Talk Autism

Communication happens when one person sends a message to another person either verbally or non-verbally.  Interaction happens when two people, for example, an adult and a child, respond to one another - a two-way communication.  

Most children with an ASD (autistic spectrum disorder) will have difficulty interacting with others. This is because in order to be successful at interaction the child needs to respond to others when they are approached by them or be able to initiate interactions. Although many children with an ASD are able to do this when they want something, they tend not to use interaction to show people things or to be sociable.

It is important to remember that communication and interaction do not have to involve the use of language and speech. Many children with an ASD are delayed in their use of language and shy away from using speech.   Therefore, other methods of communication need to be established before speech and language will follow.  

Understanding the communication of a child with an ASD

Often parents and carers of children with an ASD feel that they are unable to communicate and interact with their child and are unsure of how to do so. The child may appear not to hear what is said to them, fail to respond to their name and/or be indifferent to any attempts of communication that are made. The use of everyday opportunities and play can encourage communication and interaction in a child with ASD.

The way in which the child communicates needs to be observed in order to develop their communicative strengths and needs. For example, if the child is not using any sound or speech, rather then communicating with them through words, try using gesture. The child with an ASD may use some of the following to communicate with others: crying, taking the adults hand to the object they desire, looking at the object they desire, reaching, using pictures and echolalia.  

Echolalia is the repetition of other people's words and is a common feature of the child with an ASD. Initially when the child uses echolalia it is likely that they are repeating words that they do not understand and are doing so with no communicative intent. However, echolalia is a good sign as it shows that the child's communication is developing - in time, the child will begin to use the repeated words and phrases to communicate something significant. For example, the child may memorise the words that were said to them when they were asked if they would like a drink, and use them later, in a different situation, to ask a question of their own.

Being successful in communication with the child with an ASD, does not only involve an understanding of how they communicate but also requires an understanding of why they communicate. In understanding the purpose of the child's communication you can help the child find more ways and more reasons to communicate.

There are two main different types of communication:

1. Pre-intentional Communication: this is when the child says or does things without intending them to affect those around them. This type of communication can be used by the child to calm themselves, focus themselves or as a reaction to an upsetting/fun experience.
   
2. Intentional Communication: this is when the child says or does things with the purpose of sending a message to another person. This type of communication can be used to protest about what they are being asked to do and to make requests.

Intentional communication is easier for the child once they have learnt that their actions have an effect on other people - the move from pre-intentional communication to intentional communication is a big step for the child with an ASD.

Sussman (1999) believes that it is helpful to view children with an ASD as being on a continuum in terms of their intentional communication, at one end of the continuum are children who communicate mainly to get the things they want, "at the other end are children who communicate for many reasons, such as to ask questions, comment on something or to be sociable".

The four different stages of communication

(as defined by The Hanen Programme)

The stage of communication that the child has reached depends on three things:

1. Their ability to interact with another person
2. How and why they communicate
3. Their understanding.

Stage one - the own agenda stage:

A child at this stage of communication will appear uninterested in the people around them and will tend to play alone. Their communication will be mainly pre-intentional. The majority of children first diagnosed with an ASD are at this stage.

Stage two - the requester stage:

At this stage the child has begun to realise that their actions have an affect on other people. They are likely to communicate to the adult their wants and what they enjoy, by pulling them towards objects, areas or games.

Stage three - the early communicator stage:

At this stage the child's interactions will begin to increase in length and become more intentional. The child may also begin to echo some of the things that they hear to communicate their needs. Gradually the child will begin to point to things that they want to show the adult and begin to shift their gaze this is a sign that child is beginning to engage in a two-way interaction.

Stage four - the partner stage:

When the child reaches this stage they have become a more effective communicator. The child will be using speech to talk and will be able to carry out a simple conversation. While the child may appear confident and capable when using communication in familiar environments (eg at home), they may struggle when they enter unfamiliar territory (eg at a new nursery or school). It is in this situation that they may use memorised phrases and can often appear to be ignoring their communication partner by speaking over them and ignoring the rules of turn taking.

Ways that adults can affect the communication of the child with ASD

Take on the role of a helper and teacher:
When the child is unable to communicate their needs it is tempting to help them by constantly doing things for them. For example, fetching their shoes and tying their shoelaces. However, by doing this the opportunities for the child to show that they can do such things for themselves are reduced.   When the child is at the Own Agenda Stage it is particularly difficult to decipher how much to do for the child. In this instance it is appropriate to ask the child if they need help, wait and then ask a second time before adding the help.

Instead of letting the child do their own thing, encourage them to do things with others:
It is tempting to believe that the child is merely showing their independence when they show no interest in interacting with the adult. However, it is important that the child does learn to interact and is not just left to their own devices. In this instance the key is to persevere with joining in with whatever activity the child is engaged in, whether this is playing with a piece of string or taking toys in and out of the toy box. If the child shows anger and aggression when this is tried, still persevere. Anger is a type of interaction and is better than no interaction at all. As this interaction is continued with the child they may begin to realise in time that interaction with another person can be fun.

