Individual and Group Intervention Strategies for Children with Autism Spectrum Disorders: From nonve

1
Individual and Group Intervention Strategies for
Children with Autism Spectrum Disorders From
nonverbal communicators to high level
communicators

• Kate Hall, MS, CCC-SLP
• Autism Spectrum Disorders Program Specialist
• The Childrens Hospital
• Aurora, Colorado

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Background/Training Experience

• Fellowship at JFK Partner Autism and
  Developmental Disabilities Clinic
• TEACCH training
• Denver Model training
• Hanen training (More Than Words)
• Attended a variety of conferences on
  Aspergers/high functioning autism treatment
• Graduate grant at UNC-Chapel Hill with autism
  focus

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Some refreshers

• Autism Spectrum Disorders (ASD) and/or Pervasive
  Developmental Disorders (PDD) include
• Autism (Autistic Disorder)
• Aspergers Syndrome/Disorder
• Pervasive Developmental Disorder-not otherwise
  specified (PDD-NOS)
• CDC recently stated that the prevalence of ASD
  is 1 in every 150 children.
• Childhood Disintegrative Disorder
• Retts Syndrome/Disorder

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DSM-IV criteria for PDDs

• Autism
• Impairments in all 3 areas
• Social interaction
• Communication
• Restricted interests or repetitive behaviors
• CAN have high functioning autism and have
  normal cognition

• Aspergers
• Impairments in 2 areas
• Social interaction
• Restricted interests or repetitive behaviors
• Also has no significant delay in language or
  cognitive skills, but DOES have impairment in
  social language and pragmatic skills.

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DSM-IV criteria for PDDs

• Pervasive Developmental Disorder- Not Otherwise
  Specified (PDD-NOS)
• Do not fully meet criteria for any other PDDs or
  do not show the degree of impairment as with
  autism or Aspergers
• Meets only 2 of the 3 criteria
• MUST still have impairment in area of social
  interaction

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Review of best practice for ASD Intervention

• 2006 ASHA Ad Hoc Committee on Autism Spectrum
  Disorders
• Roles and Responsibilities of Speech-Language
  Pathologists in Diagnosis, Assessment, and
  Treatment of Autism Spectrum Disorders Across the
  Life Span Position Statement
• Knowledge and Skills Needed by Speech-Language
  Pathologists for Diagnosis, Assessment, and
  Treatment of Autism Spectrum Disorders Across the
  Life Span
• Principles for Speech-Language Pathologists in
  Diagnosis, Assessment, and Treatment of Autism
  Spectrum Disorders Across the Life Span
  Technical Report
• www.asha.org/members/deskref-journal/deskref/defau
  lt

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2006 ASHA Ad Hoc Committee on Autism Spectrum
Disorders review

• Eligibility for Services/Standardized Testing
• Individuals with ASD should be eligible for
  speech-language services, regardless of age,
  cognitive abilities, and performance on formal
  standardized language testing
• Formal assessment tools may not accurately show
  deficits in social language and communication,
  therefore eligibility should be based on informal
  measures and clinical judgment
• Meaningful outcome measures should consider gains
  in spontaneous initiation of communication, and
  generalization of skills across environments and
  activities

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2006 ASHA Ad Hoc Committee on Autism Spectrum
Disorders review

• Guidelines for Areas of Treatment
• Focus on improving social communication, related
  to joint attention and social reciprocity
• Improving language and related cognitive skills
  including understanding and use of nonverbal and
  verbal communication, functional and symbolic
  play, executive functioning/problem solving
  skills
• Improving behavior and emotional regulation,
  including initiating and maintaining social
  engagement, and focusing attention to salient
  aspects of social environment
• All areas of treatment are evaluated with
  outcomes related to the ability to form
  relationships, function effectively, and actively
  participate in everyday life

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2006 ASHA Ad Hoc Committee on Autism Spectrum
Disorders review

• Use of Empirically Supported Strategies
• Broad view of communication to enhance
• Initiation of spontaneous communication
• Comprehension of nonverbal and verbal
  communication
• A range of social communicative functions that
  promote friendships and social networks
• Providing a variety of means of communication
  (natural gestures, speech, signs, pictures,
  written words, ACC systems)
• Providing functional alternatives to challenging
  behaviors

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2006 ASHA Ad Hoc Committee on Autism Spectrum
Disorders review

