRT 0.8%). Chi-square tests showed that significantly more AMMT than SRT participants in both the overall and matched groups improved significantly in number of Syllables Approximated per stimulus and number of Consonants Correct per stimulus. Pre-treatment ability to imitate phonemes, but not chronological age or baseline performance on outcome measures, was significantly correlated with amount of improvement after 25 sessions. Intonation-based therapy may offer a promising new interventional approach for teaching spoken language to minimally verbal children with ASD.

The proportion of minimally verbal children with autism spectrum disorder in a community-based early intervention programme

BACKGROUND

Estimates of the proportion of children with autism spectrum disorder (ASD) who are minimally verbal vary from 25%to 35%. However, there is a lack of consensus in defining minimally verbal and few detailed reports of communication outcomes for these children following intervention. The aim of this study was to explore how minimally verbal children have been defined and to document the proportion of minimally verbal children in a group of children with ASD receiving a community based early intervention programme.

METHOD

A longitudinal cohort design was used to examine the proportion of children who met criteria for minimally verbal in 246 children with ASD when they entered and exited an early intervention programme.

RESULTS

Overall, 26.3% of the children in this study exited the programme using 'fewer than five spontaneous and functional words' and 36.4% exited not using 'two word phrases' as indicated by direct assessment. However, our findings were mixed depending on measures and definitions used, with parent report indicating that as many as 29.4% of children were not 'naming at least three objects' consistently, and 43.3% not using 'phrases with a noun and verb' consistently at exit. More than half of the children who entered the programme with minimal speech exited the programme with a similar language profile. A small percentage of children (1.2%-4.7%) regressed in their language level over time.

CONCLUSIONS

Despite advances in early intervention, and access to services at a younger age, around a quarter of individuals with ASD in this study exited early intervention with significant communication needs. Our findings are considered in relation to the literature and clinical implications, and future research directions are discussed.

Parents' Adoption of Social Communication Intervention Strategies: Families Including Children with Autism Spectrum Disorder Who are Minimally Verbal

Notably absent from the intervention literature are parent training programs targeting school-aged children with autism who have limited communication skills (Tager-Flusberg and Kasari in Autism Res 6:468-478, 2013). Sixty-one children with autism age 5-8 with minimal spontaneous communication received a 6-month social communication intervention including parent training. Parent-child play interactions were coded for parents' strategy implementation and children's time jointly engaged (Adamson et al. in J Autism Dev Disord 39:84-96, 2009). Parents mastered an average of 70% of the strategies. Further analyses indicated some gains in implementation occurred from mere observation of sessions, while the greatest gains occurred in the first month of active coaching and workshops. Children's joint engagement was associated with parents' implementation success across time demonstrating parents' implementation was relevant to children's social engagement.

Preschool language variation, growth, and predictors in children on the autism spectrum

BACKGROUND

There is wide variation in language abilities among young children with autism spectrum disorders (ASD), with some toddlers developing age-appropriate language while others remain minimally verbal after age 5. Conflicting findings exist regarding predictors of language outcomes in ASD and various methodological issues limit the conclusions that can be drawn about factors associated with positive language growth that could provide insights into more effective intervention approaches for increasing communication skills.

METHODS

Language development was investigated in 129 children with ASD participating in four assessments from mean age 2½ years (Visit 1) through 5½ years (Visit 4). Language ability was measured by a clinician-administered test of comprehension and production. Hierarchical linear modeling was used to identify predictors of language ability. Stability of language status was examined in subgroups of Preverbal versus Verbal children identified at Visit 1. Discriminant function analysis was used to classify another subset of cases according to Low Language (minimally verbal) versus High Language outcome at Visit 4.

RESULTS

ASD severity was a significant predictor of growth in both language comprehension and production during the preschool period, while cognition predicted growth in production. For the highest and lowest language performers at Visit 4, cognition, maternal education, and response to joint attention correctly classified over 80% of total cases. The vast majority of children who were preverbal at 2½ years attained some level of verbal skills by 5½ years.

CONCLUSIONS

Findings indicate that it is possible, by 2½ years, to predict language growth for children with ASD across the preschool years and identify factors that discriminate between children who remain minimally verbal at 5½ years from those with high language proficiency. Results suggest that early intervention focused on reducing core ASD symptoms may also be important for facilitating language development in young children with ASD.

Using Spoken Language Benchmarks to Characterize the Expressive Language Skills of Young Children With Autism Spectrum Disorders

PURPOSE

Spoken language benchmarks proposed by Tager-Flusberg et al. (2009) were used to characterize communication profiles of toddlers with autism spectrum disorders and to investigate if there were differences in variables hypothesized to influence language development at different benchmark levels.

