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Increase Expressive Communication in Individuals with ASD - October 2008

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From the Abstract to the Concrete: Five Therapy Techniques to Increase Expressive Communication in Individuals with Autism Spectrum Disorder

By: Don D'Amore, MA, CCC-SLP

Planning effective Speech-Language therapy sessions for young clients with Autism Spectrum Disorder (ASD) or other disabilities that limit expressive language skills, can often be a daunting task for many Speech-Language Pathologists (SLPs).

Countless SLPs across the country are now finding their caseloads are including an increasing number of clients with ASD and those requiring the use of Augmentative Alternative Communication (AAC). Clinicians may discover that despite their many years in the profession, they may have had few prior firsthand experiences with this type of pervasive developmental disability.

I have been a Speech-Language Pathologist for over 22 years, and have specialized in Alternative/Augmentative Communication for a large urban school district for the past ten years. Working with school teams to find effective approaches to teaching individuals with ASD how to communicate effectively has been a crucial and continuous aspect of my work. I have found that using specially structured self-motivating daily life type activities in therapy, allow the positive results of effectiveness expressive communication to become an apparent method for the client to explore on their own. Five expressive language speech therapy techniques presented here are designed to inspire successful outcomes for ASD students learning to expressively communicate.

The Individuals with Disabilities Education Act (IDEA) Amendments of 1997 (P.L. 105- 17) defines autism in part as, "A developmental disability significantly affecting verbal and nonverbal communication and social interaction, generally evident before age 3, that adversely affects a child's educational performance.." The variety of characteristics and severity of ASD vary significantly among individuals across the spectrum.

This article is intended to focus on suggestions for children with autism who often appear to have what may be described as an indifference to communicating in any structured manner. When spoken to, individuals might not attend to the words directed to them. When they appear to want something out of their reach, they may just struggle to try to reach it themselves rather than ask someone for help getting it. Yet, often, these same young children may randomly blurt out clearly understandable words at times, or perhaps echo another's verbal speech. They may even recite a commercial jingle or parts of songs. For the many individuals with these conflicting characteristics, observations suggest that their oral mechanism does function adequately for speech, as they are able to form understandable words on occasion, yet there is not functional, independent usage of verbal speech.

Advance verbal language skills rely in part on abstract processing abilities, in that the people talking must understand they each inherently have previously learned and agreed upon word meanings that may not be tangible or visible (concrete) at the time. Individuals with ASD often have difficulty with abstract concepts; yet work well with concrete tasks. The young child with ASD may be observed climbing a shelf to get to a toy rather than try to communicate the desire to a nearby adult using words.

By pre-structuring speech and language and/or AAC therapy for clients with ASD, so they understand they can achieve their highly desired outcomes through communicating a message, the act of communication can become self-evident as the efficient means to the end. Just as the concrete act of climbing the shelf for the toy resulted in the acquisition of the actual concrete toy; the student can concretely learn language in a naturalistic situation that the giving of a message to another person can also result in achieving a desired result, as well. Incorporating materials and tasks taken from typical slices of life into the goals of therapy sessions can be an effective approach to naturalistically inspire meaningful, spontaneous, expressive communication for individuals with ASD.

Therapy Planning Ideas

During the intervention process, clinicians assess and diagnose the communication deficit, plan, form therapy procedures, and implement strategies to address the targeted goals. SLPs who provide services to individuals with severe speech disorders requiring AAC, may quickly realize their typical approaches to therapy may not have the same successful outcomes for their students with ASD. Just as the students' reasons for not using the most effective method of communication vary, so must the approaches to their intervention vary as well.

The therapy ideas that follow are suggestions only, and are not intended as a universal approach applicable to any particular communication disabilities, situations, or individuals. The ultimate selection of any intervention is determined by the team of persons working with the client with ASD, family members, and related professionals. The intervention is grounded in an extensive evaluation and upon the planning of mutually agreed upon goals based on the abilities, motivations and limitations of the child. The responsibility of deciding specifically what goals and interventions would work best in specific situations depends on the families and team members working with the individual.

The reader is cautioned to keep the following conditions is mind:
  • The information presented here is not a training in a specific method of teaching communication skills to children with ASD, and should not be considered a substitute for such.
  • The clinician's familiarity with the professional concepts discussed is assumed.
  • The safety of the client is of utmost importance; therefore, the clinician is responsible to assure that materials and activities are safe and could not be not harmful to the individual.
  • These are only general ideas. Specific applications (if any) made for individual clients is entirely the responsibility of the team working with that individual.
  • Naturalistic learning ideas involve generalized typical daily events of the individual; however, actual therapy situations must be customized to encourage the client's expressive communication success based on the individual.

