AAC&ASD-ResearchtoPractice - Joanne Cafierojoannecafiero.com/articles/ResearchtoPractice.pdf · Teachers completed questionnaire regarding ... • Progress in using AAC functionally

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Autism and AAC: ��Research to Practice��

April 24, 2010 ��

Joanne M Cafiero, Ph.D. www.cafierocommunications.com

[email protected]

Joanne M. Cafiero PhD, 2010

“If you plant lettuce and the lettuce doesn’t grow, don’t blame the lettuce. You look for reasons

why it isn’t doing well.” Thich Nhat Hahn, from Peace is

Every Step


What We Will Do Today��•  What is AAC? •  The nature of Autism: What’s New? •  How do AAC and Autism fit? •  AAC, ABA & Interaction therapies •  Case Studies in AAC & Autism

– Environment & AAC – Behavior & AAC – AAC & Social Interaction – AAC & Literacy – AAC & Group Instruction


Recommendations: National Academy of Sciences Report

•  Planned, repeated learning opportunities •  Data based instruction •  Focus on social skills •  Access to typical peers •  Emphasis on functional spontaneous

communication


What is Augmentative and Alternative Communication?��

(AAC)

– Compensates for or replaces speech – Multi-modal – Provides supports for development of language –  Includes no-tech, low-tech, high tech – Sign language, pictures, text, PECS – No pre-requisites


Aided & Unaided AAC ��(Millar, Light & Schlosser, 2006, Mirenda, 2003)

•  Unaided - Manual Signs, gestures, body language –  Requires good fine motor abilities –  Unlimited vocabulary –  Portable –  Not readily comprehensible

•  Aided - SGDs, communication boards, keyboards, paper and pencil, email –  requires lower fine motor skills –  more readily comprehensible –  not portable


Both aided and unaided AAC predominantly��

promote��and do not inhibit speech.��

(and there is NO research indicating one is superior to the other)��

(Mirenda, 2005; Millar, Light and Schlosser, 2006) Joanne M. Cafiero PhD, 2010

Myths about AAC and Autism: •  Inhibit speech development •  Not needed if student has some speech •  Providing AAC insures student will use it •  Success or failure depends on trial period •  No & low-tech are better options


Learning Characteristics in ASD – the Paradoxes

•  Visual processing •  Multiple cue responding •  Stimulus over-selectivity •  Affective & Social Learning •  Sensory Issues •  Motor Planning: motor movements including

speech –  “Cannot show what they know.”


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•  Autism and Intelligence Timeline •  Reviewed 215 articles (1937-2003) •  74% of claims non-empirical sources •  53% of 74% not traced to any data •  Empirical data was from developmental or adaptive scores

rather than cognitive scores –  Language based –  Unanswered questions considered wrong


Autism and Motor Planning

•  Atypical “Reach to Grasp” Movements –  (Mari et.al, 2003)

•  Atypical & Impaired Movement Preparation & Initiation

–  (Rhinehart et.al. 2005; Rhinehart, Bellgrove, et.al., 2006)

•  Impaired Movement Toward Goal –  (Vernazza-Martin, et. Al., 2006)


Autism and Motor Planning •  Motor Delays, difficulty in executing movements,

exacerbated by stress –  Bauman, (1992)

•  Persistence of newborn reflexes, stiffening when held, stereotypies –  (Mari et.al, 2003)

•  Parkinsonian movements –  (Vilensky, 1981)

•  Failure to use gestures in communication –  (Mari et. Al., 2003)


Conclusions of Researchers in ASD and Motor Skills

•  Motor disturbances are intrinsic to autism. •  Early motor “soft signs” may indicate

autism. •  Shift in focus to movement perspective may

inform practice and intervention. •  Individuals with ASD may not be able to

show what they know.


Autism and Co morbidity with Affective Disorders

•  Oppositional-Defiant Disorder •  Obsessive-Compulsive Disorder •  Anxiety Disorder •  Psychosis •  Selective Mutism


How do our AAC approaches differ with children with autism?

•  Behavioral issues •  Motor issues •  Sensory issues •  Visual strengths •  Social and affective difficulties •  Motivation •  Multiple cue responding/stimulus

overselectivity Joanne M. Cafiero PhD, 2010

“The field of ASD is littered with the debris of dead ends, crushed hopes, ineffective treatments, and false starts.”

–  Laura Shreibman, 2005


Progress?

•  Deinstitutionalization •  Outcomes better for individuals 70 & above •  Outcomes for 50-70: dependent on others •  Outcomes dismal for individuals 50 and

below most of whom are non-verbal


Feedback from the Autism Self-Advocacy Movement

•  Fluent AAC users who started with FC •  Extinguishing behaviors = extinguishing

communication •  “Movement Inertia” •  www.neurodiversity.com •  “Real-Time Speech” (2005, Smith)


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Belief Systems about Autism and Communication

•  Nothing to communicate – no intent •  Only communicate what they want. •  Repeat the same scripts over and over. •  Too “low functioning”or cognitively disabled •  Behaviors must first be under control •  Easier to pre-empt communication


Belief Systems Research Study

•  Teachers completed questionnaire regarding their beliefs concerning students with autism.

