Parent-Child Interaction and Autism Spectrum Disorder ASD

Language and Communication Intervention for Children with Autism
Children with autism who have little or no functional speech may be taught pointing skills through modeling or physical prompting. An effective touch or point can be used to access single symbols expressing different communicative functions. Once a child has learned to use single symbols effectively, a transition from single- to multisymbol use will enable the child to express numerous semantic relationships encoded with two or more symbols. For children with autism who use AAC and have achieved single-symbol proficiency, using multisymbol combinations should enhance their communicative competence and socialization skills.

Approaches for Teaching Early Multisymbol Combinations
One of the goals of language intervention for children with autism who are using single-word or single-symbol utterances is to train them to comprehend and express, either using speech or using AAC, word combinations they have never heard or been taught before. It is not feasible to train each combination of symbols; therefore, language intervention strategies should focus on the understanding and production of novel word combinations with the least amount of training. In this section, two approaches that are useful in the instruction of early symbol combinations to children with autism are discussed. These approaches are useful during dynamic assessment to determine the potential for multisymbol productions.

Matrix Strategy
The matrix strategy employs linguistic elements (e.g., nouns, verbs, adjectives) arranged in systematic combination matrices that are designed to induce generalized, rule-like behavior. The clinician combines a limited set of words in one semantic category with another set in a related semantic category to help the child combine lexical items in unique communicative ways and to generalize these skills to new content and contexts (Nelson, 1973). The matrix strategy helps children with disabilities maximize their abilities to recombine lexical items.

The matrix strategy has been successfully used as one of the intervention procedures to teach generalized word combining skills to children with mental retardation and other developmental disabilities. Trained semantic relations using a matrix strategy include action-object (e.g., Striefiel, Wetherby, & Karlan, 1976, 1978; Karlan, Brenn-White, Lentz, Hodur, Egger, & Frankoff, 1982; Romski & Ruder, 1984), object-location or preposition-object (e.g., Bunce, Ruder, & Ruder, 1985; Ezell & Goldstein, 1989; Light, Watson, & Remington, 1990), and descriptor-object (e.g., Remington, Watson, & Light, 1990). Although attempts have been made to teach word combining skills to children with little or no functional speech using a matrix strategy with unaided systems such as Signed English (Karlan et al., 1982), speech + sign (Romski & Ruder, 1984), and manual signs (Light ct al., 1990; Remington et al., 1990), more research is needed to develop strategies for incorporating matrix training strategies into language interventions in naturalistic contexts (Goldstein, 1993).  An example of a 4 x 4 matrix with action-object combinations is shown in Figure 1. A row represents an action and a column represents an object. Each cell of the matrix represents a unique action-object combination with the possibility of 16 action-object combinations. A clinician trains a subset of symbol combinations, and once the child has learned the subset the training starts on the next subset. The stepwise progression in the matrix provides the discriminative stimuli, and the child's response to the items of the matrix that are not in training subsets determines the generalization.

The matrix strategy is clearly an effective way of teaching manual sign (Light et al., 1990; Remington et al., 1990) and graphic symbol combinations (Nigam, 1999) to children with disabilities, but there is insufficient empirical evidence to support the efficacy of the matrix strategy for teaching children with autism. To date, only Nigam (1999) has demonstrated the efficacy of matrix instruction with children with autism, and his small sample (n = 2) prevents the generalization of findings. Further systematic replication studies are needed to determine the effectiveness of the matrix strategy to teach word, manual signs, and graphic symbol combinations to children with autism. Because each child possesses different strengths and weaknesses, the case study method and single-participant design would be suitable approaches to strengthen the existing knowledge base regarding the use of the matrix strategy.

Milieu Language Teaching Strategies
Intervention approaches applying naturalistic strategies have been used effectively to teach lexical forms, early semantic relational forms, and requesting as well as to increase spontaneous use of language in children with language deficits (Kaiser & Hester, 1994). Milieu language teaching is a general model of language intervention, used to teach both the content and the pragmatic use of language; it includes specific techniques such as incidental teaching (Hart & Risley, 1968), the mand-model procedure (Rogers-Warren & Warren, 1980), time-delay (Halle, Marshall, & Spradlin, 1979), focused stimulation (Leonard, 1981), and systematic commenting (Warren & Bambara, 1989). Milieu language teaching "is characterized by use of dispersed teaching 'episodes' that are embedded in ongoing activities and interactions... and an orientation toward teaching the form and content of communication and language in the context of typical use" (Warren, Gazdag, Bambara, & Jones, 1994, p. 924). Like the matrix strategy, milieu teaching appears to provide instructional options for teaching multisymbol combinations during dynamic assessment.

