Interventions to Facilitate Communication in Autism

自闭症儿童社交能力训练策略

Journal of Autism and Developmental Disorders, Vol. 30, No. 5, 2000

Interventions to Facilitate Communication in AutismLynn Kern Koegel1

The purpose of this article is to discuss research opportunities arising from the current liter-

ature in the area of communication. Six general themes are discussed, including (a) increas-

ing spontaneity, initiations, and the variety of functions of language verbal and nonverbal chil-

dren with autism exhibit; (b) assessing and teaching precursors relating to positive outcome;

(c) the importance of family involvement in intervention programs; (d) best practices for im-

plementation of communicative interventions; (e) the interrelationship between language and

other behavioral symptoms of autism; and (f) the social and pragmatic use of language. Theseareas are discussed in terms of improving assessment and intervention practices to produce

greater long-term communicative outcomes for individuals with autism.

KEY WORDS:Autism; communicative intervention.

INTRODUCTION

Researchers and practitioners report notable gains

in reducing the behavioral symptoms of children with

autism; however the literature suggests that there remains

a major need for research in social/communicative as-

pects of development. Few studies yield sufficient data

to adequately understand linguistic and communicative

development in children with autism (Dawson & Oster-

ling, 1997; Tager-Flusberg, 1989; Wetherby, 1998), even

though these areas appear to be related more directly to

clinical outcome than other characteristics of the dis-

ability (Venter, Lord, & Schopler, 1992). This article

suggests research opportunities that arise from directions

and gaps in the current literature. Six general themes that

appear to be relevant across ability levels are discussed:

(a) spontaneity, initiations, and functions of language;

(b) precursors related to positive outcomes and mea-

surement; (c) family involvement in intervention deli-

very; (d) implementation (when, where, what, and how

much); (e) the interrelationship between language and

other areas; and (f) the social/pragmatic use of language.

Some of these research opportunities result from

the heterogeneity of communication skills and deficits

1University of California, Santa Barbara, California.across children diagnosed as having autism. Althoughformal definitions of diagnostic entities exist, the bound-aries are unclear, and in addition to behavioral overlapwith other disabilities, the degree of impairment variesconsiderably depending on the intensity of expressionof symptoms (Waterhouse, Wing, & Fein, 1989). Con-founding clinical applications of research findings isthe lack of reliable and standard diagnostic formu-lations of communicative behavior to ensure compa-rability of populations (Lord, 1999). Without such measures, describing outcomes in terms of specific de-velopmental gains is difficult. Furthermore, it is verytime consuming to implement a thorough evaluation ofsocial and communicative areas and to accurately as-sess the interrelationship among the triad of impair-ments of the disability (Volden & Lord, 1991), particu-larly because communication varies in different contexts,among various communicative partners, and over time.However, there is a large and growing corpus of rig-orous single-subject experimental studies and somegroup comparisons documenting individual differencesin outcomes that contribute to an understanding of cur-rent research opportunities and gaps.A review of programs by Prizant (1983) suggestedthat, even with intervention, approximately 50% of chil-dren diagnosed as having autism remained nonverbal.

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However, with improved teaching approaches (based onthe early work of Hart & Risley, 1978, with disadvan-taged children), especially those that systematically in-corporate motivational techniques, as many as 85–90%of children diagnosed as having autism, who begin inter-vention before the age of 5, can learn to use verbal com-munication as a primary mode of communication(Koegel, 1995; McGee, Daly, & Jacobs, 1994). Theseprocedures, resulting in substantially greater percent-ages of children who are able to use verbal expressivewords and language as their primary mode of commu-nication, focus on following the child’s lead (Yoder,Kaiser, Alpert, & Fischer, 1993), capitalize on thechild’s motivation to respond (R.L. Koegel, O’Dell, &Koegel, 1987) and provide frequent opportunities forexpressive language in natural environments through-out the day (Warren, McQuarter, & Rogers-Warren,1984) using direct and natural reinforcers (Charlop,Schreibman, & Thibodeau, 1985). When procedures in-corporating these variables are combined into an inter-vention package, children with autism who are initiallynonverbal increase their levels of immediate and de-ferred verbal imitation, word production, and sponta-neous utterances more than when the approach is amore structured discrete trial format (R.L. Koegeletal.,1987).