•  Observers completed a Classrooms Inventory

•  Belief scores were correlated with robustness of classroom materials, curriculum and student engagement


Teacher Beliefs and Quality of Instructional/Communicative Enviroment

3326

20 19

30

4654

66

109

97 98

45

0

20

40

60

80

100

120

JH MC CZ JC CP GK

Belief ScoreEnvironment


Correlation between Beliefs about Behavior and Creation of Literacy-

rich Environment

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

JC CP JH GK

BehaviorLiteracy


Communication Patterns in ASD

•  50% with no functional language 20-30% who develop speech lose it

•  Limited to requesting and refusing •  Inconsistent patterns of language expression •  Unique developmental sequence of

language skills •  Symbolic language (speech or sign)

sometimes emerging in adolescence Joanne M. Cafiero PhD, 2010

In light of what is not known about ASD, practitioners must

make the least harmful assumptions regarding the

cognitive and communicative potential of their students.


What we DO know about what students with ASD can learn

with AAC: •  Aided and unaided AAC for requesting and choice

making. •  Aided or unaided AAC to escape undesirable

situations. •  Aided AAC concurrently increases speech. •  Non-speaking is not a fixed condition.


What we DO know…

•  Manual signs as FSC requires good fine motor skills

•  Speech development with both aided and unaided AAC is dependent upon verbal imitation skills

•  Progress in using AAC functionally is dependent upon the commitment and competence of the communication partner.


Autism and Aided AAC: What are evidence-based practices?��

(Wendt, Schlosser & Lloyd, 2005) •  Functional Communication Training

–  “highly effective”

•  Picture Exchange Communication System –  “fairly effective”

•  Augmented Input Strategies –  “effective”

•  Speech Generating Devices –  “highly effective”


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AAC: Course 101��Visual Supports: Receptive Input •  Schedules •  Picture prompts •  Written directions •  Visual behavior cues •  Token boards

Joanne M. Cafiero PhD, 2010 Joanne M. Cafiero PhD, 2010 Joanne M. Cafiero PhD, 2010

Cues Effecting Single Prompt Compliance

Types of Cues Effecting Single Prompt Compliance: Academic & Play Settings

57

46

8

0

10

20

30

40

50

60

1 2 3Visual + any other Visual & Verbal Verbal no visual


Natural Aided Language

Facilitating Communication

for Students

with Autism Spectrum Disorders & other

Disabilities Joanne M. Cafiero PhD, 2010

Interface of AAC (aided) and ASD

ASD AAC Visual processing Uses visual medium

Motor planning Requires less motor skill

Multiple Cue Responding Scaffolding for complexity

Social difficulties Buffer and bridge

Interest in inanimate objects

Uses tools & technology Joanne M. Cafiero PhD, 2010

Visual Supports for Self Management: Schedules/Activity

Schedules


Schedules & Activity Schedules

•  Within and Between Activity Schedules •  Basic – Do this first & don’t discontinue! •  Decreases behavioral difficulties •  Promotes self-management •  Visual Closure Systems •  Teach “most to least” prompts


Case Study: “Justin to the Office”

•  4 years old, Down Syndrome with ASD

•  Non-compliant

•  Bolting behavior


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Activity Schedule with Far Reaching Results: Mikayla ��

•  5 years old; Dx ASD •  Severe behaviors •  Restricted food preferences •  Interest in text •  Introduced an action story about food with

Makalya as the star. •  Result: increases in speech, engagement, &

food preferences Joanne M. Cafiero PhD, 2010

Cocoy’s Visually Augmented Life

•  5 years old •  Attends special school •  Non-verbal •  Severe tantrum behaviors for variety of

antecedents, including transitions. •  Intervention: augmented input, engineered

environments


AAC (Augmented Input) for Problem Behaviors

•  Problem behaviors typical •  From the perspective of the adult

– Property destruction, non-compliance, aggression, & self-injurious behavior

•  From the perspective of the student –  confused, cannot express needs, cannot

understand expectations, painful sensory issues


AAC for Behavior Management: The Reinforcer Puzzle

•  Identify reinforcers frequently. •  Take picture (photo or scan) of reinforcer. •  Place word label above picture of reinforcer. •  Laminate; cut into vertical sections by letter. •  Place Velcro on clip board and puzzle sections.

Joanne M. Cafiero PhD, 2010 Joanne M. Cafiero PhD, 2010


When a child can’t communicate: •  Nature abhors a vacuum •  ALL behavior is communication •  What is the function of the behavior?

– Attention – Sensory – Escape – Tangible – Or they just don’t know or can’t say


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What is Functional Communication training?

•  Replacing an undesirable behavior with a functionally equivalent one

•  Identify the communicative function of the behavior

•  Design an alternative that is as efficient, effective, recognizable, acceptable


Functional Communication Training

•  Identify behavior (type, incidence) •  Identify function (MAS) •  Design FCT Intervention

–  Select replacement behavior –  Design AAC tool –  Train Staff (prompt hierarchy) –  Collect and Analyze data

–  Replaces socially unacceptable behavior with an acceptable communicative response


Functional Communication Training

•  Response match - Function of old behavior must match the message of new response.

•  Response success - Communication partners must respond to new behavior.

•  Response efficiency - New behavior must be as efficient as aberrant behavior in providing the desired response.


Utilizing student interests for AAC-PBS self monitoring��

•  Student: Nathan – 10 years old – Non-verbal – Non-compliant – Fascination with numbers


Intervention •  MAS to determine function of non-compliance:

tangible •  Use of stereotypic interest in numbers to develop

geometric token system •  Taught Nathan to self-monitor (set/reset timer)

with least to most AAC prompting •  Taught Nathan to request reinforcer using script


I am working for popcorn.

