Therapy Techniques to Remediate Language Deficits in Individuals with Autism Spectrum Disorders

Therapy Techniques to Remediate Language Deficits in Individuals with Autism Spectrum DisordersNorth Dakota Speech-Language Hearing Association Fall 2008 ConventionBy Lisa Roteliuk, M.S., CCC-SLPMinot State Universitylisa.roteliuk@minotstateu.edu

AgendaReview three essential communication skills for students with autism spectrum disorders (ASD)Review rationale for using visual support strategies for individuals with ASDDiscuss using visual schedules and transition helpersDiscuss Therapy Ideas for five areas of languagePhonologySemanticsMorphologySyntaxPragmaticsEssential Communication Skills for Individuals with ASD (Hodgdon, 2008). 1. Establishing a Social Connectionteach the students how to engage with others.2. Understanding others teach how to interpret social situations, understand meaning of facial expressions and body language, changes in routines or rules for behavior. 3. Communicating wants and needsTeach many forms of communication to help reduce frustration and get needs mete.g., pointing, gestures, pictures, written language, etc.

Communication intervention for individuals with ASD should focus on these 3 foundational areas to prepare students for advanced learning:1. Establish a social connectionMyth that students with autism are in a world of their own. Some may avoid social contact; others may be socially indifferent or socially awkward and not know how to connect, so we need to give them strategies to engage with others. 2. Understanding Others: individuals with ASD may have significant challenges understanding others in spite of a high IQ or strengths in reading, math, etc. We need to teach how to interpret social situations, understand nonverbal language, and interpret changes in routines; Using visual strategies is a highly effective way to give students more information, provide structure in their lives, and teach them needed skills for learning. 3. Communicating wants and needs: students need a reliable way to let others know what they want and need. Staff and family members may desire verbal communication, but our first goal should be to give them forms of communication to reduce frustrations and get basic needs met. These forms vary from pointing, gestures, pictures, written language, to more formal Alternative/Augmentative systems.

3Why do individuals with ASD function better visually? 1. They have difficulty shifting and reestablishing attention.

2. They have difficulty attending to foreground sounds and blocking out background noises. (Hodgdon, 1995).

Nervous system of individuals with ASD isnt able to rapidly select, prioritize, and process a variety of incoming verbal messages; therefore, we often see a non engaged student because of this difficulty and they will often have a preference for activities that are predictable, so they can process the information better. All sounds are perceived equally, so they arent able to focus on a teachers voice over the shuffling of papers

4Why do we use Visual Supports?They promote students strengths and give them a means to overcome difficult areas (Hodgdon, 1995, p. 11). Questions for the skeptic teacher, principal, etc.Do you use a calendar to write down important dates?Do you use a To Do list at your desk or in your home?Do you point out advertisement pictures to show desired items?Do you make up a shopping list before you go to the store?Have you ever followed a recipe in a cookbook? Did you return to the recipe the next time you cooked that item?Do you ever attach notes to your bathroom mirror as a reminder to do a task?Do you scan the menu before ordering in a restaurant?

If you have teachers, principals, parents, paraprofessionals, or you yourself are a skeptic, answer these questions (above)We use visual supports on a daily basis to help organize our lives, so why would we expect students to be able to learn and use new concepts presented only in an auditory mode?

5Why do we use Visual Supports? (cont)Help organize their environmentDaily, weekly, or monthly schedulesReduce anxiety felt by studentMini schedules to teach specific skillIncrease students learning efficiencyVisual cues/prompts

Rationale for Visual SchedulesGive students information about their lifeHelp students gain order for their worldServe as a communication aid to discuss and share daily eventsImprove vocabulary and language skillsAssist in developing time conceptsTeach sequence (before/after, first/then)Reduce or eliminate behavior problems related to transitions (Hodgdon, 1995, p. 44). Daily Schedule

Mini Schedule

Purpose of mini schedule is to Give student information about what is expected.Provide structure to teach independent work habits. 9Communicating NOGeneral rule when giving students instructions about their behavior is to state the expected behavior in a positive manner. May need to clarify information for students by telling them:What is not a choiceWhat is not acceptable behaviorWhat is not going to happenUniversal No sign placed over or beside a picture will help the student know what they can or cant touch

Brian loved TVs, VCRs, computers, printers, anything on the teachers desk, etc. We spent more time telling Brian not to touch items than we spent working his goals or academic work. We used the suggestions from Visual Strategies for Improving Communication to help Brian visually see what was off limits for him to touch. We made picture icons with the words Dont touch and the universal no sign and placed them on the objects. Within two weeks, Brian began to go up to the objects, read the sign and say, I cant touch that, right? He was able to regulate his own behavior and increased his on-task behavior. 10Communicating NOSame universal NO sign can be used to communicate to the student:changes in their daily schedule, changes in lunch choices, changes in personnelHaving the change represented visually can be calming for the student and provides them a way to deal with the change without having to ask for reassurance from adults (Hodgdon, 2000).