Researchers have replicated these effects with ver-bal children with autism who demonstrate delayed lan-guage. For example, R.L. Koegel, Koegel, and Surratt(1992), using an alternating treatments design, com-pared a motivational condition which closely approxi-mated natural language interactions with an analog con-dition consisting of a structured discrete trial format.This research found greater improvements in verbal at-tempts, word approximations, word production, andword combinations, as well as lower levels of disrup-tive behavior during the motivational teaching condi-tions when compared to the analog conditions. There-fore, for young children severely affected by autismwho are nonverbal or significantly delayed in the ac-quisition of expressive language, preliminary studiessuggest that such motivational procedures are particu-larly effective in early intervention (McGee, Feldman,& Maurier, 1997).

Related to this, a number of studies support theuse of such motivational teaching procedures to im-prove generalization outside of the intervention setting.Specifically, although children with autism appear todemonstrate steady and consistent gains during clini-cal sessions using highly structured analog procedures,they frequently fail to demonstrate generalization out-

side of the clinical setting in areas such as phonologyKoegel(R.L. Koegel, Camarata, Koegel, Ben-Tal, & Smith,1998) and syntax (McGee, Krantz, & McClannahan,1985) if naturalistic and motivational teaching proce-dures are not incorporated. Therefore, early and improvedintervention using a behavioral model, with specificcomponents of the procedure altered from a structuredanalog procedure to improve motivational areas suchas responsivity, rate of responding, and affect, has beenshown to be effective in increasing the number of chil-dren who become verbal and who demonstrate com-municative gains (R.L. Koegel et al.,1987; McGee,Morrier, & Daly, 1999).When one reviews overall patterns of improve-ment in scientifically documented intervention studies,the following six areas emerge as especially promisingresearch opportunities.SPONTANEITY, INITIATIONS, ANDFUNCTIONS OF LANGUAGEIn the area of autism, in contrast to other disabil-ities, lack of spontaneous verbal and nonverbal initia-tions appears to be a consistent problem. Regardless ofcommunicative level, the number of communicativeinitiations and the expansion of specific functions oflanguage seems to be particularly problematic. Thus,whether a child with autism uses verbal means of com-munication or uses augmentative and/or alternative sys-tems of communication, intervention research focusedon improving these skills is especially important.For example, consider the small percentage of chil-dren who remain nonverbal and for whom a number ofaugmentative and alternative communicative (AAC) sys-tems are now available. AAC systems can include signlanguage (Carr & Kologinsky, 1983; Horner & Day,1991), photographs (Kozleski, 1991; Reichle et al.,1996), picture exchange systems (Bondy & Frost,1998), communication books (Hunt, Alwell, Goetz, &Sailor, 1990), computer systems, and so on. Althoughteaching technologies are more clearly defined, spon-taneity has been a problem. While these nonverbal chil-dren can show large degrees of success with initial ac-quisition, they exhibit difficulties with generalizationof AAC systems (Mirenda & Mathy-Laikko, 1989;Schlosser, Belfloire, Nigam, Blischak, & Hetzroni,1997; Storey & Provost, 1996; Stiebel, 1999; Udwin &Yule, 1990). They often require constant and consistentadult prompting and fail to demonstrate the spontaneoususe of a variety of functions needed for communicativecompetence. Scientifically sound proceduresrelated toteaching the spontaneous use of AAC outside of a clin-

自闭症儿童社交能力训练策略

Interventions to Facilitate Communication in Autismical setting are clearly lacking in the literature. Althoughthe likelihood of generalization from clinic to homesettings increases if AAC is incorporated into familyroutines (Steibel, 1999),assessing the specific types ofcommunicative intentions that are most useful, perhapsby incorporating a functional analysis, may increase thechild’s use of AAC while reducing the demands on aparent or adult. Also, apraxia and difficulty with finemotor skills appear to be common in nonverbal chil-dren with autism who demonstrate difficulty with ACCsystems (Seal & Bonvillian, 1997). Thus, research onthe interrelationships between motor performance andcommunication may help determine the most appro-priate AAC systems for nonverbal children who fail toacquire verbal language.

