Digging into Prelinguistic Communication in ASD How do we best parlay nonverbal communication into language development in children on the spectrum? A panel of three SLP experts answered members’ most pressing questions in a recent ASHA Web chat. The Leader listened in. Overheard
Overheard  |   April 01, 2015
Digging into Prelinguistic Communication in ASD
Author Notes
  • Barbara A. Braddock, PhD, CCC-SLP, is an assistant professor in the Department of Pediatrics at Saint Louis University School of Medicine and adjunct assistant professor in the Department of Communication Sciences and Disorders at Saint Louis University. She is an affiliate of ASHA Special Interest Group 12, Augmentative and Alternative Communication. bbraddoc@slu.edu
    Barbara A. Braddock, PhD, CCC-SLP, is an assistant professor in the Department of Pediatrics at Saint Louis University School of Medicine and adjunct assistant professor in the Department of Communication Sciences and Disorders at Saint Louis University. She is an affiliate of ASHA Special Interest Group 12, Augmentative and Alternative Communication. bbraddoc@slu.edu×
  • Sandra M. Grether, PhD, CCC-SLP, is coordinator of speech pathology for the Division of Developmental and Behavioral Pediatrics and an adjunct associate professor at the University of Cincinnati. She is an affiliate of ASHA Special Interest Group 12, Augmentative and Alternative Communication. sandra.grether@cchmc.org
    Sandra M. Grether, PhD, CCC-SLP, is coordinator of speech pathology for the Division of Developmental and Behavioral Pediatrics and an adjunct associate professor at the University of Cincinnati. She is an affiliate of ASHA Special Interest Group 12, Augmentative and Alternative Communication. sandra.grether@cchmc.org×
  • Jane Hilton, PhD, CCC-SLP, is an assistant professor of speech-language pathology and the director of clinical services at the University of Virginia Speech-Language-Hearing Center. She is an affiliate of ASHA Special Interest Groups 1, Language Learning and Education; 11, Administration and Supervision. jch7b@virginia.edu
    Jane Hilton, PhD, CCC-SLP, is an assistant professor of speech-language pathology and the director of clinical services at the University of Virginia Speech-Language-Hearing Center. She is an affiliate of ASHA Special Interest Groups 1, Language Learning and Education; 11, Administration and Supervision. jch7b@virginia.edu×
Article Information
Development / Augmentative & Alternative Communication / Special Populations / Autism Spectrum / ASHA News & Member Stories / Overheard
Overheard   |   April 01, 2015
Digging into Prelinguistic Communication in ASD
The ASHA Leader, April 2015, Vol. 20, online only. doi:10.1044/leader.OV.20042015.np
The ASHA Leader, April 2015, Vol. 20, online only. doi:10.1044/leader.OV.20042015.np
Participant: Why is it important for clinicians and parents to pay attention to prelinguistic communication in children with ASD [autism spectrum disorder] who produce few to no functional words?
Barbara Braddock: Prelinguistic communication assessment becomes a necessary component of the evaluation in young children who are not yet speaking, or in older children with severe communication disorders.
Sandra Grether: We need to first define what these prelinguistic skills are and then determine which ones have communicative intent. We can then build on this to move these children with ASD to more functional communication. If they do not have communicative intent, then we need to establish that first.
Jane Hilton: We know that nonverbal communication skills reflect motivation to communication and understanding of how to communicate. So we need to look for them. We also know that prelinguistic skills are related to a child’s basic representational skills.
Braddock: Right, gesture observation may assist clinicians in establishing a differential communication diagnosis and treatment plan. Types of gestures produced may serve as a prognostic index of later language development.
Participant: How do you explain prelinguistic communication to parents of children with ASD? How do you help them understand its importance?
Hilton: I believe most parents can understand the prelinguistic communication skills especially if you are able to point them out as the child is demonstrating the acts. Parents are great reporters of what their child can communicate!
Grether: I think you need to start with helping them identify what skills the child has. And helping them work through understanding what the child is able to communicate and build on that.
Braddock: Following gesture coding from direct observation and scoring of the scripted assessments, we are able to inform parents about particular behaviors that are communicative. We follow with a parent questionnaire to point out behaviors of importance. It does take some time.