• Environmental supports/modifications
• Use of routines and repeated learning
  opportunities
• Adjustment of social complexity, with peer or
  adult-mediated social support
• Education of communication partners
• Use of natural reinforcers
• Following childs attentional focus
• Structuring predictability and turn taking into
  activities
• Accommodating the learning styles of individuals
  with ASD (visual cues and supports, routines and
  structure, scripts and social stories, video
  modeling)

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2006 ASHA Ad Hoc Committee on Autism Spectrum
Disorders review

• Promoting play and interaction with typically
  developing peers
• Range of applications of AAC (gestures, signs,
  body language, picture symbols, communication
  books, assistive devices)
• Positive relationship of AAC to development of
  speech, language comprehension, prevention of
  challenging behaviors, and social communication
• Positive behavior support including hypothesizing
  on the purpose of the behavior, use of prevention
  strategies, teaching replacement skills, and
  response to behaviors
• Individualized services for the individual and
  family, rather than use of a packaged program

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2006 ASHA Ad Hoc Committee on Autism Spectrum
Disorders review

• Treatment Setting
• Services must be tied to meaningful and
  functional outcomes
• Pull-out services only to be provided to work on
  functional skills in a more focused environment,
  when repeated opportunities do not occur in
  natural learning environments
• Encourage treatment in a natural social settings
  with a variety of communication partners (peers
  and adults)
• Provide opportunities for the individual to
  practice problem-solving and communication across
  environments
• Positive outcomes in areas of joint attention,
  social reciprocity, language, and behavioral and
  emotional regulation are most predictive of later
  gains in socially adaptive functioning, language
  acquisition, and academic achievement

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Nonverbal/Early Communicators

• Description of children at this stage
• Using physical means to communicate
• May be using non-meaningful speech/echolalia
• Verbal comprehension could be very limited
• Likely to be visual learners and routine-driven
• Limited communicative means and functions
• May have difficult behaviors

• PRIORITIES
• Keep child engaged
• Build functional communication skills
• Focus on social/relational skills
• Adapt environment to increase comprehension
• Expand play skills
• Decrease difficult behaviors

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Nonverbal/Early Communicators Environmental
Supports/Modifications

• Limit distractions in the environment when
  possible
• Cover toy choices with a sheet
• Put toys on top of a high shelf
• Take highly distracting or perseverative items
  out of room (ie- trains)
• Mirrors! Avoid when you can, think about
  positioning

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Nonverbal/Early Communicators Environmental
Supports/Modifications

• Video Example Irvin on swing

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Nonverbal/Early Communicators Environmental
Supports/Modifications

• Try 1-2 toy choices out at once
• Increases attention span for each activity
  (rather than quickly moving from one to the next)
• Allows more opportunities for repetition and
  communication
• Encourages child to try new things, expand play
  routine
• Or dont have any toys out and focus on social
  engagement (more to come..)
• Songs or social routines
• Motor movement
• You are more fun than the toys!

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Nonverbal/Early Communicators Environmental
Supports/Modifications

• Build Predictability
• Establish a simple routine, examples
• Motor Play then Table Time (back and forth)
• Table Time then Gym/Motor at the end of the
  session
• Do the same activity last each time (snack?)
• Try to be in the same space when possible

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Nonverbal/Early Communicators Environmental
Supports/Modifications

• Video Irvin with routine

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Nonverbal/Early Communicators Shared Enjoyment

• First aim for shared enjoyment between you/the
  parent and the child
• Goal at first is building a social relationship
• Work to make the child smile and engage with you
• Follow the childs lead when possible and
  appropriate (use something they are doing and
  turn in into a shared experience)
• Be specific to each child (remember their sensory
  needs and preferences)
• Be physical!

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Nonverbal/Early Communicators Activity Choices-
Social Games

• Video Example Jasmine in gym- squishes

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Nonverbal/Early Communicators Activity Choices-
Social Games

• Songs with motor movement, add something fun or
  motivating for the child to request
• Row Your Boat with tickle/crash at the end
• Ring Around the Rosie emphasize falling down
  together
• Be consistent so the child can be comfortable to
  participate
• Keep it simple
• Do it the same way each time
• Later you may add or change steps to promote
  flexibility

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Nonverbal/Early Communicators Activity Choices-
Social Games

• Video Example Irvin with Ring around the Rosie

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Nonverbal/Early Communicators Activity Choices

• Motor Play can be extremely motivating!
• Remember possibility of sensory needs
• Seeking movement to get organized
• OR- Needing movement to wake up and be able to
  participate
• Swinging, crashing, jumping, squishing in pillows
• How to make motor activities social and
  communicative?
• Add structure/routine if it isnt there already
• Jumping on trampoline 1-2-3 crash
• Swinging ready, set, go, swing 5 times then
  stop, sing a song then stop (repeat)
• Create opportunities for child to communicate
• Add songs and create routines
• Use physical support to keep it going as needed