FIVE THERAPY TECHNIQUES THAT WORK!

1. Puzzle Power!
Do you have a client who loves to build puzzles? If so, that strong motivation to complete the puzzle can be a great place to start to trigger the client's motivation to communicate. Communication is inspired by having a reason to communicate and a method of communication. The universal desire to complete the puzzle by connecting matching pieces to make the puzzle come together provides the motivation in a tangible manner, which is readily understandable because its goal is concrete. With proper therapy set up, communication can become the concrete solution to achieve the motivating goal of puzzle completion. Puzzles come with different unique shape pieces that can be distinguishable and can lead to further opportunities of expanding upon communication to teach generalization of the skill to acquire the different types of puzzle pieces.

Begin by choosing a puzzle that is child-appropriate in terms of interest level, type, complexity, and number of easily identifiable pieces. Large wood framed puzzles often work well. It may be helpful to use a puzzle that has the image of the pieces under each place where a piece belongs, as this will make it clear to the client which piece is still needed (e.g. a puzzle of a car that has wheels, bumper, hood, window, door, etc. showing in on the background).

Prepare for the session by having readily accessible, a system of communication which the client understands and has been previously successful (i.e. speech generating device, picture symbols, communication board, etc.). Taking a digital picture of each piece of the puzzle (without background distraction) is one method of acquiring matching symbols for this activity, to add to the expressive communication system.

Place the empty wood puzzle frame in front of the client, along with the expressive communication system with the appropriate number of puzzle piece symbols displayed. Clinicians keep all the puzzle pieces, and may begin by just showing that they have one puzzle piece such as a tire. The client is typically motivated to begin to assemble the puzzle. This is the inherent inspiration to clients to utilize their communication system to initiate a request for the puzzle piece.
Indirect assistance from a communicative partner may help the client during early attempts to learn how to use the communication system to achieve the outcome they desire. If the client has previously verbally spoken words, often words will be used to request the puzzle pieces. Sometimes the use of a simple one or two location speech generating device paired with communication symbols allows the client to understand which words they can speak in the future to yield the same result as their expressions using the device.

It is important to note that the client with ASD should not be verbally directed to communicate for any of these activities. A clinician giving direction to the client to complete their communication would ultimately be switching the intent of the task to the client to following a receptive language direction rather than spontaneously expressing themselves. The goal in these activities is for the client to use spontaneous expressive communication, which would imply that the clients generated their communication through their own volition and not because they were directed to do so. The motivation of the activity is the prompt that starts the expression.

2. Where Actions are the Outcome!
This therapy plan is similar to Puzzle Power, in that there is a clear motivating desired outcome. However, this suggested idea/technique is different in that the outcome is for a desired action to occur, and not to gain an object. Frequently, clinicians rely upon real objects (e.g. puzzle piece, cookie, or toys) in therapy sessions. However, everyone has real-life moments involving the need to ask another person to perform an action (e.g. tie my shoe, fix my bike, open my milk). In this regard, this therapy technique involves arrangements that make asking for an outcome of an action to be the resulting expression.
A basic activity to practice asking for outcomes involves the clinician making desired shapes requested by the client out of whipped cream or shaving cream. (Conducting these sessions near a sink using a paper plate on a tray will help for easy cleanup). Place an empty paper plate on a tray, and place on the client's communication system symbols representing the possible foamy cream creations that you can create (snowman, star, mountain, letters, spiral, etc.). Once students understand their completed communication results in your action of creating fun looking cream structures, the communication attempts should increase as the client's desire is to see more fun shapes formed by you with the cream can.
In this theme, another action as outcome activity might involve the clinician creating simple food or drink recipes step-by-step, such as instant pudding, powdered drink mix, cold smores, etc.) Pre-set the communication system with the matching symbols needed for the client to request the steps needed for the clinician to complete the recipe. Sharing in the reward of the completed treat provides extra motivation.

3. What Did You Just See?
(A print-out version of the expressive language stimulus materials for this activity are available as a Free Download at http://www.speechpage.com/FreeStuff.html)
This one is fun for younger clients and easy for the clinician to make! Simply take a standard file folder and put a large picture of a window on the cover. The window can be drawn or printed out and glued on. The purpose of the activity is to encourage a reporting form of expressive communication. The client is asked to inform another person (or the clinician) of what they saw in the window. The clinician places pictures of items that of are interest to the child (i.e. kite, bike, dog, etc.) one at a time, inside the folder. Each attempt involves the clinician (or the client) opening the folder to allow the client to see their pictures inside, with the expectation that the client will use the available communication system to report to another person what has just been seen. The intent is to allow for the generalization of expressive reporting skills. This activity is designed to recreate the naturalistic language event of a child coming back from a window in at home and reporting to a parent that there was a dog, or some other item, in the yard.