METHOD

The communication abilities of a large sample of toddlers with autism spectrum disorders (N = 105) were characterized in terms of spoken language benchmarks. The toddlers were grouped according to these benchmarks to investigate whether there were differences in selected variables across benchmark groups at a mean age of 2.5 years.

RESULTS

The majority of children in the sample presented with uneven communication profiles with relative strengths in phonology and significant weaknesses in pragmatics. When children were grouped according to one expressive language domain, across-group differences were observed in response to joint attention and gestures but not cognition or restricted and repetitive behaviors.

CONCLUSION

The spoken language benchmarks are useful for characterizing early communication profiles and investigating features that influence expressive language growth.

Methods to improve joint attention in young children with autism: a review

We provide an overview of studies in the past 10 years (2004-2014) that have aimed to improve joint attention (JA) in young children at risk for, or with, autism spectrum disorder. Thirteen randomized controlled trial (RCT) interventions were found, which received particular focus. Three studies used intervention methods with a developmental orientation and focused on caregiver-mediated methods. Others used combined developmental and behavioral approaches and delivered intervention via trained interventionists, caregivers, and teachers. Interventions ranged widely in density, both with respect to the amount of intervention delivered weekly and the total duration of intervention. Fourteen single-subject research design (SSRD) studies and one quasi-experimental pre-post design study were also included. Notably absent in the RCTs were studies using only behavioral methods, while behavioral methods dominated in the SSRDs. The outcomes of the RCTs using combined behavioral and developmental methods generally demonstrate short-term social communication gains. While some studies demonstrated long-term maintenance and positive outcomes in related areas such as language, many did not. The mixed results for language outcomes indicate a need for further investigation. In addition, future studies should further examine participants' developmental readiness and intervention dose in relation to outcome, as well as aim to isolate active ingredients of interventions.

"Look who's talking!" Gaze Patterns for Implicit and Explicit Audio-Visual Speech Synchrony Detection in Children With High-Functioning Autism

Conversation requires integration of information from faces and voices to fully understand the speaker's message. To detect auditory-visual asynchrony of speech, listeners must integrate visual movements of the face, particularly the mouth, with auditory speech information. Individuals with autism spectrum disorder may be less successful at such multisensory integration, despite their demonstrated preference for looking at the mouth region of a speaker. We showed participants (individuals with and without high-functioning autism (HFA) aged 8-19) a split-screen video of two identical individuals speaking side by side. Only one of the speakers was in synchrony with the corresponding audio track and synchrony switched between the two speakers every few seconds. Participants were asked to watch the video without further instructions (implicit condition) or to specifically watch the in-synch speaker (explicit condition). We recorded which part of the screen and face their eyes targeted. Both groups looked at the in-synch video significantly more with explicit instructions. However, participants with HFA looked at the in-synch video less than typically developing (TD) peers and did not increase their gaze time as much as TD participants in the explicit task. Importantly, the HFA group looked significantly less at the mouth than their TD peers, and significantly more at non-face regions of the image. There were no between-group differences for eye-directed gaze. Overall, individuals with HFA spend less time looking at the crucially important mouth region of the face during auditory-visual speech integration, which is maladaptive gaze behavior for this type of task.

Longitudinal study of symptom severity and language in minimally verbal children with autism

BACKGROUND

A significant minority of children with autism spectrum disorder (ASD) are considered 'minimally verbal' due to language development stagnating at a few words. Recent developments allow for the severity of ASD symptoms to be examined using Autism Diagnostic Observation Schedule (ADOS) Social Affect (SA) and Restricted and Repetitive Behaviors (RRB) domain severity scores. The aim of the current study was to explore language outcomes in a cohort of minimally verbal children with autism evaluated through the preschool years and determine if and how ASD symptom severity in core domains predicts the development of spoken language by age 5.

METHODS

The sample consisted of 70 children with autism aged 1-5 years at the first evaluation who were examined at least 1 year later, during their fifth year of age. The ADOS overall level of language item was used to categorize children as minimally verbal or having phrase speech, and the Mullen Scales of Early Learning was used as a continuous measure of expressive language.

RESULTS

At Time 1, 65% (n = 47) of children in the sample were minimally verbal and by Time 2, 36% (n = 17 of 47) of them had developed phrase speech. While the Time 1 ADOS calibrated severity scores did not predict whether or not a child remained minimally verbal at Time 2, change in the SA calibrated severity score (but not RRB) was predictive of the continuous measure of expressive language. However, change in SA severity no longer predicted continuous expressive language when nonverbal cognitive ability was added to the model.