I need to earn 40

10 10 10

10 10 10


Applying AAC-based Behavior Management Systems to HFA

and Asperger’s •  Provide visual (with self-monitoring)

–  Task expectations •  How many must be completed; how much time to spend

–  Rewards •  Give choice of rewards; vary rewards

–  How much time between work and break •  (work; 9:00-10:30 Break: 10:30-10:45)


Zach’s Contingency Map


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Augmented Input: ��System for Augmenting Language (SAL)

•  Romski & Sevcik (2009) •  Visual symbols on SGD •  Communication partner integrates SGD use

with own spoken language •  Pairs speech with symbols •  Language model for non-speaker


System for Augmenting Language: Research

•  School-aged children •  Integrated use of SGDs into extant vocal

and gestural repertoires •  Able to communicate more appropriate, less

ambiguous information to symbol-naïve communication partners.

•  (Romski, Sevcik, Robinson et.al. 1994; Romski, Sevcik & Wilkinson, 1994)


Toddler Study: SAL��Romski, Sevcik, Smith, Barker, Folan & Barton-Hulsey, 2009)

•  60 randomly placed toddler/parent dyads •  ACI (input); ACO (output) & SCI (speech) •  Parent Training (8 weeks); parent practice

w. feedback (7 weeks); parent solos (9 weeks)

•  30 minutes: 10 minutes of play; 10 minutes, literacy; 10 minutes snack


Toddler Study: Results for ASD Participants ��

•  Retrospective Analysis of 11 of 60 dyads •  ACI & ACO had gains of 4 and 3 months

on Sequenced Inventory of Communication Development (4/6 children)

•  SCI had gains of .5 and 3.6 months (all 5 children)

•  Are gains maturational?


Toddler Study: More Results ��

•  All children in ACI & ACO were able to communicate after 18 sessions & maintained those skills.

•  Only some in the SCI group spoke

•  ACI/ACO= 5% SCI = 1.13%


Augmented Input and Behavior Regulation

•  Lilly –  5 years old – Non-verbal – Frequent behavioral issues (tantrums,

aggression) – Failure of ABA “DRO” “DRI” and extinction

techniques


PODDs ��Pragmatically Organized Dynamic Displays-

promising practice in ASD

•  Ultimate augmented input tool •  Used with physical disabilities first •  Large static vocabulary set •  Addresses multiple communicative

functions •  Uses pragmatic branch starters


PODDS as “pencil” •  The PAS tool:

–  No-tech or light tech –  Print alphabet flip chart is option –  May include a SGD (“keep going” “that’s it”) –  Includes “finished” as a choice

•  The communication partner: –  States choices –  Does not ask questions –  Pauses between choices –  Offers finished as a choice –  Attributes meaning to choices


PODDS & Partner Assisted Scanning��(Burkhart & Porter)


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Augmented Input & Behavior Regulation ��

•  Adapted PODDS •  Input given at first sign of difficulty •  Lilly was asked “What’s wrong” on

PODDS •  Lilly said “I don’t know” using PODDS •  Difficulty immediately stopped


Goossens’, Crain and Elder


Implementing Data Based AAC Interventions

•  Merging AAC and ABA •  Moving towards center from DTT to

Naturalistic •  Natural Language Paradigm + Aided

Language Stimulation = Natural Aided Language

•  Natural Language Paradigm > Pivotal Response Treatments


Pivotal Response Treatments (PRT)��

(Koegel & Koegel, 2006)

•  Applied Behavior Analysis Treatment •  Delivered in Natural Environments •  Validated by 100+ published studies •  University of California, Santa Barbara •  Interfaces with AAC Interventions


What is Natural Aided Language?

•  Receptive language training

•  Speech paired with key visuals

•  Expectation, but no pressure that language will occur

•  Input, Input, Input: communication partner


Natural Aided Language Requires enough vocabulary to say what you want

to say and when you want to say it!


Natural Aided Language is NOT

•  Quizzing with an AAC tool or device •  Saying “Touch this one.” or “Do this.” •  Using hand over hand •  Communication boards only •  Restricted to 100% non-verbal individuals


What are you modeling?

• Verbs, nouns, descriptors •  Syntax and pragmatics • Operational use of vocabulary • Mistakes and repair strategies


Aided Language: Backing it up!

•  Cafiero (1995, 2001) •  Dexter (1998) •  Drager, Postal et.al., (2006) •  Acheson, (2006) •  Romski, Sevcik et.al., (1994, 2009)


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Natural Aided Language

•  The “mother tongue” method •  Requires practice •  Requires developing a habit & a Mind

Change •  Communication device/tools must

ALWAYS be available


PRT and NAL: How do they compare?

Pivotal Response Treatments •  Shared control •  Natural reinforcers •  Mix new with mastered

vocabularies •  Partner extends engagement •  All attempts are reinforced

Natural Aided Language •  Shared control •  Natural reinforcers •  Mixes new with mastered

vocabularies •  Communication partner

extends engagement •  All communicative attempts

reinforced


Looking at typical babies & toddlers

•  How long do we talk to babies and toddlers giving them receptive input before we expect them to start talking?

– One month? –  3 months? –  1 year?