Similar issues regarding the lack of spontaneity,initiations, and functions of language exist for verbalchildren with autism. Wetherby and Prutting (1984) an-alyzed language samples of verbal children with autismand found them limited in both quantity and quality.Children with autism use language almost exclusivelyfor requesting objects, requesting actions, and protest-ing. A growing body of research is demonstrating ef-fective procedures for teaching children with autismto use absent or depressed language functions such asasking questions (Hung, 1977; L.K. Koegel, Cama-rata, Valdez-Menchaca, & Koegel, 1998; Taylor &Harris, 1995; Warren, Baxter, Anderson, Marshall, & Baer, 1981) and other verbal initiations (L. Koegel,Koegel, Shoshan, & McNerney, 1999). Spontaneousinitiations are necessary for children with autism tobe judged as socially competent during interactions.Research designed to develop intervention proceduresto teach spontaneity and initiations and research as-sessing and defining the types and numbers of initia-tions children need to exhibit to appear communica-tively competent will enhance our understanding ofbest intervention practices.

PRECURSORS RELATED TO POSITIVEOUTCOMES AND MEASUREMENT

The literature suggests that the single most im-portant prognostic indicator for young children withautism is language ability (Schreibman, 1988). Specificinformation regarding the types and amounts of lan-guage precursors that lead to positive outcomes, bothfor verbal and preverbal children with autism, shouldgreatly enhance our research base. For example, jointattention is consistently noted as important in prelin-

guistic development. For typical language learners the385onset of joint attention appears to signal a new level ofunderstanding, and to have an intrinsic motivationalbase, which is social in nature and is strongly corre-lated with the emergence of naming (Bates, Thal, &Marchman, 1991). Unfortunately, children with autismgenerally demonstrate a lack of, or a reduced numberof, important referential gestures, such as showing, gi-ving, and pointing, and using eye gaze to communicate(Stone, Ousley, Yoder, Hogan, & Hepburn, 1997). Thisdeficit can be noted early in life in children with dis-abilities and appears to be an important milestone war-ranting research attention.For verbal children with autism, a similar perva-sive lack of social initiations appears to be a consistentpattern and likely precursor to communicative impair-ment during social interactions. A common utteranceduring initial lexical development in typical languagedevelopment is “that?” (/daet/), often used in conjunc-tion with pointing to items. This interrogative verbal-ization along with nonverbal cues, such as pointing,can be a specific prompt for a parent to label the itemfor the child (Halliday, 1975). Over time, this type ofutterance becomes increasingly more sophisticated andvaried, resulting in steadily more sophisticated questions(who, where, when, why, etc.). Rather than exhibitingthese typical developmental linguistic milestones, chil-dren with autism emit fewer utterances and fail to uselanguage as a means of social initiation (Calloway,Myles, & Earles, 1999).In a preliminary study, L. Koegel et al.(1999) com-pared archival data of adolescents who were diagnosedas having autism with extremely favorable versus ex-tremely poor outcomes following intervention. Analy-ses included pragmatic ratings during social interactions,school and community functioning (including academicfunctioning, social circles, and extracurricular activities),and adaptive behavior composites. At baseline, when thechildren were preschoolers, all exhibited characteristicsassociated with the likelihood of a favorable postinter-vention outcome, such as high verbal intelligence quo-tients (IQ above 60) and the presence of functionalspeech before 5 years of age (DeMyer et al.,1973; Free-man, Ritvo, Needleman, & Yokota, 1985; Gillberg &Steffenburg, 1987; Lotter, 1974; Venter et al.,1992).However, after long-term intensive intervention pro-grams, which were similar across all participants, thedata showed very different outcomes. Preliminary dataanalyses suggested that the children who had the mostpositive outcomes also exhibited the greatest numbersof social initiations prior to intervention, whereas thechildren with the least favorable outcomes exhibited fewor no social initiations prior to intervention.