CONCLUSIONS

Findings indicate that the severity of SA symptoms has some relationship with continuous language outcome, but not categorical. However, the omnipresent influence of nonverbal cognitive ability was confirmed in the current study, as the addition of it to the model rendered null the predictive utility of SA severity.

Use of the ADOS for assessing spontaneous expressive language in young children with ASD: a comparison of sampling contexts

PURPOSE

The current study compared the spontaneous expressive language of children with autism spectrum disorder (ASD) across multiple language sampling contexts: the Autism Diagnostic Observation Schedule (ADOS; Lord, Rutter, DiLavore, & Risi, 1999) and play with an examiner or parent.

METHOD

Participants were children with ASD (n = 63; 55 boys) with a mean age of 45 months (SD = 3.94, range = 37-53). The number of utterances produced; percentage of intelligible utterances; number of different words; mean length of utterance; and the number of requests, comments, and instances of turn-taking were calculated for the ADOS, examiner-child play, and parent-child play. Children were categorized into Tager-Flusberg et al.'s (2009) developmental language phases for each context.

RESULTS

Effects of sampling context were identified for all variables examined. The ADOS resulted in fewer utterances and lower structural and pragmatic language performance than examiner-child play and/or parent-child play. Categorization of children into language phases differed across contexts.

CONCLUSIONS

Use of the ADOS as a language sampling context may lead to underestimating the abilities of young children with ASD relative to play with an examiner or parent. Researchers and clinicians should be aware of context effects, particularly for assessments designed to observe autism symptoms.

Psychosocial treatments for individuals with autism spectrum disorder across the lifespan: new developments and underlying mechanisms

Researchers have studied many interventions to address the core impairment in social interactions in autism spectrum disorder. We reviewed the social skills intervention literature over the past two years (2012-2014). Social skills intervention studies have increased by 35% over our previous review of 2010-2012. Nearly equal numbers of studies reported results using single subject research designs (n = 29) and group designs (n = 25). Consistent with our previous review, many studies focused on joint attention/joint engagement for young children and interventions addressing peer interactions for older children. Advancements in this review period included more replications of intervention models, longitudinal outcomes, and a focus on minimally verbal children. Notably absent are social interventions for adults, and interventions addressing school-based inclusion. In addition to these target areas, future studies should isolate active ingredients of social interventions, include broader participant representation, and further examine the relation between neural development and behavioral outcomes.

Communication interventions for minimally verbal children with autism: a sequential multiple assignment randomized trial

OBJECTIVE

This study tested the effect of beginning treatment with a speech-generating device (SGD) in the context of a blended, adaptive treatment design for improving spontaneous, communicative utterances in school-aged, minimally verbal children with autism.

METHOD

A total of 61 minimally verbal children with autism, aged 5 to 8 years, were randomized to a blended developmental/behavioral intervention (JASP+EMT) with or without the augmentation of a SGD for 6 months with a 3-month follow-up. The intervention consisted of 2 stages. In stage 1, all children received 2 sessions per week for 3 months. Stage 2 intervention was adapted (by increased sessions or adding the SGD) based on the child's early response. The primary outcome was the total number of spontaneous communicative utterances; secondary measures were the total number of novel words and total comments from a natural language sample.

RESULTS

Primary aim results found improvements in spontaneous communicative utterances, novel words, and comments that all favored the blended behavioral intervention that began by including an SGD (JASP+EMT+SGD) as opposed to spoken words alone (JASP+EMT). Secondary aim results suggest that the adaptive intervention beginning with JASP+EMT+SGD and intensifying JASP+EMT+SGD for children who were slow responders led to better posttreatment outcomes.

CONCLUSION

Minimally verbal school-aged children can make significant and rapid gains in spoken spontaneous language with a novel, blended intervention that focuses on joint engagement and play skills and incorporates an SGD. Future studies should further explore the tailoring design used in this study to better understand children's response to treatment. Clinical trial registration information-Developmental and Augmented Intervention for Facilitating Expressive Language (CCNIA); http://clinicaltrials.gov/; NCT01013545.

How relevant is the framework being used with autism spectrum disorders today?

Camarata (2014) provides a comprehensive summary of the current state of the research on early identification and intervention for children with autism spectrum disorders (ASD). Extending on the foundations provided by Camarata, this commentary discusses the value of a diagnosis of ASD and questions whether there is sufficient evidence on which to base continuing calls for early identification and ASD-specific intervention. Gaps are highlighted in the evidence base, suggestions made about how to fill those gaps, and an alternative framework is proposed for achieving best outcomes for children with early developmental problems of the type seen in ASD and their families.