Milieu language teaching has been effective in teaching children with language disorders who do not speak frequently and who are learning early vocabulary and early semantic relations (Kaiser, Yoder, & Keetz, 1992). Early semantic relationships taught using specific milieu teaching approaches include agent-action, action-object, modifier-noun, and agent-action-object (Cavallaro & Bambara, 1982; Charlop, Schreibman, & Thibodeau, 1985; Hart & Risely, 1974; Warren & Gazdag, 1990; Warren et al., 1994). Specific training techniques such as incidental teaching, time delay and the mand-model procedure have been integrated into systematic approaches for early communication intervention. Strategies investigated have included the following:

1. A combination of the mand-model procedure and incidental teaching (Warren & Bambara, 1989; Warren & Gazdag, 1990; Warren et al., 1994).
2. A combination of incidental teaching, the mand-model procedure, and time delay (Warren, Yoder, Gazdag, Kim, & Jones, 1993).
3. A combination of child-cued modeling, the mand-model procedure, time delay, and incidental teaching (Kaiser & Hester, 1994).

Incidental Teaching. Incidental teaching has strong empirical support to validate its effectiveness in developing generalized communication skills in children with autism (McGee, Daly, Izeman, Mann, & Risley, 1991; McGee, Krantz, Manson, & McClannahan, 1983; McGee, Krantz, & McClannahan, 1999). Incidental teaching and the mand-model procedure are similar except that incidental teaching is child initiated, whereas the mand-model procedure is adult initiated through open-ended questions (e.g., "What is this?") or mands (e.g., "Tell me what do you want?").  The incidental-teaching strategy uses the naturally arising interactions between an adult and a child (e.g., play activity), and the adult systematically provides language instruction to develop communication skills (Hart & Risley, 1975). The child controls the incidence or activity in which language teaching occurs. A single, incidental-teaching episode with a child using graphic symbols might work like this:

(Context: During snack time, a child points to the symbol for "juice." The goal is to teach the graphic symbol combination with an action [verb] and object [noun].)

Child: Gains attention of an adult by vocalization and points to the symbol for "juice."
Adult: Focuses attention on the child and asks, "What do you want?"
Child: Points to the symbol for "juice."
Adult: Points to the symbol for "want" followed by the symbol for "juice" (modeling).
Child: Imitates the adult model by pointing to the symbol for "want" followed by the symbol for "juice."
Adult: Gives the child juice and says, "Alright. You want some juice. Here it is" (verbal acknowledgement + expansion).

Mand-Model.The mand-model strategy is a variation of incidental teaching in which teaching interactions are adult or clinician controlled rather than child initiated. The adult chooses a time to approach the child and request verbal behavior by using mands (a non-yes/no question) and if the child's response is incomplete or incorrect, provides a model (imitative prompts). A typical episode using the mand-model procedure with a child using graphic symbols might work like this:

(Context: Child is washing face after a snack activity. The goal is to teach the graphic symbol combination with an action [verb] and object [noun].)

Adult: "What are you doing?" (an open-ended question that requires more than a "yes" or "no" answer).
Child: No response
Adult: "Tell me by pointing to symbols" (mand).
Child: "Face" (points to the symbol for "face").
Adult: "Wash face" (provides a model by pointing to the symbol for "wash" followed by the symbol for "face").
Child: "Wash face" (imitates adult's model by first pointing to the symbol for "wash" followed by the symbol for "face").
Adult: "That's right, you are washing your face" (positive feedback + verbal acknowledgement + expansion).

The adult will wait for another opportunity to use the procedure if the child does not respond to the model. After an open-ended question, mand, and model, an expectant pause of 3 to 4 seconds is provided.

Conclusions
Each child with autism has different strengths and weaknesses and poses unique challenges for speech and language practitioners considering the use of AAC. It is this author's hope that this article will encourage readers to consider the use of dynamic assessment when evaluating children for AAC systems. Furthermore, this author encourages practitioners to try the instructional strategies reviewed in the paper both during and after dynamic assessment to determine the potential for, and facilitate, multisymbol productions in children with autism.
- Nigam, Ravi; Dynamic assessment of graphic symbol combinations by children with autism; Focus on Autism & Other Developmental Disabilities, Fall 2001, Vol. 16, Issue 3.

Personal Reflection Exercise #8
The preceding section contained information about intervention strategies useful during and after dynamic assessment.   Write three case study examples regarding how you might use the content of this section in your practice.

Update
Sensory Integration Training
and Social Sports Games Integrated
Intervention for the Occupational Therapy
of Children with Autism

- Wang, Z., Gui, Y., & Nie, W. (2022). Sensory Integration Training and Social Sports Games Integrated Intervention for the Occupational Therapy of Children with Autism. Occupational therapy international, 2022, 9693648.

Peer-Reviewed Journal Article References:
Crown, N. J. (2021). Oh no! I see a pit: Making sense of the sensory on the autism spectrum. Psychoanalytic Psychology. Advance online publication.

Proff, I., Williams, G. L., Quadt, L., & Garfinkel, S. N. (2021). Sensory processing in autism across exteroceptive and interoceptive domains. Psychology & Neuroscience. Advance online publication.

Ungar, W. J., Tsiplova, K., Millar, N., & Smith, I. M. (2018). Development of the Resource Use Questionnaire (RUQ–P) for families with preschool children with neurodevelopmental disorders: Validation in children with autism spectrum disorder. Clinical Practice in Pediatric Psychology, 6(2), 164–178.

Online Continuing Education QUESTION 15
What is one of the goals of language intervention for children with autism who are using single-word or single-symbol utterances? Record the letter of the correct answer the CEU Test.