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Such assessment data on joint attention and initi-ations have led researchers to begin to develop inter-vention procedures to teach these potentially importantprerequisites. For example, Yoder and Warren (1999)have begun to develop interventions to increase thegeneralized use of self-initiated proto-declaratives andproto-imperatives in prelinguistic children with devel-opmental disabilities (some of whom present withsymptoms of autism). Others (Hung, 1977; L. Koegel,Camarata, Valdez-Menchaca & Koegel, 1998; Taylor& Harris, 1995; Warren et al.,1981) have designed in-tervention programs to improve the use of self-initiatedquestions and other spontaneous verbalizations. Pre-liminary data suggest that teaching these linguisticskills may result in more widespread clinical gains andmore favorable long-term outcomes.

The literature strongly suggests that without ade-quate early social input, the neurological and behavioraldevelopment of children with autism may be further de-flected from a typical developmental path (Mundy &Crowson, 1997). There appear to be large individual dif-ferences in joint attention and social-verbal initiationsacross children diagnosed as having autism. Improvedprecision in measuring the nature of early social com-munication in children with autism, as well as compre-hensive outcome measures, appears to be a productiveavenue for future research.

It is important, however, that information regar-ding prognostic indicators not be used to deny servicesto very young children who do not exhibit positive in-dicators (Parisy, 1999). Instead, determination of thevariety of verbal and nonverbal behaviors that lead toimproved prognoses through more precise and compre-hensive longitudinal studies should help improve out-comes. Research identifying critical communicative be-haviors that need to be targeted is likely to result in moreefficient interventions for greater numbers of children.FAMILY INVOLVEMENT IN

INTERVENTION DELIVERY

Schopler and Reichler (1971) pointed out in theearly 1970s that parents of children with autism are crit-ical components of the habilitation process, withoutwhom gains are unlikely to be maintained (Lovaas,Koegel, Simmons, & Long, 1973). Unfortunately, manylanguage programs are implemented without involvingfamily members, even though the transactional natureof communication suggests that appropriate modifica-tions of a caregiver’s interactive style may help chil-

dren to develop a sense of efficacy and competence inKoegelcommunicative development (Prizant & Wetherby,1998).With respect to the development of parent educa-tion programs, several important themes are emergingin the literature. First, it is well documented that thedemands associated with having a child with a disabil-ity greatly increase parental stress (Bristol & Schopler,1983; Moes, Koegel, Schreibman, & Loos, 1992). In oursociety, there is a lack of preparation, assistance, andopportunities for socialization for parents of childrenwith disabilities. Many parents of children with autismexperience a lack of welcome in public places, and theirfamilies’ social circles may change or decrease signif-icantly because of the challenging behaviors and delays their child exhibits.Lord and O’Neill (1983) pointed out that pro-gramming for children with autism is particularly dif-ficult because many of their deficits, such as languagedevelopment and socialization, are learned by typicallydeveloping children with little or no direct interven-tion. Research has demonstrated that parent educationprograms that obligate the parents to designate certaintime periods to work one-on-one with their children in-crease parental stress. However, parent education pro-grams, when implemented properly, can help to reduceparent stress while greatly improving communication(Moes, 1995). Programs designed to fit into families’lifestyles and routines, so that teaching can occur onan ongoing basis throughout the day in natural settings,actually decrease family stress while resulting in greatergains in child communication (Koegel, Bimbela, &Schreibman, 1996; Schreibman, Kaneko & Koegel,1991).In light of the documented need for coordinatedefforts with family members, some areas appear highlylikely to benefit from further research. For example, in-dividualizing the intervention to adjust for contextualvariables that may result in less effective parent edu-cation programs, such as poverty, social isolation, de-pression, stress, and marital discord, may be of greatimportance (Baker, 1984; Dumas & Wahler, 1983;Forehand, Furey, & McMahon, 1984; Plienis, Robbins,& Dunlap, 1988; Robbins, Dunlap, & Plienis, 1991).In addition, with increases in cultural diversity in oursociety, parent education programs that develop cul-turally and linguistically sensitive intervention plansmight also benefit from further research. Research re-garding the concepts of “goodness of fit” and “contex-tual fit” (Bailey et al.,1990), when incorporated intoresearch on intervention plans, may improve parent edu-cation programs, benefit the general family system,and the child’s overall functioning.