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Nonverbal/Early Communicators Activity Choices

• Video Irvin with 1-2-3 Jump

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Nonverbal/Early Communicators Activity Choices

• Video Jasmine on swing with song

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Nonverbal/Early Communicators Activity Choices

• Use hands-on activities with actions that they
  can manipulate
• Ball/car runs, puzzle with sounds, books with
  manipulatives, drums/musical instruments
• Add structured opportunities for child to
  participate
• Keep control of the materials!

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Nonverbal/Early Communicators Activity Choices-
Table Play

• If the child has trouble focusing or attending to
  activities
• Use close-ended activities with a clear
  beginning and end
• Activities where you have a certain number of
  items to use and then it is clear visually that
  it is done
• Helps the child to understand the expectations
• Builds opportunities for communication
  (requesting, commenting)
• puzzles, toys with pieces that you put together,
  shape sorters

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Nonverbal/Early Communicators Activity Choices-
Table Play

• Open-ended activities barn figures, train set,
  cars
• Child doesnt know how long the activity will
  last
• More likely to get upset when it is over
• Fewer opportunities for communication and adult
  control

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Nonverbal/Early Communicators Activity Choices-
Table Play

• How to make something close-ended?
• Only have out the number of items you will use
• Keep materials visible to the child, but YOU have
  control of the materials!
• Establish an all done place (tray, box)
• Work from left to right

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Nonverbal/Early Communicators Activity Choices-
Table Play

• Video Lane cutting fruit
• Video Lane with markers

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Nonverbal/Early Communicators Activity Choices-
Table Play

• Find balance between following childs lead and
  being in control
• Child moves quickly or gives up quickly when
  something is hard or new
• Do it one more time before transitioning
• Clean up before leaving (even if just one piece!)
• Use physical hand-over-hand support to put the
  child through the motions
• Help child indicate all done before leaving an
  activity (hand-over-hand for sign)
• Be consistent!

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Nonverbal/Early Communicators Nonverbal
Communication Skills

• Focus on all modalities of communication
• Natural forms of nonverbal communication
• Eye contact
• Gestures (pointing, reaching, nodding, etc.)
• Physical means (pulling adults hand, pushing
  items away)
• Beginning stages, accept all attempts at
  communication
• Acknowledge/reward their attempt
• Provide a simple model of what else they could
  have done
• Gesture that could have been used (point, touch,
  sign)
• Simple language model (Go, help, juice, more)
• Give support to help them communicate at the next
  level
• Use physical support if needed to help the child
  use the appropriate gesture

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Nonverbal/Early Communicators Nonverbal
Communication Skills

• Increasing use of eye contact as a communicative
  means
• Use a repetitive, motivating activity
• Cue with expectant waiting
• Be on childs level, make it as easy as possible
  for the child to look at your eyes
• Immediately reward child when eye contact is used
  (even if just for a second)
• Use simple language to label what their look
  communicated (go, more, etc.)
• Avoid verbal prompting look at me, especially
  if childs comprehension is limited!
• Keep it natural
• If needed, hold desired object close to your
  face/eyes

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Nonverbal/Early Communicators Nonverbal
Communication Skills

• Video Irvin with drum

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Nonverbal/Early Communicators Nonverbal
Communication Skills

• Start by encouraging natural forms of
  communication, then add additional supports as
  needed
• Symbolic forms of nonverbal communication
• Signs
• Pictures/Photographs
• (more to come)

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Nonverbal/Early Communicators Nonverbal
Communication Skills

• Teaching a point
• Pointing is a very natural form of communication
• Helps child to understand gesture use and the
  power of communication
• Teach in structured way if needed
• Desired object in clear container
• Repetitive activity
• When child reaches for the object, help form
  their hand into a point (fade physical support)
• If needed, put a dot or simple sticker on the
  container
• Limit verbal cues and models (especially if child
  echoes)
• Fade cues (proximal to distal point, take out of
  container, less repetitive activities)
• Model and support pointing in natural situations
  as well

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Nonverbal/Early Communicators Nonverbal
Communication Skills

• Video Irvin with blocks

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Nonverbal/Early CommunicatorsIncreasing
Receptive Language

• Use hand-over-hand support to help the child
  follow a direction
• Give verbal directions only 1 time, then give
  physical support for the child to succeed if
  needed (dont want child to become dependent on
  verbal repetitions)
• Pair verbal directions with gestures
• Give directions within a structured predictable
  routine (get your shoes, sit down, time to swing,
  etc.)