Participant: Can you list some of the prelinguistic communicative behaviors that lead to language?
Grether: Using eye gaze or a gesture to make requests. We need to make sure that the gestures have communication intent in order to build on them.
Hilton: We know that joint attention is extremely important as a prelinguistic skill for communication development. We need to remember that it is both initiating joint attention and responding to it. We often forget to look at the initiating piece. Gestures as a means for behavior regulation are also important to look for as a prelinguistic skill.
Braddock: Clinicians may classify symbolic forms of communications, such as deictic points and iconic (or pictorial) gestures, as well as conventional gestures, which are learned gestures such as waving good-bye. Symbolic gestures are related to later language growth. In ASD, clinicians examine prelinguistic communication directionality (i.e., communication intent with another), form (i.e., point or wave) and function. Measurements of communication complexity, or the coordination of prelinguistic communications, are important (i.e., vocalizing and pointing out).
Participant: Can you describe some gestures for behavior regulation?
Hilton: For kids with ASD, we often see them using another’s hand as a tool to get what they desire.
Braddock: Right, we often see children at risk for ASD reaching to request, but not pointing. Prelinguistic communication varies in function. Some communication acts are used for behavioral regulation, such as requesting or rejecting. Other communicative acts are used for joint attention, such as showing or pointing out. In ASD, it is necessary to note different communicative functions.
Participant: Sometimes we can teach intent after the child uses a gesture expressively. We sometimes see joint attention rarely because what we are trying with an individual with ASD is just not of interest to them. But when we go with their interests, joint attention may be seen.
Grether: It is important to look at what is motivating for the child.
Braddock: Good point, clinicians react to reinforce the targeted prelinguistic communication behavior and potentially shape the child’s responses.
Hilton: Yes, we do need to determine the child’s interest or motivation as I view it, prior to trying teach them a skill.
Participant: Are there standardized protocols for assessing communicative intent for students with severe communication disorders?
Grether: I use the Communication Matrix by Charity Rowland as a tool.
Braddock: In response to assessment, clinicians may consider direct communication observations, videotaped observations of scripted communication assessments, and parent report measures. To understand how individuals communicate in specific contexts, clinicians may use scripted communication (standard) assessments. For example, the Communication and Symbolic Behavior Scales (CSBS; Wetherby & Prizant, 1993) may be used to examine an individual’s requesting abilities.
Hilton: The CSBS provides us with wonderful information across a broad range of skill sets.
Participant: Can you explain scripted communication assessments?
Braddock: Scripted communication assessment involve some structure, such as setting up a communication temptation task, while direct observation is naturalistic. The Autism Diagnostic Observation Schedule-2 (ADOS-2; Lord et al., 2012) allows for direct communication observation and scripted communication assessment as part of the measure.
Grether: The ADOS Modules have three specific goals: (1) to observe the participant’s spontaneous social-communicative behavior, given a situation that provides a press to communicate or interact; (2) to assess the participant’s ability to behave appropriately, given the demands of particular situations; and (3) to provide a standard context for the collection of a language sample. Special attention is given to strategies used for gaining and sustaining interaction including: gestures, verbalizations and eye contact.
Hilton: The CSBS also uses communication temptations to see just how the child is communicating.
Participant: Is the CSBS a tool that can be used to monitor progress for older students with significant impairments?
Hilton: The CSBS is given in a naturalistic context (play-based format) so it can be used for children with delays. It is geared toward younger children or those with ID.
Braddock: Parent report measures are very helpful and should be used as a complement to direct observation. You will not be able to score the instrument with an older child—yet the structure or test script may be helpful. For example, CSBS observation tasks may be combined with other measures, such as parent report.
Participant: I am interested in hearing the panelists discuss standard frameworks for assessing older students on the spectrum who continue to demonstrate low verbal and/or emerging language skills. While we see evidence-based assessments for diagnosing students on the spectrum, I am struggling with what assessment tools are appropriate for already-identified students with significant communication needs. I find therapists continuing to use tools such as the CELF-5 [Clinical Evaluation of Language Fundamentals] but question the use of the information when all subtests show more than 2SD below the mean.
Grether: We do use the CELF-5 in combination with the ADOS-2 as a standardized measure but rely heavily on subjectively how the child performed on the assessment.