How many times???

•  Does a typical one-year-old hear the word “daddy” before she/he says it?

•  Does a non-speaking student see/hear a word from a communication partner before she/he can functionally use it?


Typical Babies and Toddlers

•  Hear spoken language from their caregivers for a year before they speak.

•  Prior to speaking, have a receptive vocabulary of about 50 words.

•  Develop vocalizations & gestures for requesting & commenting.

•  At 12-15 months, produce word approximations & have a 50 word vocabulary.

•  Focus is on pragmatics of language. Joanne M. Cafiero PhD, 2010

LET’S COMPARE: SPEAKING CHILD SYMBOL USING CHILD

Receiving speech services 2x/wk, 30 minutes

4380 hours exposure to oral language by 18 months of age

84 years

36,500 hours of language immersion, including corrective feedback @ 9-12 years of age

701 years


Zak

•  3 years old; middle child of 3 •  Involved parents •  Communicates by taking hand of adult

(non-symbolic) •  Tantrums •  Aggressive •  Seems to “read” video material


Objective: will increase communicative interactions ��

•  Intervention – Identify reinforcing activity – Identify vocabulary – Create Natural Aided Language

comboard – Train communication partners


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Prompts & Protocols

•  Natural Aided Language – Environmental – Modeling – Shaping – Expanding – Reinforcing –  (“A picture is not a demand for speech, but a

model for language.” [Delsack, 2007]) Joanne M. Cafiero PhD, 2010

Natural Aided Language: Parent-Child Time Sample

•  Parent verbal initiations •  Parent verbal responses •  Parent picture initiations •  Parent picture responses •  Child verbal initiations •  Child verbal responses •  Child picture initiations •  Child picture responses


Number of Communicative Initiations and Responses: Parent and Child with and

without NALS

02468

1012

1 2 3 4 5 6 7 8Weekly Probes

parentchild


00.5

11.5

22.5

33.5

4

NVComm

BodyUse

VerbalComm

Pre-NAL

Post NAL

Parent Perception of Autistic Symptoms on CARS (mean)


Parent Stress (Mean) on Parent Stress Index Pre & Post NALS

0%10%20%30%40%50%60%70%80%90%

Pre-NALSPost NALS


Observable, Measurable Communication Behaviors

•  Receptive – Eye contact with communication device – Visual shifting from icon to icon – Visually following “point” of partner – Shifting attention from device to partner – Global change in behavior – Modeling – Responding with voice or AAC


Observable, Measurable Communication Behaviors

•  Expressive – Visually echoing communication partner – Vocalizations – Visual shifting as a response – Pointing, touching symbols, chaining symbols –  Initiating by pointing, touching, vocalizing or

using speech


Case Study: Timothy

•  13 years old, non-verbal •  Learned 5 signs in 5 years •  Diagnosis of Autism (severe range) •  Aggressive, bolts from classroom •  Self-stimulatory behaviors •  Screaming


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Timothy- Natural Aided Language Intervention

•  Increased augmented communicative input (visual symbols) from 9 to over 60

•  Engineered all environments and activities for communication

•  All staff trained in Natural Aided Language


Number of PCS Initiations with Natural Aided Language Intervention

0

5

10

15

20

25

30

Baseline INV AfterESY

ResumeNAL



Charting “Bolting” (standing up, leaving instructional group without directions to do so)

Mean Weekly Incidence of Bolting

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4/29/03

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Week


Results of Natural Aided Language Intervention for Timothy ��

1.  Increased compliance 2.  Decreased bolting 3.  Increase in number of symbols used 4.  More complex & academic IEP 5.  Greater staff satisfaction


What is the ultimate goal of AAC? SNUG

•  Spontaneous •  Novel •  Utterance •  Generation

– The ability to access individual words, expressions, and commonly used phrases.

– Allows an individual to say anything at anytime.


Creating Interactive Communication Boards

•  Observe typical kids; what do they say; what do they need to hear to interact?

•  Include words the student does NOT know; he/she will learn them by exposure to them.

•  Include descriptors, comments •  Each communication board is specific to a

particular environment.


Creating Interactive Comboards

•  Key vocabulary •  Driving vocabulary (beginning, middle, ending

words) •  Directive Vocabulary •  Interactive vocabulary •  Commenting vocabulary •  Exiting vocabulary


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Communication opportunities don’t just happen!

•  They are overtly or covertly embedded in everyday routines

•  Practitioner needs to recognize them or… •  Practitioner needs to create them

•  Engineering the environment •  Creative sabotage •  Interrupted behavior chain •  Time delay


Transitions, PECS and Aided Language Strategies

•  Make least harmful assumption •  Remember communication must be efficient to be

reinforcing •  Include receptive language input always! •  Communication is multi-modal, and inclusive,

not either/or •  Students may transition in and out of needing

Picture Exchange


Natural Aided Language to Facilitate Group Instruction

•  1st year pre-K teacher •  6 students ASD; 2 assistants •  Mandatory group instruction •  All 6 students have behavioral & attention

deficits


Tools & Strategies

•  Identify highly reinforcing activity •  Identify common IEP objectives •  Identify vocabulary •  Create communication boards •  Use Goossens’ Group Instruction model


Using AAC to Facilitate Group Instruction��

(Goossens”, 1998)

•  Identify primary facilitator •  Identify secondary facilitator(s) •  Separate “hot” numbers •  Pair attention magnets with couch potatoes •  Consider symbol size & developmental levels •  Consider symbol location & developmental levels •  Provide a book or comboard for EACH child.