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Nonverbal/Early CommunicatorsIncreasing
Receptive Language

• Use picture or photographs with verbal directions
  to aid comprehension
• Single picture presented to child right before
  the activity
• If child not focused on picture, take their hand
  to help touch or point to it
• May continue to show picture to the child,
  comment during the activity for repeated
  opportunities (ex- swing, you are swinging!)
• Use photographs of activity or child doing the
  activity if needed
• Consider whether child truly understands visual
  aid
• A full picture schedule may be overwhelming at
  this stage, individualize for childs needs and
  understanding
• Picture choices may be used if child shows clear
  understanding of pictures/photos

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Documenting Progress

• No gold standard assessment tools exist that
  accurately capture progress for most children
  with ASD
• Use of standardized language tests may still give
  information, but not likely to capture gains in
  social/relational development, nonverbal skills,
  etc.
• Concentrate on developing goals that are
  measurable and objective
• Use narratives to provide clinical judgment about
  progress made
• ASHA position statement

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Nonverbal/Early Communicators Example Goals

• Use eye contact as a simple request or to show
  shared enjoyment, during 80 of opportunities for
  3 consecutive sessions.
• Participate in 2-3 social routines (songs, motor
  games, etc.) per session for 3 consecutive
  sessions.
• Follow 4-5 simple directions, with
  visual/gestural support, for 3 consecutive
  sessions.
• Use 4-5 single words, gestures or pictures
  independently to make requests, comment or
  protest, for 3 consecutive sessions.
• Parents will show understanding of 1-2 home
  language facilitation strategies and follow
  through with recommended home practice
  suggestions each week for the duration of
  therapy.

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Goal development for school therapists

• Limitation of developing annual goals verses
  short-term objectives
• Consider creating sub-goals with each long-term
  goal
• Document small steps towards larger goals
• Include levels of cueing (visual, gestural,
  verbal) in goals to document progress

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Nonverbal/Early CommunicatorsParent
Training/Involvement

• Essential in early stages
• Promotes generalization of skills in natural
  settings
• Provides many more hours of meaningful
  interaction for the child
• Recommend parent training course when possible
  (Hanen- More Than Words)

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Nonverbal/Early CommunicatorsParent
Training/Involvement

• When parents are participating in therapy or
  observing therapy
• Choose 1-2 strategies to explain to parents per
  session (dont overwhelm!)
• Use simple language they can remember
• Break down what exactly you are doing in an
  activity, and why
• Be direct! (ex Today we are all going to try not
  to talk much and WAIT, so your child has a chance
  to communicate on his own)
• Involve parents in the activity when possible- on
  the spot coaching
• Give parent 1 specific job to work on at home
• Parents will leave with a plan for some
  activities they will practice with at home
  (bubbles, bath time, etc.)

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Nonverbal/Early CommunicatorsParent
Training/Involvement

• Video Example Lane and Dad with tunnel

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Nonverbal/Early CommunicatorsParent
Training/Involvement

• School therapists
• Challenge less time spent with parents, parents
  are not observing sessions
• Communication notebook back and forth, describes
  in simple way what you focused on with the child
  (eye contact, imitating words, saying words
  independently)
• Handouts/homework sheets for parents, Example
• When your child wants something, wait for 5-10
  seconds before saying the word for them. If they
  attempt to try a word, reward their attempt! If
  not, say the word for them.
• Parents complete and return with questions
• Times when I waited
• When I waited for my child to say something on
  their own, what happened?

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Collaboration with other disciplines

• Essential to collaborate with other
• professionals and disciplines (teacher/special
• educator, school SLP, school OT, private
• therapists, home therapists)
• Consistent treatment methods and language being
  used across settings
• Child will not learn specific skills only to use
  in certain settings or with certain people

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Co-treating with Occupational Therapy

• When is a co-treat with Occupational Therapy
  appropriate?
• You need support to help child be organized and
  calm in order to participate in learning
  activities
• Child is really motivated by movement/motor
  activities (OTs have great ideas for motor
  routines)
• Some children require more than 1 adult to
  support them in following a routine and trying
  new activities
• Provide physical support behind the child for
  pointing or picture requesting
• Talk with the OT about their goals for the child,
  types of activities they need to use (fine motor
  verses play/social activities)
• Plan sessions ahead with activities that will
  meet both of your goals
• OTs are a great support when dealing with
  behavioral problems