Hilton: I agree this is a difficult issue. While the CSBS give us great insight into the ways a child is communicating, it does not provide us with what a standardized test can provide. We also use the ADOS with a number of instruments, such as the CELF, but also cognitive testing and some academic testing.
Braddock: Excellent question. For older children with ASD who communicate largely through nonconventional means, I recommend the ADOS-2 as a standard observation because the module selected is based on expressive language level.
Participant: Can you speak to the efficacy of using tests such as the EOWPVT [Expressive One-Word Picture Vocabulary Test] and ROWPVT [Receptive One-Word Picture Vocabulary Test] with these students?
Grether: It depends on why you are using them. If you need to determine vocabulary, then they are appropriate. But they don’t give you any other information about communication.
Hilton: Yes, I agree. The information we are seeking should guide our assessment choices. The purpose drives the choices.
Braddock: Generally, when examining prelinguistic communication, you will need to use other instruments or procedures, such as parent report and direct observation. The Inventory of Potential Communicative Acts (IPCA) is a parent-report instrument used to describe prelinguistic behaviors (Sigafoos et al., 2000; Sigafoos, Aruthur-Kelly, & Butterfield, 2006).
Participant: I struggle with what those tests really tell us about a student’s functional vocabulary use and understanding.
Braddock: To assess prelinguistic communication, many use the Communication Matrix, an interactive online assessment (Rowland & Fried-Oken, 2010).
Participant: Do you ever see how they do with an AAC [augmentative and alternative communication], such as PODD [Pragmatic Organization Dynamic Display], during the evaluation or first few sessions or would you always refer to an AAC evaluation if you are considering that route?
Grether: The Communication Matrix looks at seven levels of communicative competence moving from pre-intentional (reactive) behavior, intentional (proactive) behavior, unconventional pre-symbolic (intentional) behavior, conventional pre-symbolic communication (pointing, waving), concrete symbolic communication (using tangible symbols), abstract symbolic communication (single words—symbol, sign, Braille) to formal symbolic communication (language).
Braddock: In children with ASD, clinicians will want a direct observation to examine spontaneous gesture or potential communication acts in social contexts with others. Direct observations complement parent reports.
Hilton: Since most of these children will be young, we will generally look at AAC at another time. We also find that parents may not be ready to jump to AAC. Sometimes they want us to examine the child’s current communication system. Sometimes we prefer to get to know the child prior to the AAC evaluation too.
Grether: We usually introduce AAC tools such as the PODD during diagnostic therapy. We have found that individuals who have not had prior experience using any form of AAC need to have it introduced in therapy rather than in a one-time evaluation.
Braddock: Good point, PECS [Picture Exchange Communication System] and other AAC tools can be used as part of the assessment practice.
Participant: Is the best practice to build up a gestural repertoire first? Or do we try using AAC without building up the gestural repertoire? In other words, is there a sequence you recommended, or just whatever works?
Grether: I don’t think you need to build a gestural repertoire first. I determine what meaning the gestures have and then see if we can provide a photo or symbol to represent and build from there. I make sure that everyone knows what the gestures mean and have families build a “brag book” that gives the meaning and provides a photo of the gesture for the rest of their team.
Braddock: Excellent question. Multi-modal. Make it work for the child given individual strengths. We often see children producing natural gestures, potential communication acts, a few manual signs, etc.
Hilton: I think it depends on the child. Before determining treatment plans for children with autism, it is important to understand their prelinguistic communicative strengths. Children may respond differently to different treatments based on these skills.
Participant: Is there a standard process for identifying what level of representation works best for a student? Object, photo, symbol?
Braddock: I continue to educate others that multi-modal communication (combined speech, gesture, and other aided AAC) is an effective and efficient communication strategy for many learners. A complete AAC assessment is always needed for any particular learner.
Grether: By building on the intents already exhibited, we can begin to provide communication boards and devices with core and fringe vocabulary to support. We need to teach caregivers and communication partners to use aided language stimulation techniques to model, model, model, both receptively and expressively. Children need to hear the words paired with the objects, photos, and/or symbols, whether low-tech or introducing a high-tech SGD [speech-generating device].
Participant: If there is no joint attention, how do you work to establish that across environments?