Brian loved TVs, VCRs, computers, printers, anything on the teachers desk, etc. We spent more time telling Brian not to touch items than we spent working his goals or academic work. We used the suggestions from Visual Strategies for Improving Communication to help Brian visually see what was off limits for him to touch. We made picture icons with the words Dont touch and the universal no sign and placed them on the objects. Within two weeks, Brian began to go up to the objects, read the sign and say, I cant touch that, right? He was able to regulate his own behavior and increased his on-task behavior. 11Transition HelpersPrepare students for transitions.You have 3 more turns before we stop.Only 30 more seconds and the time is out.Always let the students know before they start a game how long the activity will last; as the transition time approaches, give students a verbal or physical warning.Show ending time on clock or timer. Create a natural ending by setting out last three cards.Make transitions part of the routine by adding clean up ritual to allow student to naturally shift gears.

Transition Helpers (cont)Give information and cues to prepare students for what comes next by having them carry the object or a representative picture icon to the next activity. Let students know when they can return to the activity they dont want to leave.Let the student know what will be happening next if you are moving to an undesired activity (Hodgdon, 1995).

Visual Support RemindersUse areas of interest as a motivator and as a learning toolThink outside the box what works for typical student doesnt always work for students with ASDMost teachers use some visual supports, but often not enough for students with ASDEverything the teacher says doesnt need to be put into a visual form, only the things that have to be repeated often.

Visual supports for PhonologyUse mouth puppet as a visual cue to teach placementUse mirror as a visual cueUse visual phonics or other signs to represent target soundUse tactile cues Touch neck for /k/ soundTouch top of head for /r/, /k/, & /g/ soundsDraw finger down arm for /s/ sound and s-clusters

Phonology (cont)Intonation Patterns (Harrington, 2000, p. 71-72).When prosody issues appear in your students speech, use these signs to help them understand how and when to make your voice raise and lower. Question your voice will rise at the end of a question.? How was your day? Statement your voice will lower at the end of a statement..The sun is hot.

Therapy Ideas for SemanticsCategorization (Harrington, 2000, p. 73)Cut circles out of construction paper. (diameter of circles - red = 6 inch, blue = 4 inch, green = 3 inch, yellow = 1 inch).Show smallest circle (yellow) to student and write animal on it (e.g., giraffe). This circle stands for a specific animal.Show next smallest circle (green) and place beneath yellow circle, stating it stands for zoo animals, the group giraffes belong to.Add last two circles when the student begins to understand and identify first two categories well. The last two categories would encompass all animals and living things.

GiraffeLiving ThingsZoo AnimalAll AnimalsSemantics (cont)Figurative languageLearning IdiomsFocus on 2-3 idioms at a time.Have the students draw what they think the idiom means on half of the paper. Discuss actual meaning of idiom and have student draw the actual meaning on the other half. Review the actual meaning of all three idioms and have the students share their drawings and the meanings with a peer, teacher, etc.

Semantics (cont)Things I Can Say and Do by Michelle Zucker SaundersUses visual organizers to help students understand and use functional vocabulary. E.g., Things I Can Do: ShirtsTell someone what I do with a shirt.Describe my shirt.Tell someone where I keep my shirts.Ask someone to tell me about a favorite shirt. shirtsVisual Supports for MorphologyVerb Bingo game to teach verb tense using visual prompts:

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Verb BingoMay need to modify card to include only regular verbs, only irregular verbs, or a mixture such as this example. 22Morphology (cont.)Verb tense (Past, Present, Future)Use tape to divide room and signs with today, yesterday, tomorrow Use Starter Phrase Cards Today we ____., Yesterday we ____. Use backward chaining to gradually fade cues 1. Student imitates whole phrase said by clinician (e.g., Yesterday, we went to town.2. Student imitates phrase stated by clinician and fills in the last word independently. (e.g., Yesterday, we went to ____.)3. Student imitates phrase stated by clinician and fills in the last two words independently. (e.g., Yesterday, we went ___ ______.) 4. Fading continues until the student completes whole sentence independently. **You may have to provide two written verb tense choices for the client to choose from and then gradually fade choices once they are able to independently fill in the verb. Just for Kids Autism from LinguiSystems is a great resource for working on receptive, expressive, and social language skills. 23Visual supports for SyntaxIncrease sentence length

Start out with blank cards to visually represent the different parts of speech being targeted. 24Syntax (cont)

Increase sentence lengthStudents fill in blanks with different cards (or actual objects) from each of the categories. Backward chaining is used to gradually fade cues. The biggest mistake Ive made is fading the cues to quickly. I usually faded cues once the students were successful on three consecutive trials and/or using them in different settings (classroom and speech room)25Syntax (cont)Increase sentence complexity by adding prepositions

Use the same concept discussed earlier but adding different parts of speech. Some parts of speech previously mastered can be written out without a picture. Students loved making their sentences on the wall using sticky tack, making sentences using magnets (if you have access and funding to purchase magnet boards for your printer), and drawing their own pictures to represent the nouns or verbs.