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Verbal Communicators

• Description of Verbal Communicators
• May use single words or short phrases
  spontaneously
• May still echo often
• Understanding more verbal language
• Mat start responding to questions with support
  needed

• PRIORITIES
• Continue to build expressive language
• Integrate social and nonverbal skills with verbal
  language
• Build comprehension skills
• Expand play skills

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Verbal Communicators Activity Choices

• Continue to use close-ended activities if needed
• If using open-ended activities, give verbal or
  visual warnings to prepare child for transition
• Verbal 3 more times, 5 more minutes, etc.
• Visual check boxes, visual timer
• Manipulatives to maintain attention and
  motivation
• Books with velcro pieces
• Toys you put together

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Verbal Communicators Activity Choices

• Simple pretend play
• Play food/kitchen items
• Building blocks
• Feeding animals
• Dolls/dollhouse
• Zoo animals

• Motor sequences with multiple steps
• Swing to knock a tower of big blocks over
• Throw bean bags into a bucket, barrel
• 3-4 step obstacle course

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Verbal Communicators Activity Choices

• Simple turn taking games when appropriate
• Kerplunk
• Dont Break the Ice
• Caribou
• Adapt games for the childs attention level and
  comprehension level

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Verbal Communicators Visual Supports

• Provide picture choices for 2 activities
• To help child make intentional choice rather than
  echo or not respond
• To help the child feel organized
• Visual schedule
• Useful to help the child transition between
  activities and know what is expected
• Eventually becomes a tool to increase flexibility
  and accept change
• all done place for child to put picture after
  activity
• Difference between activity choices and a
  schedule

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Verbal Communicators Visual Supports

• Video Lane with picture choices

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Verbal Communicators Visual Supports

• Video Jack with schedule

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Verbal CommunicatorsThe Echoer

• Be aware of limited understanding even though the
  child can mimic words/phrases/sentences!
• Focus on generating spontaneous language from the
  child (without a verbal model)
• Greatly decrease the amount of talking that you
  (the adult) are doing
• Use a lot of waiting and expectant looking
• Use repetitive activities and fade verbal models

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Verbal CommunicatorsThe Echoer

• Gestures and visual supports can really help
• Provide choices without having to give a verbal
  model
• Object choices or picture choices
• Give verbal model after child has made a choice
  through nonverbal communication
• When appropriate, say it the way you want the
  child to say it (help me please, I see Mom, etc.)

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Verbal Communicators Scripted/Stereotyped
Language

• Ignore when possible
• Provide appropriate language models to redirect
  the child
• Keep child engaged and motivated for the task at
  hand
• If very persistent, you can say Its not time
  for ___, were doing ___.

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Verbal Communicators Scripted/Stereotyped
Language

• Some children MAY use scripted language to try to
  communicate
• Parents may understand what their child is
  trying to communicate through scripted language
• Encourage parents NOT to engage in scripted
  language with their child
• Teach parents to provide more appropriate
  language models once they are aware what their
  child is trying to communicate
• Child Oh no Diego, you need help!
• Adult model help me please

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Verbal Communicators Increase Expressive Language

• Stay functional but still provide specific
  vocabulary
• May start with more, help me, all done if
  needed for functional communication
• Move quickly and model/encourage more specific
  vocabulary
• Easy to get stuck
• Build strong base of spontaneous single word
  vocabulary before moving on to phrases (objects,
  verbs, peoples names)
• To encourage 2-3 word phrases
• Start with a few very simple combinations that
  child can generalize in a variety of settings
• I want/see/like object
• more noun
• all done activity
• no object

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Verbal Communicators Increase Expressive Language

• Use of pictures/gestures/signs to aid child in
  learning new combinations
• Child still has to generate object in phrase
• Different than a true PECS program
• Next step Use of simple questions to request
• Can I have ___?
• Games to encourage simple question asking
• Go Fish
• Do you have ___?
• Can I have it?