Slow down the pace and give the child a chance to communicate:
Caring for a child with an ASD can be hard work and time consuming.   There is often the temptation to rush the child when they are performing daily tasks such as eating breakfast and getting dressed. A child with ASD will benefit from an extra few minutes extra time when engaged in these tasks to help them understand what is happening around them and to think about what they can say during these activities.

When playing with the child take on the role of a partner rather than a leader:
As the child becomes more capable at communicating, they need less direction - if they are given too many questions and suggestions it can become difficult for them to initiate their own conversations. It is important to follow the child's lead and respond to what they do.

Present the child with feedback:
It is important to reward the child when they attempt to understand and communicate. By doing this you can increase the likelihood that they will try and do it again. By using simple descriptive praise that comment on what the child has achieved, the child can make a connection between their own actions and your specific words.

Giving the child with ASD a reason to communicate

If the child with ASD has no difficulty getting what they want, they will have no reason to communicate and interact. Therefore, on many occasions the adult will need to engineer a situation in order to create a communicative opportunity for the child and encourage interaction.

Encouraging requests:
This can be achieved by placing the child's favourite toy/food/video in a place where the child can see it but is unable to reach it, for example, a high shelf. Alternatively, place the child's favourite object in a container, which the child finds difficult to open such as an old ice-cream tub or an old jam jar. This will encourage the child to ask for help and result in an interaction between adult and child.

Give the child a toy that is difficult to operate:
Wind up toys and games that need to be squeezed to make them work will be difficult for the child to operate alone but will also interest the child.   Once the child has been given the toy/game, allow them some time to establish how to use it. When the child becomes frustrated at their inability to work the toy/game, the adult can step in and help them. Examples of this type of toy include Jack-in-the-boxes, spinning tops and music boxes.

Give the child a toy that is "high interest":
Balloons and bubbles are high interest toys and can be easily adapted to involve two people. Simple games such as blowing up a balloon and then letting it go so that it flies up in the air may appeal to the child. Blowing up the balloon part way and waiting for a response from the child before blowing it up to its full capacity is also a clever way to enhance interaction between adult and child.  A similar thing can be achieved with bubbles - blow a few bubbles towards the child, once their attention has been captured, close the container and wait for a response from them before you blow any more.

Give things to the child gradually:
If the child is given everything that they wants they will have no reason to ask the adult for anything else. By staggering how much food/how many toys are given to the child they are provided with opportunities to interact by expressing their wants and needs. For example, if the child wants a biscuit, break it into small pieces, initially give them one piece and then gradually given them more once they have communicated a request for it.

Let the child decide when to end an activity:
Once the child is engaged in an activity with the adult, carry on with that activity until the child indicates that they have had enough. Look out for facial grimaces or the child pushing away the activity. This way, the child is forced to communicate that they are ready to finish the activity. If the child does not use language to indicate they have finished, accompany their form of communication with words such as had enough and stop to encourage their language development.

Increasing interaction by following the child's lead

Following the child's lead rather than directing them will enable them to learn to communicate while they do things with another person, hence increasing their interaction. The child that leads is more likely to pay attention to the activity, more likely to focus on the same thing as the adult and will learn how to make choices for themselves.

When following the child's lead it is beneficial to be in a position where the adult is face-to-face with the child, this way the adult can easily observe what it is that the child is interested in. It will also help the child to make eye contact - something that can often be difficult for the child with an ASD.   Being level with the child will also ensure that they are in a position to see the variety of facial expressions that are used in communication. A child with an ASD will often fail to pick up on these non-verbal communicative behaviours during conversation; therefore, it is important to draw attention to them where possible. It is hoped that the child will eventually become used to the adult playing with them at their level and begin to anticipate their presence, fetching them if they are not there.

Imitating the child's actions and words will help the child become involved in two-way interactions. If the child bangs the spoon on the table, and the adult does the same, it is likely that the child will pay attention to the adult. This idea can also be used with sounds that the child makes or with the child's sensory behaviours, for example, hand flapping and spinning.   Once the child has established that the adult is imitating her actions, they may begin to imitate back. This creates the opportunity for the adult to add something new to the exchange for the child to duplicate.

When the child with an ASD is disinterested in playing with any of the toys presented, or prefers to line toys up rather then play with them, there are still communication and interaction opportunities available. For example, if the child is lining up their cars in a row, the adult can join in the activity by handing the child the cars one by one. This way, the adult plays a part in the game and the child has to include them in what they are doing. If the child is only interested in throwing the toys on the floor, the adult could use a basket to collect them before giving them back to them, thus establishing a pattern of interaction and communication with the child.

