By Christie Linkes, MSLP/CCC-SLP
According to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, autism spectrum disorder is a complex neuro-developmental disorder characterized by the core symptoms of social communication and interaction difficulties, restricted interests and repetitive behaviors (Autism Speaks, 2014). These symptoms cause relationship and learning difficulties when interacting with caregivers, peers and others at home and within the community. Because each child with autism has a different severity level and requires a different level of support (National Institute of Mental Health, 2014), it may be difficult for a speech-language pathologist to know where to start when developing a treatment plan.
A Range of Children with Autism Spectrum Disorder
Johnny is a 3 year old child with autism spectrum disorder (ASD). He is nonverbal, engages in self-stimulatory behaviors, and does not play with toys. The goals of his therapists may be for him to look at pictures or objects and say the corresponding sound or word. In order to communicate his wants and needs immediately and successfully, it may be necessary to try an augmentative alternative communication method, such as a picture exchange system to request his immediate desires.
Abigail is a 6 year old child with ASD. She is verbal, speaks in ungrammatical sentences and engages in parallel play with peers. Goals may be for her to improve her word and sentence structure as well as to participate in turn-taking activities with peers.
Bobby is an 11 year old boy with ASD. He is very verbal, engages in guided conversation with adults only, and tends to perseverate on desired topics. Goals may be for him to engage in reciprocal conversation with peers and to maintain appropriate topics of conversation.
Johnny, Abigail and Bobby are all children with ASD. As speech-language pathologists, we are most concerned with the language aspect of social communication, so our initial instinct may be to teach children with ASD to talk, request wants and needs, follow directions, maintain eye contact, take turns, and have a conversation. These goals are meaningful to families of children with ASD; however, learning the skill of interaction is important, and often missing within treatment plans.
First Things First – Developing Interaction
When beginning a treatment plan, it is common practice for a speech-language pathologist to teach skills such as speech production, labeling, requesting, and following directions. These skills are very important to reduce communication frustration and breakdowns; however, it is first necessary to realize that pre-linguistic skills are required for interaction. Interaction skills are required before secondary skills such as symbolic language can be mastered. Interaction skills help the child form relationships along with helping him become available for learning. If a child is not able to form a relationship with a person, then he cannot learn from a person. Consequently, he may become at risk for learning in a rote manner and may not be able to generalize skills well.
Basic interaction skills include two main skill areas: joint attention and theory of mind. These skills are learned early in a child’s life, even during the infancy period of development (Miller, 2006).
Joint attention is a precursor to the development of theory of mind (Miller, 2006). Joint attention is demonstrated when the child is simultaneously engaged in an activity with another person or group of people. The three main focal points of joint attention are the child, the activity or object, and the communication partner (Charman, 2003). If one of these focal points is absent or not active, then joint attention has not been obtained and the engagement is lost. Joint attention may be shown by initiating and responding to eye gazing, coordinating joint looks, showing, and pointing. The following are examples of a child initiating and responding to joint attention:
Initiating Joint Attention-Examples
Activity – Child’s initiation – Partner’s response
Rolling ball: Child rolls ball to partner: Partner notices and catches ball.
A bird in the sky: Child gazes at bird in sky, smiles at mom and then looks back at the bird: Mom notices child’s smile, notices his gaze at the bird, and then looks at the bird.
Block is under blanket: Child points to blanket while playing with blocks: Father notices child’s point at blanket and removes blanket to obtain block.
Peek-A-Boo: Child looks at sister, covers his eyes, uncovers his eyes, and smiles at sister: Sister notices gaze and action of child and then responds by continuing with Peek A Boo social game.
Responding to Joint Attention-Examples
Activity – Partner’s action – Child’s response
Rolling ball: Partner rolls ball to child: Child notices ball and catches ball.
Bird in the sky: Mother gazes at bird in sky, smiles at child and then looks back at the bird: Child notices mother’s smile, notices her gaze at the bird, and then looks at the bird.
Block is under the blanket: Father points to blanket while building blocks: Child notices father’s point at blanket and removes blanket to obtain block.
Peek-A-Boo: Sister looks at child, covers her eyes, uncovers her eyes, and smiles at the child: Child notices gaze and action of sister and then responds by continuing with Peek A Boo social game.
Theory of mind is the understanding that others have thoughts and feelings that may be similar or different than your thoughts and feelings (Westby, 2012). It answers questions such as “What are you thinking?”, “What do you intend to do or say?”, “How do you feel?”, “What do you know?”, “Why are you doing that?” Successful interaction depends on the development of this skill because a child must understand what another child is thinking and feeling before he can react and act appropriately during social situations. Advanced theory of mind leads to understanding and using sarcasm, figurative language, jokes, discussion, judgment, compromise, negotiation, etc.