4. Each Word Used Is Important!
Pairing two specific key words together, that are both needed to gain a desired result, can provide naturalistic learning that each word the client uses has unique meaning. Word pairs that work well for this approach are action type words, that when combined together result in a positive outcome. For example, with bubble blowing, it can be effective using the word pair of DIP and BLOW. If the client only uses one of these words, such as BLOW, the clinician would blow through an empty bubble wand which would be not be satisfying, as there would be no stream of bubbles. Using just the DIP word results in the clinician just dipping the wand into the bubble container, yet there would still not be any bubbles. The result of bubbles filling the air occurs only when the two key words are communicated of both DIP and then BLOW.

Other effective teaching word pairs include CUP and POUR. The clinician has a juice bottle and an empty cup. If the client asks for CUP, a cup is given, but would be empty. If the client asks for POUR, the clinician pours a small amount of juice into the cup, but clients also have to ask for the CUP if they want to complete the request for the drink and receive the juice. Another motivating both are needed word pair to create a desired result is CRAYON and PAPER. Make sure the approach is FUN and not frustrating!

5. Multiple Requesting For Non-Edibles!
Food has often been a beginning point to teach expressive requesting. Asking for food is important for survival, as well as naturally motivating. One of the benefits for therapy sessions is that once the piece of food is consumed by the client, there is a need to practice the asking once again. The downside is that the client may not want, or be allowed to eat the food. There is also a large amount of valuable extra time spent eating while in therapy. Asking for most toys or other single item objects, on the other hand, would results in the client acquiring the goal in one attempt, and thus there are no further opportunities for more asking practice. The important set-up for this type of therapy, therefore, is to make the asking for a non-edible item result in the acquired item going away, and more items (and more asking attempts) therefore being needed. As with each of these suggestions, it must first be determined what is motivating and worthy of the attention of the client. Then the common theme for this type of therapy is to stretch out that motivation or attention over a long period of time, so that many opportunities to use expressive communication occur bit by bit. One method to accomplish this is with an empty oatmeal container (or small shoe box) with a small hole or cross cut put into the top of the soft plastic lid. Items such as blocks, toy animals, crayons, etc. can be easily pushed though the lid opening and into the container. The act of collecting these items is motivating and fun for younger clients as the items 'disappear' into the container with a 'plunk'. The client may have the container in front of them as the clinician holds up various items, and using their communication system, the client learns to ask for items to acquire and plunk them into the container. The container consumes the item, therefore creating the need for the client to use their communication skills to ask for another item to make disappear. Variations of this theme are possible with other consuming activities, such as sliding wood beads on a string, or assembling click-link type blocks, etc.

At all times, ensure the therapy atmosphere is fun and inviting, so clients are motivated to be a part of the session and have a desire to communicate as a natural exchange. Avoid working above a client's ability level, which could result in frustration. With all these exercises, the clinician may gradually introduce more verbal clients into the session activities. When clients hear a nearby peer use communication effectively to gain a desired result using the same activity, this also provides a natural language learning environment. Modeling a peer's communication is far more practical and natural to learning for the client, than being directed to communicate by being told to say or repeat words out of context.
Allowing the effectiveness of the client with ASD's spontaneous expressive communication to become self-evident, using pre-structured, motivating, daily life activities is a powerful teaching approach for AAC or other expressive communication therapy. These five ideas were compiled as a guide to demonstrate that through specialized structured planning and set-up, spontaneous expressive communication can occur, and may be generalized outside of therapy sessions.


This Month's Featured Vendor:SpeechPage.com

Special Thanks to Don D'Amore, MA CCC-SLP for contributing this month's Therapy Corner Article.

Don D'Amore M.A. CCC-SLP a licensed and ASHA Certified Speech/Language Pathologist with over 20 years of Experience working with individuals with a wide variety of disabilities, including both school age and adult clients. Don D'Amore has presented regularly for over 15 years at speech-language pathology conventions and at other SLP and educator gatherings. He has specialized in AAC for a large urban school district for the past 10 years.

Don is the founder and co-owner of SpeechPage.com Publishing Company http://www.speechpage.com which specializes in colorful and creative ready-to-use Speech and Language therapy materials all Written, Designed, & Illustrated by this Speech-Language Pathologist.

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Tags: October 2008 Newsletter SLP OT Autism Article