Promising Practices in Autism & AAC: High Tech and state-of-

the-art Low Tech


Activity Boards vs. more Core-based Vocabulary

Activity Boards Core Vocabulary AAC Situation specific Cross activities/situations Less intimidating to communication partners

Can be daunting (PODDS books) & high tech AAC

Self-contained; limited generalizability Structure upon which to build real language

Vocabulary selected by partners More flexible; potential for SNUG Automaticity difficult Automaticity possible Visual discrimination Visual discrimination and motor

planning Expressive/receptive Expressive/receptive


Core & Fringe Vocabulary: both are required for

communication •  Core

–  More open ended –  Applicable to many situations

•  Fringe –  Specific to a particular activity –  Vocabulary size across activities can be enormous


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Selecting Core Vocabulary��(With a few 100 words an individual can

say 80% of what is needed).��

•  Powerful •  Interactive •  Flexible •  Pragmatic


8 Location Phrase-based Core Vocabulary


Amber: First Try with P2G

•  15 years old •  In full inclusion •  Severe SIB and aggression •  No AAC •  Some speech but not always accessible •  Within 2 minutes gave novel information to

communication partner Joanne M. Cafiero PhD, 2010

AAC, Literacy and

Communication ��Literacy as

Augmented Input


Literacy learning includes communication

•  Includes reading, writing and communicating

•  Begins at birth and perhaps even before

•  Occurs around interactions with caregivers

•  Improves quality of life


Emergent Literacy: Reading and writing activities that are precursors

to conventional literacy.

–  Looking at picture books –  Constructing a story from adult readings –  Scribbling on chalkboard or paper –  Manipulating concrete symbols –  Reading logos –  Using storybook language in play


“…the developing understanding of emergent literacy is that much of that learning occurs through interactions with others around

print in naturally occurring situations.”��

(Koppenhaver & Erikson, 2003)


Children with ASD have fewer literacy experiences due to:

– Low expectations – Behavioral difficulties – Lack of appropriate materials – Ghosts of litigation from Facilitated

Communication – Atypical developmental trajectories


Why literacy for children with ASD? ��

•  Visual learners; literacy is visual medium •  Mark of competence in our society •  Supports and stimulates communication •  Provides scaffolding for independence •  Can pre-empt difficult behaviors •  Enriching and appropriate leisure activity •  Can be “window” on hidden cognitive skills •  Mandated by NCLB


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Literacy as Augmented Input Promotes:

•  Pre-linguistic behaviors – Eye contact, babbling, gesturing, attention

shifting, joint attention •  Socialization •  Appropriate play and leisure skills •  Language and communication skills


Promoting Communication through Literacy

•  Dexter (1998) Storybook Aided Language Stimulation increased MLU, initiations and responses

•  Cafiero (2003) Adapted literacy increased use of speech in self-selected reading.

•  Cafiero, Cairns & Silvio (2004) Shared Adapted Literacy increased speech and engagement between parent & child.


Promoting Communication through Literacy

•  Cafiero, Manthey-Silvio & Pearl (2006). Adapted Literature increased appropriate play language and actions.

•  Cafiero & Pearl (2009). Adapted literature around play themes increased speech & language and appropriate play behaviors


Assume EVERY one of your students with ASD has the potential for

enriching and successful literacy experiences

Regardless of how: •  “low functioning” •  “behaviorally disordered” •  “Intense the sensory needs” •  or any other limiting, pre-determined

concept you may have


Investigations of Literacy in Children with Autism

•  Until recently have been limited to conventional literacy (not emergent literacy) focusing on – Hyperlexia – Sight word instruction for basic wants & needs – Reading environmental print


Pre-K Autism & Literacy��Erikson & Koppenhaver (2003)

•  Baseline –  No evidence of print knowledge, selection of books or

emergent writing behaviors •  Intervention

–  Print-rich environment, access to variety of books, writing tools, relaxed practitioner interaction around books

•  Results –  Children selected reading 1/3 of time in free play, more

conventional reading behaviors, vocalized during reading Joanne M. Cafiero PhD, 2010

Adapting Literature: Storybook Aided Language Stimulation ��

(Dexter, 1998)

•  Students with PDD-NOS •  Baseline: read story without AAC supports •  Intervention

–  Adapted age appropriate literature by creating “storyboards” with PCS©

–  Read text; re-read using AAC supports. –  Asked questions, made comments using storyboard

•  Increases in imitative and spontaneous speech and language and mean length of utterances


Interactive Vocabulary for Story Reading

I want More That’s funny!

Uh-oh!

My turn Open the book.

That’s scary!

Close the book.

Your turn Turn the page.

Time for bed.

Where’s the…

Read it again.

Finished


Sample Books with Repeated Lines

The 3 Little Pigs “Little pig, little pig, let me come in.”

Moonbear’s Canoe “Can I come too?”

The Carrot Seed “It won’t come up.”

The Little Engine that Could.

“I think I can, I think I can.”