自闭症儿童社交能力训练策略

Interventions to Facilitate Communication in AutismIMPLEMENTATION (WHEN, WHERE, WHAT,AND HOW MUCH)

An issue that has created heated controversy in re-cent years relates to the quantity of implementation ofservices. Just a few decades ago, most children withautism received little or no systematic intervention incommunity settings. Now, the importance of intensiveand early intervention in natural settings has becomean especially salient issue (Lovaas, 1987). In the areaof communication, Hart and Risley (1995) have docu-mented the importance of verbal stimulation on futuredevelopment for typically developing children. Unfor-tunately, children with autism often actively avoid so-cial interactions (Carr & Durand, 1985), thereby greatlyreducing the number of language learning and teach-ing opportunities (Peck, 1985). Even when languageteaching is provided, many programs do not work oncommunication in social and natural community set-tings. This has become increasingly important as chil-dren with autism are having more contact with typi-cally developing children as school and communityinclusion increases (Harrower, 1999; Kennedy, Shukla,& Fryxell, 1997; Strain, McGee, & Kohler, in press).

Best practices and procedures, so that childrenwith autism progress toward connected coherent socialdiscourse for communicative competence, are unknownat this time, and thus comprehensive investigation ofthis area is needed. Research regarding wheninterven-tion for linguistic and social development should takeplace, whereor in what settings intervention shouldoccur, how muchintervention is optimal, and whattypesof interventions need to be implemented for ac-celerated social and linguistic gains and communica-tive competence may be of considerable benefit to thefield. Certainly this issue relates to the individualiza-tion of intervention, as responsivity to different typesof interventions are likely to depend on particular childand family characteristics.

INTERRELATIONSHIP BETWEEN

LANGUAGE AND OTHER AREAS

The interrelationship between communicative de-ficits and other behavioral symptoms of autism hascome to the forefront of behavioral intervention. Epi-demiological studies suggest that as many as 75–80%of behavior problems may have a communicative func-tion (Derby et al.,1992; Iwata et al.,1994). Reportedchanges in behavior that occur when antecedent sti-

muli are addressed and functionally equivalent behaviors387are taught can be quite dramatic (Wacker, Berg, Asmus,Harding, & Cooper, 1998) and can improve generalfamily harmony and affect (L. Koegel, Steibel, & Koegel,1998). Furthermore, the reconceptualization of problembehavior as communicative rather than “maladaptive”or “noncompliant” has led researchers and practition-ers toward developing more functional and humaneintervention procedures. Similarly, researchers haverecently been attempting to define and quantify prag-matic areas of disability and the complex interactionbetween language, social, and cognitive development(Volden & Lord, 1991).Research relating to the understanding and as-sessment of interrelationships between communicationand behavior has been prolific in the last decade andhas created numerous new research opportunities forpromoting communication in autism. Assessing thefunctions of behavior problems is now a common prac-tice and an essential component of most behavioral sup-port plans, and a number of tools are readily availablethrough direct observation (Frea, Koegel, & Koegel,1993), interviews (O’Neill, Horner, Albin, Storey, &Newton, 1990), and review of records. However, thescience of teaching functionally equivalent behaviorsis less well defined. How often and at what times prac-titioners need to prompt functionally equivalent re-placement behaviors before behavior problems areeliminated is not yet clear. In addition, studies that im-prove our understanding of the social contexts that sup-port problem behaviors, particularly when there aremultiple maintaining variables, are needed. The rela-tionship between the acquisition and spontaneity offunctionally equivalent replacement behaviors is notwell understood. There appears to be an inverse rela-tionship between the acquisition of a functionallyequivalent replacement behavior and the decrease ofproblem behaviors. However, the exact interaction be-tween the appropriate and inappropriate behaviors maybe complex and dependent on how well established theproblem behavior is, the context in which the behaviorproblems occur, the child’s level of functioning, andother variables. The issue of transfer of interventiongains across community settings may be better under-stood with additional research. Although the essenceof teaching a functionally equivalent behavior is to pro-vide a socially appropriate mode of communication, ag-gression and self-injury often are effective and efficientin terms of communication. Therefore, even though in-appropriate, they may be well established in terms ofproducing desired outcomes. Areas such as efficiencyof communicative responses, reinforcement schedules,and delayed consequences are likely to have a direct