Ways that adults can help the child with an ASD understand what is said to them

A child with an ASD will find processing information a difficult thing to do.   This is because they may find it difficult to understand the world around them. Even when the child with an ASD does understand a situation, they may not understand the words that go with that situation. Sometimes it is easy to assume that the child understands what is being said to them because they appear to follow instructions. However, the likelihood is that the child will know what to do when instructions are given in certain contexts because they have done it numerous times previously.

There are several ways in which to enhance a child's comprehension of what people are saying to them.

Say less and say it slowly:
The adult can limit the amount of words they use to communicate with the child but still communicate the relevant information. Use key words that are specific to the context of the situation, repeat and stress them and use gesture, such as pointing, to accompany them. Sussman (1999) uses the following rhyme as a reminder of how an adult make it easier for a child with an ASD to understand them:

"Say less and stress, go slow and show!"

If the child has only recently begun to use speech as a means of communication, the adult should use single words to communicate with them. For example, labelling favourite toys and food. When using this method of communication it is important to label things when they are immediately given to the child. If the child's attention has shifted onto the something else, the word will lose its meaning.

Pausing in between spoken words and phrases can also help the child with an ASD to understand what is said to them. The adult should use pauses to give the child time to process what has been said to them and to give them an opportunity to think of a response.

Using gestures to accompany language can also encourage the child to understand what is being said to them. For example, when offering the child a drink the adult should gesture the action of drinking by pretending to hold a glass in one hand and bringing it their mouth as if they were taking a sip. A similar thing can be used for eating. Over exaggerated facial expressions can also be used along with shaking the head for "yes" and "no" and a waving of the had for "hello" and "goodbye". When talking to the child about people, for example "grandma is staying", it helps to present the child with a photo of who is being spoken about.

Other visual methods that can be used to increase understanding include picture timetables, line drawings, cue cards and object/picture schedules.  

Using Augmentative and Alternative Communication (AAC) supports

AAC describes any form of language other than speech that assists a child in social-communicative interactions. There is a large range of AAC devices available for children who have no speech, and these children themselves are very diverse. Therefore, it is essential that a team of appropriate individuals evaluate different AAC options with the parents of a child with ASD, before a decision about their use is made. Criteria that need to be discussed before an AAC device is implemented include, cognitive and motor abilities, learning style, communication needs and literacy ability.

The use of AAC devices for children with ASD can be particularly helpful.   Those children with ASD who have no spoken language often resort to challenging behaviours to meet their needs and feelings. The use of an AAC device can give them a primary means of social communicative interactions with others. If it is decided that an AAC device is appropriate for the child it is the responsibility of those around them to model the system.

Different types of AAC devices that are suitable for the child with ASD include:

• Picture Exchange Communication System (PECS, Frost and Bondy, 1994)*
• Sign Language
• Interactive Communication Boards
• Communication Cue Cards
• Conversation Books
• Voice Output Communication Aids.

* An information sheet on this system is available from the NAS Helpline.

Sign language:

There are several difference sign language systems, for example, American Sign Language (ASL), British Sign Language (BSL), Makaton^TM , Paget Gorman Signed Speech^TM  and Signed Exact English. When using sign language with a child with an ASD, it can be beneficial to use a total communication approach. Total Communication is the use of combined speech and sign so that the same language structure is modelled for the child in two modalities. The use of total communication helps to highlight key word meanings and help language comprehension.

Interactive communication boards:

Interactive Communication Boards contain visual symbols organised by topic. They can be created in different sizes and formats depending on the activity and environment that they are needed for. They can be both portable and stationary - one board is designed to stay in one location. The selection and organisation of the symbols that are used need to be motivating and chosen to enhance functional communication for the child.

Cue cards:

Cue cards are primarily used with verbal children. They are used to remind the child what to say and to provide them with an alternative means to communication. They can contain one or more messages in pictorial or written form and can replace verbal prompts. They are therefore, particularly useful for children who are reliant on verbal prompts. Cue cards can work well in situations where the child with an ASD needs to express a message in a stressful situation.

Conversation books:

A conversation book can be pictorial or consist of a written summary of conversation topics used for increasing conversational abilities. The conversational topics are organised in a small book, wallet or something similar and are used as a focus of conversation with an adult. It is important that the book is age appropriate and the topics chosen, meaningful to the child. This can often be achieved best using photographs - especially for the younger child. Conversation books work by organising the conversation for the child. They provide a concrete, visual means to share and maintain topics.

Voice output communication aids:

Speech output devices give non-verbal children a "voice". A team of relevant professionals should determine the most appropriate technology option. Once this has been established the team then need to decide on an appropriate vocabulary selection, the layout of the device, the size of the symbols and the principal situations to encourage the child to use the device. There are a wide range of devices available including simpler ones for people who do not understand visual symbols. In order to use these devices, the child will need an understanding of cause and effect. One type of such a device is the BIGmack^TM  (contact Ability Net or the Ace Centre for further information).

The combined use of AAC, social supports, organisational supports and visually cued instruction can enhance the social communicative interactions in children with autism.

© The National Autistic Society 2003