Many individuals with Autism can have impairments or difficulties with functional communication. Sometimes this is due to medical conditions, such as tongue abnormalities or Apraxia. More often this is due to severe deficits in the areas of motivation, processing language, and social interaction skills. Speech delays can also be caused by excessive ear infections, which can lead to hearing loss or impair speech processing during times of critical brain development.
The majority of the kiddos I have worked with were nonverbal when I first met them. Terms like pre-verbal or non-verbal describe an individual who does not consistently use vocal communication in a functional manner (*non vocal is the preferred clinical term, because verbal behavior can include non-expressive communication such as sign language). In most situations ineffective or inappropriate ways of communicating are used instead of typical language, such as engaging in echolalia or scripting behaviors.
These individuals often communicate by pointing, leading, or the majority of the time: through their behavior. I have observed quite a few toddlers who without saying a word had an entire household catering to their every desire. The parents knew that 2 screams meant “turn the TV on”, a crying fit meant “pick me up”, pushing a sibling meant “I don’t want to play”, and so on.
The goal when working with non-verbal individuals or children should be more than just "talking". The goal should be getting the child to effectively communicate. Even children who are verbal don’t always communicate well. If I teach a 5 year old to label colors and body parts but she can't tell me when she is hungry, that's a good example of a child who can talk but isn't using language to communicate.
When you think of “verbal” think bigger than just being able to talk.
How does the child communicate? Does the child appear to be strong in receptive language, even if they cant verbalize? Does the child hum, have verbal stims, sing songs or melodies? Does the child shout when upset or make wordless noises? From my experiences, positive indicators that a nonverbal child will become verbal include verbal stims, frequent babble, and demonstrating social awareness or alertness (e.g. child stares intently at your face when you sing to them). A young child who will echo, sing wordless songs, or babble, often is quickly successful with intensive language intervention.
The behavioral piece of communication is HUGE. It can't be stated enough: Children who cannot communicate or are non-verbal have some of the most persistent and challenging problem behaviors. Why? Well, just imagine that you are placed in an environment where no one speaks your language. If you speak English, everyone else speaks French. If you speak Arabic, everyone else speaks German. Now imagine that you are hungry and must convince these people to feed you. How long would you try pointing and gesturing, before you started pushing people and throwing things?
If a child has no internal motivation to communicate, and isn’t externally required to communicate, then from the child’s perspective its much easier to engage in behaviors. A child who is allowed to fling their plate to the floor during dinner to signify “I'm done” has zero incentive to think up words, form them with their lips, and then speak.
Reinforcement is also huge. For a child with Autism to learn to communicate, reinforcement must be present. You might be wondering, “Why do I have to reinforce my child to talk? My other children just started talking, they didn’t require M&M’s to do so”. A characteristic of Autistic Disorder is qualitative impairments in communication. This can mean the child has no language, exhibits speech delays, or has no motivation to use the language they do have.
There are many options for teaching a non-verbal child to communicate (and often a BCBA/Consultant will recommend multiple options at once, I know I often do):
Various Communication Methods
- Verbal Behavior Approach (ABA) – There are many different ways to do ABA, and VB is a branch on the ABA therapy tree. VB has a functional language focus. VB captures and builds upon internal motivations, and uses rewards to reinforce communication across verbal operants (requesting, labeling, describing, etc). Language is taught as a behavior and each component is broken down. If the child likes ice cream, one of the first things they learn to say is “ice cream”. This way, the child’s motivation to get a desired item is used to pull language out of the child: You say ice cream, you get ice cream. The VB approach also uses repetition, prompting, and shaping to get desired responses. Initially, “buh” is acceptable to request the ball. Over time (and with careful data analysis), the criteria become more demanding until the child can say “BALL”. For a detailed description of VB, see my Verbal Behavior post.
- Speech Therapy- For every 10 clients I see, probably 6-7 are also receiving speech therapy. Many parents think that ST is the only way to get a non-verbal child talking. SLP's often work with conditions such as stuttering, language impairment, feeding/swallowing, etc. (for more information see www.asha.org). I have worked with kids who made huge gains from ST, and I have also worked with kids who did not. I have had some great experiences collaborating ABA goals with what the ST is working on, and some not so great experiences. Its important as a consumer to pursue speech and language professionals who have experience with Autism or behavior management. Its also important to look at the intensity of services being offered. Many of my kiddos who get speech therapy only receive 15-45 minute ST sessions once per week. For a nonverbal, lower functioning child with Autism, that may not be enough therapy to produce significant gains. If your child is currently receiving speech therapy and experiencing success and making great progress, I highly suggest encouraging collaboration between the ABA team and the SLP. Its so important that we all collaborate with each other! Approaching communication with a team approach and having everyone on the same page can only help your child.