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Literacy Engagement Study: Secondary Autism Classroom��

(Cafiero, 2003)

•  Literature adapted around meaningful themes •  Use of photos to enhance comprehension •  Text augmented with PCS© or WWS 2000© •  Increase in literacy behaviors, use of speech and

time on task during self-selected reading


Criteria for effective shared storybook reading session:

•  Student is engaged (observable, measurable) –  looking at book –  touching pictures or icons –  turning pages –  shifting attention from book to parent –  responding through speech, gesture, point –  Pleasurable affect

•  Engagement is sustained


Shared Adapted Literacy Pilot Project ��

(Cafiero, Cairns & Manthey-Silvio, 2005). •  Children with ASD can be literate. •  Literacy development occurs around naturally

occurring social interactions. •  Children with ASD and their parents experience

fewer satisfying social interactions with each other.

•  Shared adapted literacy can increase pivotal social skills, positive parent-child interactions and literacy development.


Shared Adapted Literacy Research Protocols

•  Baseline Adapted Parenting Stress Index (PSI) •  Baseline videos parent-child shared reading •  Parent workshops in Shared Adapted Literacy •  Intervention videos parent-child shared reading •  Post administration of PSI


Billy and Mom

•  4 years old; diagnosed with ASD •  “failure to thrive” issues •  Passive in interactions and learning •  Non-speaking •  Active, engaged mother


On the Adapted Parenting Stress Index, each parent in the study gave the highest stress score to the following statements:

–  “I expected to have a closer relationship with my child”

–  “Most times I feel like my child doesn’t like me”

–  “There are things my child does that bother me a lot”

–  “My child is not able to do as much as I expected.”

–  “I feel I am not a good parent.” Joanne M. Cafiero PhD, 2010

Reading with your child: •  Point to text and PCS left to right

•  Minimize physical prompts to helping your child isolate his “reading finger”

•  Ask questions while reading, such as” –  “Touch the _____” –  “Where is the_____?”

•  Be patient; be optimistic.


Parent Perception of Child & Parent Child Relationship-Post Shared

Adapted Literacy Program

•  Parent found fewer behaviors annoying. •  Parent felt more in control of child. •  Parent felt child’s eating and sleeping habits were less problematic.

(????) •  Parent felt child smiled more (???) •  Parent went from feeling like “bad parent” to “better than average

parent.” •  Parent felt child was more capable.


Parent Scores on Adapted Parent Stress Index: Pre and Post

Literacy Training Parent/Child Dyad A

0

1

2

3

4

5

6

7

annoyed control slp/eat good parent percept ofchild

pre post


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Parent report: 10/4/05 •  “Billy now initiates interacting with me. He will bring his book to me and want to sit and read with me. He has never done anything like this before. It’s like a miracle; he is focused, not running all over the place and happier than I have ever seen him.”!

Billy’s Mom!


• Reflect

• Connect

• Project Joanne M. Cafiero PhD, 2010

Danny’s Story: from stereotypies to adapted reading and writing

•  3 years old, Dx Autism •  Stereotypies including, circling, spinning •  Non-verbal •  Severe anxiety upon separation from Mom


Danny: Intervention

•  Natural Aided Language - given consistent, pervasive visual input

•  Literacy (reading) - given consistent, regular exposure to adapted literature in reading

•  Literacy (writing) - given consistent opportunities for expression with adapted writing tools (PCS/Velcro)


Partner Reading with Natural Aided Language-phase 1

•  Book is adapted with PCS.

•  Partner reads text and points to adapted (PCS) words.

•  Child is encouraged to attend; there is no pressure to point.


Partner Reading with Natural Aided Language- phase 2

•  Partner reads text; points to PCS

•  Partner and child point together


Partner Reading with Natural Aided Language- phase 3

•  Partner reads text.

•  Child points to PCS as partner reads.


Danny - results of literacy (reading and writing) intervention

•  Followed read of teacher •  Responded to “wh” questions •  Independently selected icon to complete in

Home-School Journal (with close activity and word bank)


Writing Literacy Objectives •  Select objectives that address pivotal skill acquisition

rather than rote word identification such as:

– Time engaged with literature – Turn taking during partner reading – Functional spontaneous use of

vocabulary or concepts during work or play


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AAC-based Literacy Interventions for Adolescents with ASD ��

procedures •  Select theme & target vocabulary. •  Augment with PCS©, WWS 2000© or Picture-It©. •  Use short concise sentences. •  Use photographs, magazine pictures. •  Ensure each student has a book. •  While reading point above symbol and text. •  Use time delay to give student opportunity to read


Sentence structures that support emergent literacy for students

with ASD OK: “Sam feeds Nita the dog food” (concepts: Sam, Nita, feed, dog food)

NOT OK: “Sam knows Nita is hungry so she pours the dog food into

Nita’s bowl.” (concepts:Sam, knows, Nita, hungry, pours, dog food, bowl)


Demonstrating Comprehension of Adapted Literature

•  Create close writing activities using keyboard, pen/pencil, Velcro®

•  Create comboard for communication and participation using target vocabulary concepts.

•  If literature is social story or skill sequence, measure demonstration of target behavior.