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Verbal Communicators Tricky pronouns

• Be aware of limited understanding of personal
  pronouns (I, you, we, my, your)
• Verbal directions/questions can be very difficult
  for child
• Should I do it or you do it?
• Adults gestures can also confuse child
  (pointing)
• Use names at first to avoid confusion (Kates
  turn, Mommy help, etc)
• Then move into pronoun use with repetitive simple
  activities, continue to include names to aid
  comprehension
• Teach phrases like Kate, its your turn,
  Mommy, you do it
• Respond quickly to childs attempts to use
  pronouns, to increase childs comprehension

63
Verbal Communicators Tricky pronouns

• Video Jack with bee game- pronouns

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Verbal Communicators Increase Receptive Language

• Response to questions
• Yes/no questions good opportunity to model
  natural gestures (head nodding)
• Very simple wh questions in books or pictures
  sequences
• Concrete verses Abstract Language
• Simple concepts can be very difficult
• Like/dont like
• Favorite/best

65
Verbal Communicators Increase Receptive Language

• Model and teach appropriate ways to
  express/understand opinions
• Ex play food
• Exaggerated facial expressions and tone of voice
• Yum, I like apples!
• Yucky, Mommy doesnt like peas
• Very beginning stages of developing opinions and
  understanding that others perspectives are
  different than yours

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Verbal Communicators Social Skills

• Continue to stress social skills and shared
  enjoyment
• Turn taking games (must be fun!)
• Functional skills that can be generalized with
  family and peers
• Exaggerated facial expressions and tone of voice
• Still wait for and reward eye contact with verbal
  language

67
Verbal Communicators Social Skills

• Video Jack with bee game- shared enjoyment

68
Verbal Communicators Social Skills

• Simple conversational skills
• Greetings/closings
• Use visuals to help support
• Eye contact/body language
• Keep it natural Who are you talking to?
• Visuals- look with your eyes and your body
• Responding to simple social questions from adults
  (Whats your name? How old are you? Etc.)

69
Verbal Communicators Social Skills

• Have practice conversations around the
  clinic/school
• Take visual cue with you
• Support child in short, natural social exchanges
• Find adults and peers
• Example goal
• Say hi to 3 people with eyes/body

70
Dealing with difficult behaviors

• A- Antecedent What happens right before the
  behavior?
• B- Behavior What is the behavior? What might the
  purpose be?
• C- Consequence How do we respond to the
  behavior? Are we rewarding the behavior with
  positive or negative attention/reinforcement?
• Determine what child is trying to communicate,
  then teach replacement skills (language,
  nonverbal communication)
• Throwing items when finished/gets too hard teach
  all done or natural gesture of pushing items
  away

71
Dealing with difficult behaviors

• But still be consistent!
• If your goal is for child to complete an
  activity, help them to complete it then support
  them to use the desired behavior
• Use your judgment as to whether the child can
  handle this
• Consider if you are working above/below the
  childs optimal level
• Too hard? Too easy?
• Is the child engaged?

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Dealing with difficult behaviors

• Attention-seeking behaviors
• Is child trying to communicate, or simply
  experimenting/gaining attention?
• Ignore as much as possible, redirect
• Aggressive/Dangerous Behaviors
• Dont hesitate to seek support from
  psychologist/social worker/counselor!
• Refer family to an appropriate behavioral
  therapist or psychology program
• Seek support during your session (parent present,
  co-treat with another therapist)

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Dealing with difficult behaviors

• Provide positive behavior support when possible
• You did good listening for the book, you get a
  sticker!
• Use natural reinforcers when possible (smiles,
  hugs, tickles, high fives, verbal reward)
• Consider childs cognitive/developmental level
• Will they comprehend a time-out?
• Comprehend a simple consequence? (You hit, so no
  swing today)

74
Dealing with difficult behaviors

• VIDEO Jasmine (goal is to complete activity)

75
Dealing with difficult behaviors

• VIDEO Jack (attention-seeking)

76
Verbal Communicators Example Goals

• Combine familiar words into 2-3 word phrases,
  with visual and verbal cues, during 80 of
  opportunities for 3 consecutive sessions.
• Follow familiar and novel 1-step directions, with
  limited gestural support, during 80 of
  opportunities for 3 consecutive sessions.
• Respond to simple questions (yes/no, what, who)
  with minimum adult support, with 80 accuracy
  over 3 sessions.
• Greet/close with 2-3 familiar adults and peers,
  using eye contact/body positioning, with visual
  or verbal cues, for 3 consecutive sessions.
• Use familiar questions to gain information or
  request, with minimum cues, 5-6 times per session
  for 3 consecutive sessions.
• Use simple pronouns in short phrases (I, me, you,
  my your), independently, with 80 accuracy over 3
  sessions.