- Sign Language- Always combine labeling with sign language so the child hears the correct word, as well as learns the sign. When considering sign language you want to think about the child’s age and fine motor skills. If a child has poor fine motor abilities and cannot make multiple, intricate signs to communicate then sign language may not be a good choice (although you can always teach approximations to signs). Age is important because you want to think about how big that child’s world is. If the child is only 2 and spends all day at home with Mom or Dad, then sign language is probably a good choice. However if the child is 11 and goes to school, after school care, karate practice, and then home, then all of the people the child has regular contact with must know the child’s signs. If the child walks up to a teacher on the playground and signs for her “red notebook”, will the teacher understand? If the child doesn’t get a prompt response to their sign language, they may stop signing. Also a very common error I see with non- verbal kiddos who have learned ASL is getting stuck on the sign "more". Many professionals and parents teach the child to sign "more", and unfortunately the sign then gets generalized. The child will randomly walk up to people and sign for more, and no one knows what they want. More of what?? Imagine how frustrating this must be to the child. If you decide to teach your child to sign "more", always pair it to the specific item they are requesting.
- Picture Exchange Communication System- With the PECS system the child learns to communicate by exchanging photos of items to receive the actual item. PECS are simple to use, can be transported across environments, and can eventually be very elaborate. You can teach a child to request in full sentences using PECS, to request multiple items, to describe their day, to have a conversation, etc. An advantage that PECS has over sign language is the cards or photographs are easy for anyone to understand. With signing if a child makes a sign sloppily then people don’t know what they want. With PECS you can use pictures or actual photographs of the items, depending on what works best for the child. Another advantage to a PECS system is communication between peers. The average 3 year old may not recognize the sign for "play", but they may understand that a photo of a dollhouse means "Do you want to play with the dollhouse?. Disadvantages of PECS can include: difficult to keep up with all the various photos/pictures, and the child's interests change so frequently it may require changing the cards very often.
- Assisted Communication Devices- An assisted communication device will create speech for the child by speaking in a simulated voice. The child inserts cards, types, or pushes buttons, and the machine speaks. Since these are technological devices they do require the child have the cognitive ability to independently operate them to be effective. However, if you have access to an Ipad there are some really great communication apps (such as Proloquo 2 Go) that nonverbal kiddos can use to communicate with just a few swipes of their fingers. An advantage of an AAC is they can be used with individuals of varying physical capability, because they can be modified or adapted if the child has vision difficulties, cant type, or has hearing loss. An AAC can be transported easily and allows the child to quickly communicate wants, thoughts, opinions, and needs. Some of these devices can be programmed however they need to be, with very specific information that would be hard to put on a photo (such as a lengthy knock-knock joke). Other devices are more basic and difficult to program for detailed conversations, or elaborate back and forth exchanges. I know a few kiddos who were able to get communication devices (including Ipads) provided by the school system or Easter Seals, so that may be a resource worth looking into if you are unable to afford to purchase a device....some of them can get pretty expensive.
- Language Immersion- This is a method typically seen in preschools or daycares that accept very young children with special needs. The classroom immerses the children in language throughout the day with the intention of creating a stimulating environment conducive to speech. Items are clearly labeled with photos and words, children are engaged in conversation even if they cant talk (“David, is my coat blue? Nod if my coat is blue”), and the teachers spend time working 1:1 with each child on turntaking, eye contact, and joint attention. To me, these classrooms often look similar to the Koegel method, or Pivotal Response Training. Often these types of techniques are implemented by early childhood education teachers, or parents. An advantage of language immersion, or focusing on pivotal skills to enhance communication, is this method can be easy for a parent to implement with their own child. These types of techniques focus on developmental milestones leading to first words, such as babbling, recognizing distinct sounds, imitating actions, responding to receptive commands, and communicating using gestures. Working with the child 1:1 will include lots of intrinsic rewards, and naturally occurring interactions. For example: treat the child’s babble as if they are words, and carry on a conversation with them. Narrate your actions and the child's actions, even if the child doesn't respond to you ("We're walking upstairs now. Lets count the stairs: 1,2,3,4....."). While you are narrating try to make eye contact with the child, build upon shared interests, have an animated facial expression, and make learning fun.
The wide array of programs, books, resources, and clinics out there that promise to get children with Autism to talk can be very intimidating and confusing for consumers. Be a critical consumer and look for research proven methods that clearly explain how the treatment works, and what is involved.
Ask lots of questions! If you have to buy the treatment or purchase a book before anyone will explain exactly how it works, be suspicious.
No matter which option you select to teach communication to a kiddo with Autism, in order for it to be effective and consistent across settings and people you will likely need to incorporate behavior management. The child must learn that anything less than the communication system will no longer be accepted. That means if you are teaching the child to use sign language to request a cookie, then they are no longer allowed to climb up onto the kitchen counter and get the box of cookies off the top of the refrigerator. Make communicating with you a requirement, or the child wont do it.
The child must also learn that communicating with people leads to good things. If the child just learned to request “juice”, then initially every time the child says juice they should get a sip of juice. The child needs to see that communicating with people promptly gets needs and wants met.
If you have implemented a system of communication for a child with Autism and the results are inconsistent, ask yourself: “Is this communication system the only way he/she can get this need or want met?” If the answer is no, that may be why you aren't seeing progress.
**Quick Tip: Early intervention is critical when it comes to targeting speech production and development. You want to start working with the child from a very young age to ensure the best results. However, research shows that all hope is not lost for older individuals with Autism who are non-verbal. It will be more challenging for an older child to learn to talk, but it is not impossible. The most promising methods for children over the age of 5 include speech generating devices (which do not inhibit language) and developmental approaches that facilitate joint attention.
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