Same concepts can be used to target auxiliary and copula verbs (is/are/was/were) if clients are leaving them out of their connected speech. 26Visual supports for PragmaticsInitiating & Maintaining a TopicUse communication journal between home and schoolAutism and PDD Tell Me About It by Michelle Zucker SaundersProvides students with fill-in-blank worksheets that the student completes at school or home to help them increase conversational skills.Helps students:Give DetailsTalk about something that happenedDescribe routinesProblem solve language needed for difficult situations.Pragmatics (cont)Topic Initiation and Topic MaintenanceTopic Talk Conversation Card Game by Susan Pike (Super Duper)Targets topic initiation, asking and answering questions, making comments, and maintaining a topic. All About You, All About Me Fun Deck by Molly DeShong (Super Duper)E.g., Tell me about your favorite flavor of ice cream. Turn TakingUse microphone to designate whose turn it is to speakHave chip or other object that is passed back and forth between the speakers/listeners

Pragmatics (cont)Conversational SkillsComic Strip Conversations by Carol Gray http://www.thegraycenter.org/store/index.cfm?fuseaction=product.display&product_id=41Uses simple drawings to illustrate a conversation between two or more peopleColors may be used to represent emotions felt during conversation E.g., red = anger; green = happy; blue = sad, etc.Defines different parts of a conversation for students Talk bubble, thought bubble, listening, etc.Students may start out making a comic strip for a conversation previously taped or drawing as they talk with their teacherEventually they may be used to help the students problem solve an area of difficulty, such as topic initiationMain point behind this strategy is to provide the students with a visual script while learning how to initiate, continue, and/or end a conversation. 29Pragmatics (cont)Answering Wh and Yes/No QuestionsAsk and Answer by Sharon Webber (Super Duper) work well to provide visual cue to get students started in asking and answering questions. Typically start with more concrete Wh forms (What, Where, Who) and then add more abstract forms (When, Why, How)Yes/No Questions - Want to ensure the questions you develop are ones where you know if the student answers correctlyE.g., Do you have a brother? Is this a book? Typically practice these questions individually until the student shows mastery; then, develop a game board and practice asking and answering questions within our social skills group.

30Pragmatics (cont)References for Asking/Answering QuestionsLinguiSystemsAutism and PDD Answering QuestionsThe Basic Reading Comprehension Kit for Hyperlexia and Autism Autism and PDD Photo Cards Wh-Question and Interactive SoftwareAutism and PDD Buddy Bear and Becca Bunny Book Sets and Interactive SoftwarePragmatics (cont)Identifying Emotions of OthersStudent watches video clips of familiar people or use picture cards with people displaying various emotionsStudent looks at various facial features and answers questions on a checklist about the featuresOnce student completes the checklist for each emotion, they make a master list stating what the facial features do for each emotion (Sussman, 2006, p. 21).Other resources for Emotions [LinguiSystems The Nonverbal Language Kit; Room 14: A Social Language Program (age 6-10); Room 28: A Social Language Program (age 11-18)]Are corners of mouth turned up to a smile? Are corners of mouth turned downward?Are lips narrowed to a thin line?Does lower lip sticks out over upper lip? Is mouth slightly open?Are lips pulled tight?Is upper lip raised?

Is the nose wrinkled?Are the eyebrows lowered in a frown and forehead creased?Are the eyebrows raised?

Do the eyes look down?Are the eyes filling with tears?Are the eyes narrow?Are the eyes open wide?Are the eyes blinking fast?Are the eyes crinkled at outer corners?Do the eyes appear smaller or narrow?

FeelingWhat the Eye Area May Look LikeWhat the Mouth and Nose May Look LikeHappy*Eyes crinkled at outer corners*Eyes are open

*Mouth corners turned up to smile

Sad*Eyebrows lowered in a frown*Eyes look smaller*Eyes look down*Eyes filling with tears*Mouth corners turned downward*Lips narrow to thin line*Lower lip sticks out over upper lipI hear and I forget.

I see and I remember.

I do and I understand.

Chinese ProverbReferencesBoardmaker, Version Six (2008). Solana Beach, CA: Mayer-JohnsonGray, C. (1994). Comic strip conversations. Arlington, TX: Future Horizons, Inc. Harrington, K. (2000). For parents and professionals: Autism in Adolescents and Adults. East Moline, IL: LinguiSystems. Hodgdon, L.A. (1995). Visual strategies for improving communication : Practical supports for school and home. Troy, MI: Quirk Roberts Publishing. Hodgdon, L. A. (2008). Three essential communication skills for students with autism spectrum disorders. Retrieved from http://lindahodgdon.com/newsletter/welcome_issue.html#article2Sussman, F. (2006). TalkAbility: People Skills for verbal children on the autism spectrum A guide for parents. Toronto, ON: The Hanen Center.