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High-Level Verbal Communicators

• Description
• Generating long sentences and questions
• Could be conversational
• Receptive language could be good for concrete
  concepts
• Struggles with true meaningful back and forth
  conversation
• Struggles with subtleties of social interactions
• Could be rigid about play, language, routines

• PRIORITIES
• Comprehension and use of abstract and social
  language
• Analyzing social cues and scenarios
• Understanding others perspectives
• Conversational skills

78
High-Level Verbal Communicators

• Continue to use structure and predictability as
  needed
• Visual/Picture or written schedules if needed
• For difficult activities, explain how many
  times and show visually
• Show number of cards/objects
• Use check boxes, penny board
• When possible, change routine/schedule to promote
  flexibility and adaptability
• Still give a warning with a schedule and
  repetitive verbal cues
• Schedule begins to be a tool to aid child with
  transitions and changes in routine

79
High-Level Verbal Communicators Abstract and
Social Language understanding

• Children with ASD are very likely to misinterpret
  or completely miss out on social scenarios
  happening around them!
• Analyzing Social Situations
• Use books or pictures of simple social scenarios
• Point out context clues that child might miss
  (birthday hat, broken toy, band-aid, etc.)
• First establish what probably happened, before
  discussing feelings
• Point out facial expressions and body language
• Probe for childs understanding of what happened
  and how it made someone feel
• What happened to them? Why do they feel ____?
  What might they do next?

80
High-Level Verbal Communicators Abstract and
Social Language understanding

• Video Alex with book

81
High-Level Verbal Communicators Abstract and
Social Language understanding

• Video Sunay with cards

82
High-Level Verbal Communicators Abstract and
Social Language understanding

• Carry over into real life social scenarios, talk
  with the child immediately about what happened
  (Billy just fell off of his swing, I wonder how
  that made him feel? Look at his face, etc.)
• Make it personal what makes you feel that way?

83
High-Level Verbal Communicators Understanding of
Others Perspectives

• First establish childs opinion/experiences
• Do you like to eat spinach?
• Are you in first grade?
• What animals do you like?
• Help child express opinion when needed (get
  information from teachers, parents about childs
  true preferences)

84
High-Level Verbal Communicators Understanding of
Others Perspectives

• Then ask others their opinion/about their
  experiences
• Idea take a poll and document everyones
  response
• Also a good opportunity for child to practice
  greetings and asking questions
• Also address with picture scenarios and books
  when needed
• Exaggerate your own opinion, especially if
  different from the childs

85
High-Level Verbal Communicators Understanding of
Others Perspectives

• Video Example Sunay

86
High-Level Verbal Communicators Understanding of
Others Perspectives

• Guess Who or barrier games
• Help the child understand the concept that you
  see something different than them
• Easier with 3 people (2 adults or a typical peer)
• Figurative Language
• Address as it comes up in natural contexts
• Youre crazy!, Get out of here
• Use consistent language
• Joking/silly words
• Doesnt really mean what it sounds like
• Exaggerated tone of voice and facial expressions

87
High-Level Verbal Communicators Conversational
Skills

• Address more complex conversational skills (more
  to come with group therapy ideas)
• Use of more complex visual supports (many can
  read- OK to use written cues)
• Practice conversations, walk around your
  building, school, etc.
• First review with visuals/social story, take it
  with you

88
High-Level Verbal Communicators Conversational
Skills

• Use consistent language (ex look with your eyes
  and your body so they know who you are talking
  to)
• Dont forget the why we do things, how this
  makes others feel, etc.
• Response to social questions (What things do you
  like to play? What did you do today? Etc.)
• Keeping it short- teach child only to give
  relevant details in narratives

89
Social Story
90
High-Level Verbal Communicators Example Goals

• Improve his social interaction skills by
  responding to familiar personal/social questions
  from familiar and unfamiliar adults and peers,
  with moderate cues, during 80 of opportunities
  for 3 consecutive sessions.
• Make inferences about social scenarios, with
  visual support, with 80 accuracy over 3
  consecutive sessions.
• Use eye contact and body positioning when
  talking/listening to others, with minimum visual
  and verbal cues, during 70 of opportunities over
  3 consecutive sessions.
• Show understanding of the perspectives of others,
  with moderate adult support, with 80 accuracy
  over 3 consecutive sessions.
• Use familiar phrases to express his preferences
  (I like it, don't like it, it's OK, etc.) with
  visual and verbal support, 4-5 times per session
  over 3 consecutive sessions.
• Greet and ask a social question to 3-4 unfamiliar
  adults or peers, with moderate visual support,
  for 3 consecutive sessions.