Grether: If we don’t have joint attention, we introduce the Picture Exchange Communication System (PECS) at phase 1.
Braddock: Increased opportunities for social engagement. We often work through games and routines, play, and imitation tasks.
Hilton: Exactly, so we try to move back to the child’s interests. Providing lots of opportunities is very important. Simple nonverbal routines are great for establishing joint attention.
Participant: Can you give some examples of simple nonverbal routines you use for establishing joint attention?
Hilton: During our summer program this year, simple songs with hand motions were very effective. The favorite was “I’m a Little Teapot,” but they also enjoyed “London Bridge”—any song that we could get them to be physically engaged. Even on a gross motor level.
Braddock: Peek-a-boo, jumping-up games (waiting and pausing until next turn) often work well with young children with ASD.
Participant: What, if any, are some key indicators that a child might be moving out of the stage of prelinguistic communication? What are flags that you are watching out for?
Hilton: I would look for imitation to increase and spontaneous use of the skill. Also, increased use of joint attention, increased gesture, increased vocalizations.
Grether: Also an increase in intentionality directed toward a communication partner.
Braddock: Types of gesture forms produced and associated communicative function is a key indicator. Complexity of prelinguistic communication (or the coordination of prelinguistic communications with others) indicates progress.
Participant: We’ve all seen difficulty with behavior modification in this population. How important do you believe early response to prelinguistic communication to be to development of behavior issues?
Hilton: I agree that these children can get frustrated by the communication partners not understanding their intentions due to the unconventional means they are communicated. I have also noticed that as we increase their skills, such as intentionality and joint attention, behavior issues seem to ease a bit. All behavior is communicative and it is important to help the children learn a way that is understood by others.
Grether: I think we need parents to help us identify when a behavior has communication intent that may be idiosyncratic and not recognized by all partners.
Braddock: Very important. Parents and caregivers must be responsive to understand children’s often unconventional communications. Clinicians must consider the learner’s existing communication forms and functions, as well as communication environment.
Participant: Have you or would you use a high-tech AAC device with someone who is at a prelinguistic level? I think it has a lot of potential, but people are often hesitant to recommend a high-tech device because they think they do not need all that technology. What are your feelings?
Grether: If an individual has any photo or picture recognition, we can use pictures or symbols and organize the vocabulary on multiple pages with fewer symbols depending on the cognitive abilities. We can use many communication applications to support this. GoTalk NOW is an app I use often.
Braddock: Begin with a communication assessment and continue to build multi-modes of communication, which may or may not include a high-tech device. The goal is efficient and effective communication across partners.
Hilton: Examining the child and identifying the child’s needs and capabilities is important. A good evaluation is the first step in determining what is needed by the child.
Participant: How do you prevent people from “giving up” on the teens or young adults who are at a prelinguistic level? How do you get the school to see the viability in still working on these skills to move them toward becoming a more competent communicator?
Braddock: Excellent question. I believe that through careful assessment of prelinguistic communication and setting appropriate goals, we can show others that goals are appropriate and measure change.
Grether: That’s hard. We need to get the team working with the child and family to identify what to focus on and then determine how often that skill can be practiced or used throughout their day. Many times, goals are set for one time per day and the team does not look across the day to increase the opportunities to practice a skill.
Hilton: It is difficult for schools to understand that even older teens or young adults can be helped with AAC. Sometimes the best way to convince them is to be able to show that, even if we use simple AAC devices, the person can learn. It takes time and is often a slow process, but well worth it.
Participant: What evidence-based interventions should we put in place as tier-one supports for their classrooms?
Hilton: EBP is truly lacking for both young children and older people on the spectrum. We have the most evidence in behavioral therapy and some in naturalistic approaches. Difficult question.
Braddock: For best clinical practice for improving communicative interactions involving individuals with severe disabilities, see the ASHA website.
Participant: The issue I see is that a teen who is still at a prelinguistic level is often no longer receiving speech services in the schools, and so a critical component of the team is missing.
Braddock: Yes, parents and educators must advocate for ongoing services. Requesting a re-evaluation may be a good starting point.

Barbara Braddock recommends more valuable resources:

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April 2015
Volume 20, Issue 4