Adapted Literacy Skill Sequences: Fading prompts to

independence 1.  Practitioner points and reads 2.  Practitioner invites student to point 3.  Joint reading and pointing 4.  Practitioner reads; student points 5.  Student reads (aloud or silently); student

points


Reading Engagement Pilot Study

Measuring: – Emergent literacy behaviors – Time on task during self-selected reading

(SSR) – Specific selection of literacy – Stereotypies during SSR – Use of speech or verbal approximations


Mean % Literacy Behaviors with Conventional and Adapted Literature

0%

20%

40%

60%

80%

100%

120%

sp kg jl kc pc dt aa

conventionaladapted


Mean % Literacy Behaviors with Adapted & Conventional Literature for 7 adolescents

with ASD

0%

10%

20%

30%

40%

50%

60%

conventional adapted


% of 5 minute time sample students on task (engaged in literacy behaviors) with conventional and adapted literature

15%

53%

0%

10%

20%

30%

40%

50%

60%



Mean % of Time Reading Aloud (verbal or approximations) Used during Self-Selected

Reading

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%


Mean

% o

f ti

me


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Outcomes •  Student engagement increased

–  Increased motivation & enthusiasm •  Development of emergent and conventional literacy skills •  Upped the ante on IEP objectives •  More understanding of sound-symbol correspondence •  Increased use of speech •  More parent satisfaction •  Greater levels of self-management

–  Independence –  Longer and more appropriate use of leisure time

•  Greater practitioner job satisfaction


Teaching Pretend Play to Pre-K students with ASD Through Adapted

Literature ��(Cafiero, Manthey-Silvio & Pearl, 2007)

•  Rationale: –  pretend play stimulates complex language development –  is age appropriate

•  Method –  Collected language samples from typical kids –  Developed adapted literature from sample –  Read book in group reading for 3 weeks –  Videotaped independent unprompted play for baseline

and 5 intervention probes Joanne M. Cafiero PhD, 2010

Pretend-play Behaviors: Gas Station: Actions

Putting man in car

Driving to gas pump

Putting in nozzle; filling up

Leaving gas station Joanne M. Cafiero PhD, 2010

Pretend-play Behaviors: Gas Station: Scripts

“This is my car”

“Uh-oh, I’m out of gas.”

“I’m putting in gas.”

“I’m putting in more gas”

“Gas is finished, bye-bye.” Joanne M. Cafiero PhD, 2010

Results: Teaching Pretend Play Through Adapted Literature

•  Qualitative: –  “crystal clear” speech and spontaneous

generating of appropriate language. – Longer periods of engaging in targeted pretend

play behaviors – Fewer off-task and stereotypic and self-

stimulatory behaviors


% Pretend Play Behaviors with Play-Based Literacy (DiDi)

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

Date Baseline week 1 week 2 week 3

Video Probes

% o

f To

tal P

lay

Beh

avi

ors


Use of Language During Play: (Didi)

0%

10%

20%

30%

40%

50%

60%

70%

baseline week 1 week 2 week 3

video probes

% o

f p

lay

scri

pts


Teaching Pretend Play through Modeling and Literacy

•  Target play scheme identified •  Scripts and actions of typical children •  Condition 1: play scheme taught through

modeling •  Condition 2: play scheme taught through

modeling and with play scheme-based literature


A Comparison of Pretend Play Skill Acquisition with Conventional

Modeling and Modeling + Adapted Literature

(Cafiero & Pearl, 2009)

•  Action research in Autism Intervention Classroom for Inclusion students

•  Pretend play “primed” for general education inclusion

•  Contexts and language identified from observation of typical Pre-K children


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Theme: Caring for Baby •  Modeled only

–  Baby Takes a Bath (water, tub, doll, washcloth, soap, towel)

•  Modeled + Adapted Literature –  Time for Bed (cradle, blanket, bottle, book)


% of Actions Performed in Pretend Play: Modeling & Modeling with Literacy

Supports "M"

46%

48%

50%

52%

54%

56%

58%

60%

62%

64%

modeling modeling + literacy


% of Actions Performed in Pretend Play, Modeling and Modeling with Literacy

Conditions "L"

15%

37%

0%

5%

10%

15%

20%

25%

30%

35%

40%



% Language Used in Modeling and Modeling + Literacy Conditions; Mikayla

8%

44%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%



Integrated Literacy Plan: High School: Ali

•  17 years old, Dx ASD •  Verbal with serious pragmatic issues •  Verbal comprehension impaired •  Generalization issues •  High energy, high anxiety parent •  Opportunity to work at Internet Café


Ali Works at “DownUnder” Internet Café��

•  Core concepts identified •  Task analyses for tasks •  Intensive support for new vocabulary

provided in school settings •  Data collected, analyzed to inform practice •  Photo-modeled literature created


Core Concepts for Ali at Internet Café��

Café Route Latte punctual

Greeting subtle customer Inter- action

Cash Register

Key in Artist tips


Ali’s Integrated Literacy Program: Math Applications

Calculating time for travel to work

Using cash register

Measuring correct liquid ingredients for latte

Counting tips

Reading bus schedule

Balancing receipts with cash in register Joanne M. Cafiero PhD, 2010

Ali’s Integrated Literacy Program: Vocabulary comprehension

•  Protocols for teaching functional spontaneous use of vocabulary –  Write definition –  Use correctly in relevant written sentence from choice

of 3 –  Use correctly in written sentence in journal –  Use verbally in role play with teacher –  Use independently with peer or job coach/supervisor.