Joint attention and theory of mind are learned as early as infancy. A few months after a child is born, he is able to learn basic imitation and emotion sharing (Watson, et. al., 2003). The brain’s maturation of mirror neurons helps children to develop the imitative skills required to model and show facial movements (Ramachandran, 2000). A child must be able to imitate an action before he can show or share an action with someone. Imitation of a facial movement leads to sharing a facial movement. Sharing facial movements leads to the skill of emotion sharing. The following are examples of a child demonstrating emotion sharing:
1. Mother is eating a meal with her infant son. Mother sucks on a lemon and puckers her lips to the sour taste. Baby does not taste the lemon but still puckers his lips to share his reaction with his mother.
2. Baby is creeping across a table. He falls and bumps his head. He immediately looks at his father and wrinkles his face to share his reaction to pain with his father.
3. A boy is playing chase with his older sister. They are laughing and smiling. Sister falls down and scrapes her knee. She cries. The boy stops running, stops laughing, and looks seriously at his sister to share his reaction to her pain with her.
Theory of mind and joint attention skills can develop simultaneously and continue to mature with increasing complexity throughout childhood and into adulthood. They allow children to become actively and willfully engaged with others during activities and help children to learn academically, to socialize with others, and to sustain friendships throughout life. Exposure to and enrichment of these concepts must be provided in therapy sessions by the speech-language pathologist but most importantly then should be taught to parents for generalization purposes. Parents should be taught easy and fun ways to elicit these skills throughout daily activities at home such as playing on the playground, completing chores, going to the movies, eating a meal with family, shopping for groceries, packing a lunchbox, walking through a parking lot, etc.
Developing Social Interaction in Therapy Sessions for Family and Life Skills
Based on the nature and complexities of ASD, there are many reasons a child may not be able to interact well with others. Medical, psychological, and cognitive issues may inhibit learning and responsiveness to treatment and should be taken into consideration when addressing interaction skills.
For a speech-language pathologist, understanding pre-linguistic development and language development is essential to proper assessment and treatment of children with ASD. For instance, a child like Johnny (an early level learner) would benefit from learning: solitary play, parallel play, exploratory play, constructive play, simple pretend play, responsive joint attention, initiated joint attention, brief nonverbal reciprocal interaction, tuning to others’ emotions, sharing intentions, basic imitation, and emotion sharing. Following these skills, then a child like Johnny will be ready to learn more attention-based tasks such as proper articulation, basic language production, safety concepts, printing on paper, playing appropriately with toys and peers, and better behavior management. A child like Abigail (a moderate level learner) would benefit from learning: associative play with others, pretend play with a variety of toys and others, symbolic language use (e.g., verbalizations, picture exchange, sign language), longer reciprocal interactions, reacting to a variety of expressions, and using language to regulate behavior. Following these skills, then a child like Abigail will be ready to learn more complex interactions such as basic conversation. A child like Bobby (an advanced level learner) would benefit from learning complex skills: cooperative play, imaginative play, social problem solving, written expression, self-regulation, sharing thoughts and opinions, group conversation, and inferencing. These skills can lead to more independent functioning for a child at any learning level within the home or community.
Joint attention and theory of mind difficulties are often considered the hallmark characteristics of ASD (Bruinsma, 2004, Palmer, 2015). It can deepen the speech-language pathologist’s understanding of a child’s possible thoughts, intentions, expectations, comprehension, behavior, etc. Understanding these concepts can also help speech-language pathologists learn how to teach families to successfully interact with their child. Prelinguistic skills and interaction skills should be an integral part of a child’s treatment plan, despite the child’s support level.
Christie Linkes, MSLP/CCC-SLP
Previously published in the March/April 2016 NDTA Network: Early Intervention Across the Lifespan.
Autism Speaks Inc. (2014). What is autism? Autism Speaks. Retrieved from http://www.autismspeaks.org/what-autism
Bruinsma, Y., et. al. (2004). Joint attention and children with autism: A review of the literature. Mental Retardation and Developmental Disabilities Research Reviews. Vol. 10, 169-175.
Charman, T. (2003). Why is joint attention a pivotal skill in autism? Philosophical Transactions of the Royal Society Biological Sciences. Vol. 358, 315 – 324. DOI 10.1098/rstb.2002.1199.
Miller, C. (2006). Developmental Relationships between Language and Theory of Mind. American Journal of Speech-Language Pathology. Vol. 15, 142-154.
National Institute of Mental Health (2014). What is autism spectrum disorder? National Institutes of Health. Retrieved from http://www.nimh.nih.gov/health/topics/autism-spectrum-disorders-asd/index.shtml
Palmer, et al. (2015). Consciousness and Cognition. pii: S1053-8100(15)00084-7.