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• Reflect

• Connect

• Project Joanne M. Cafiero PhD, 2010

Writing as Input; Writing as Communication

•  Keyboards •  White boards •  Post-its™ •  Alphabet boards •  Keyboard VOCAs


Writing is an essential part of the communication continuum: ��

all components are mutually reinforcing •  Receptive Language

– Listening, processing graphics or print (reading)

•  Expressive Language – Speaking, using AAC, adapted and

conventional pencils (writing)


Typical Kids:

•  Have meaningful interactions with others around print

•  Are automatically supported by others in this process

•  Show us the way to provide meaningful writing experiences for kids with disabilities.


Why kids with ASD do not have writing experiences:

•  Low expectations •  Behavioral difficulties •  Delayed developmental milestones •  Motor planning challenges •  Medication issues •  Other


Emergent Writing:

•  “Children begin reading by writing. People are natural message makers; we want to leave our mark.” (Erikson, 2008)

•  Writing challenges children to think about print.

•  Provides scaffolding for cognitive development


The Home-School Journal - Tools-No/Low Tech

•  Boardmaker Symbols for home and school •  Visible storage bank for symbols at both home and school •  Custom made journal sheets •  Laminated bifold or file folder •  Velcro and laminate


Ongoing Assessment of Early Writing

•  Interest in other’s writing •  Time engaged in writing •  Preference for particular letters (letters of name) •  Use of variety of letter patterns •  Use of spaces to reflect word-like groupings •  Use of early sound or inventive spelling


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Why kids with ASD should have writing experiences:

•  Print is visual medium •  Communication is core challenge •  Reports from adult autism advocacy

movement – Real time speech, keyboard communication,

later adopters of AAC •  Basic human right •  May become primary means of FSC & SNUG


Constructivist Education ��(Reggio-Emilia Pre-School)

•  The Writing Center – A designated, safe, non-judgmental place – A variety of adapted “pencils” & keyboards – Envelopes, stamps, paper, rubber stamps,

mailboxes – Writing buddies and mentors (communication

partners and models)


What kind of pencils can we provide for kids with ASD?

•  Print alphabet flip charts •  Tactile alphabet flip charts •  Intellikeys •  Onscreen keyboards •  Portable word processors

– Alphasmart, NEO, labelers


Writing as a Communication Modality

•  Sign-in Sheets •  Letters, notes, messages •  Lists •  Moveable Word Banks •  Personal Dictionaries with writing frames •  Task analyses & check-off sheets


Why include the entire alphabet?

•  Natural •  Models for increasing literacy development •  More opportunities for generating higher

level language •  Inherent potential of student


The “writing” communication partner

•  Pairs his/her speech with written language •  Gives text-based visual input •  Provides choices in written text as input •  Models creating the written input •  Gives the communication partner the option

to respond by pointing or by generating written communication


Increasing Natural Opportunities for Written

Communication

•  Classroom writing center •  Dry erase boards throughout classroom •  Labeling objects, requests •  Velcro Writing Tools •  Personal Dictionaries •  Old computers with large print word processing programs •  Keyboards


Jacob: The Journey to Communication

•  At 4 years; no functional communication •  Beginning severe self-injurious behavior •  Receiving augmented input in curriculum,

play, group instruction


Jacob’s Journey •  From engineered environment, picture

exchange and augmented input to… •  High tech device provided with training for

staff •  Communication partners provided input &

created communication opportunities •  Device used for academics (math, reading)


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Jacob’s Journey

•  Adopted device as his voice •  Maintained some intermittent vocalizations

for requests •  Developed an interest in writing •  Uses multi-modal communication; sign,

paper communication boards, writing on white boards and high-tech device


Feedback from Autism Self-Advocacy Movement

“I like my keyboard. I spent my whole life struggling with speech, and I like to have an alternative means of communication. I feel more comfortable with the keyboard because it does not involve the painful and complicated process of speech in addition to language…” (A. Baggs)


Applying Adapted Literacy to HFA and Asperger’s Syndrome •  Be aware that hyperlexia does not mean comprehension. •  Some students may require text augmented with PCS,

pictures or photographs. •  Provide age appropriate adapted literature using photo-

journals. •  Use photo-journals to teach tasks and social skills. Use

photos of student or peers. •  Text for journal should include social scripts.


Autism Learning Pyramid

Curriculum

Communication

Motivation

Behavior Mgt. BIP

relevance of task, intrinsic reinforcement, preferred activities

interaction, generalization, expressive language, receptive language

pacing of instruction, multi-sensory, adapted literacy, schedules, level appropriate

The Questions? •  How can we assess and individuals who

cannot show what they know? •  Are there subgroups of people with ASD

that require specific AAC? •  How to match the system with the user? •  How to teach SNUG? •  Will learned scripts generalize across

people, activities and environments? Joanne M. Cafiero PhD, 2010

Basic Principles of AAC for People with ASD

•  No pre-requisites •  Communication partner is key •  Augment Input •  Shape, reinforce, reflect do not correct •  Assume communicative potential •  Honor existing appropriate communication •  Remember communication is multi-modal •  Don’t create arbitrary timelines. •  Don’t give up!


Take this home with you, too…

•  Give augmented communicative input. •  Assume that every student, especially those

with most difficult behaviors, have the potential to communicate with AAC.

•  Remember AAC helps develop language. •  Provide robust literacy experiences. •  Functional spontaneous communication is

the most important skill your students can learn!


Documents

AAC&ASD-ResearchtoPractice - Joanne Cafierojoannecafiero.com/articles/ResearchtoPractice.pdf · Teachers completed questionnaire regarding ... • Progress in using AAC functionally