91
Co-existing conditions/Referrals

• Anxiety and ASD
• ADD and ASD
• Other Mental Health Disorders (OCD)
• Potential referral sources (consult with family
  and PCP first)
• Psychologist
• Psychiatrist
• Social Worker/counselor
• Occupational Therapy referrals
• Motor, play, sensory, self-regulation, daily
  living skills

92
Social Skills Groups

• Designed for children with ASD, but can be
  effective for children with other social deficits
• ADD/ADHD, Nonverbal Learning Disorder, children
  with limited social experiences, shy children
• Generally most effective for children with
  language and cognition skills close to age-level
• May be adapted for children at different levels
  when appropriate
• Children MUST be grouped together with peers at
  similar levels and with similar or complementary
  needs
• Significant behavior or mental health concerns
  should be addressed in a different setting
• Consider difference between a true knowledge
  deficit in social understanding, verses a
  performance deficit
• Children with ASD will have a knowledge deficit

93
Social Skills Groups Key Points

• Teach skills first in a direct and clear manner
• Explain why skills are important- keep it
  meaningful
• Teach social thinking verses learning rote
  skills
• Provide supported opportunities to practice new
  skills with peers
• Strive for the most natural setting possible to
  practice skills
• Use visual teaching methods with consistent
  language
• Provide parents with materials and knowledge to
  help the child use new skills outside of your
  setting
• Consider individual needs of each child
  (attention, sensory needs, motor coordination,
  motivation)

94
Social Skills Groups

• Age Range 3 years through adolescence
• Preschool (3-4 years)
• Early Elementary (5-6 years)
• Late Elementary/Middle School (7-9 years, 8-10
  years)
• Adolescent (11 years)
• Recommended that groups are run by both an SLP
  and an Occupational Therapist. Children with ASD
  need occupational therapy support due to
• limited play skills
• sensory needs/self-regulation
• difficulties with daily living skills
• motor needs/accommodations

95
Social Skills Groups

• Appropriate for psychologist, social worker,
  counselor with ASD experience to also participate
• Groups meet once/week (1 hour )
• New skills are supported by school staff and
  parents in natural social situations throughout
  the week

96
Pragmatic Skills Developmental Expectations
(Gard, Gilman, Gorman)
97
Social Skills Groups Preschool and Early
Elementary

• ASD Supports
• Visual Picture Schedule
• Structured Routines
• Environmental Modifications
• Carpet squares/cube chairs, decrease distractions
• Names and Feelings Board
• Visual rules
• Social Stories
• Motor/sensory Activities
• Social Thinking focus to address behaviors and
  rigidity concerns

98
Social Skills Groups Preschool and Early
Elementary

• SOCIAL RULES
• Quiet hands and body
• Quiet mouth
• Look at the person

99
Social Skills Groups Preschool and Early
Elementary

• Hello Time
• Each child takes a turn introducing topic or
  answering questions
• Focus on eye contact and body positioning
• Why does this matter?
• So we know who you are talking to
• So we know who you are listening to
• Simple conversation skills
• Greeting hi
• Asking simple questions, ex What do you like to
  play?
• Responding to peers question
• Sharing an experience I went to Disney World
• Comment to show you are listening Oh cool
• Structured chance to learn skills, then practice
  in more natural setting

100
Social Skills Groups Preschool and Early
Elementary

• Feelings Board
• Ask a peer How are you feeling?
• Choose from visual choices
• sad, happy, tired, mad
• Point out peers facial expression and body
  language
• Bobbys face looks sad and his head is down
• Comment or ask question about peers feeling
• Thats too bad
• What made you sad?

101
Social Skills Groups Preschool and Early
Elementary

• Video Example of Hello Time

102
Social Skills Groups Preschool and Early
Elementary

• Social Stories
• Based on Carol Grays concept of Social
  Stories
• (www.thegraycenter.org)
• Teach beginner-level social skills in a clear and
  direct manner
• Strong visual component to teach a skill
• Written from the perspective of the child
• Personalized for the needs of the specific
  students in your group
• Use a computer program, or just draw them
  yourself!
• Read and review at each group session, and send
  copies home with families for home practice

103
Possible Skills To Address Preschool and Early
Elementary Groupa

• Eye contact/Body language
• Personal Space
• Simple Greetings
• Asking peers to play
• Play ideas
• Dealing with rejection
• Bullying/negative peers

• Asking questions
• Commenting
• Expressing feelings
• Reading peers facial expressions and body
  language
• Gaining peers attention
• Voice level

104
Social Stories Preschool and Early Elementary

• Most of the time, peoples eyes are looking at
  the same thing that they are thinking about.
• When you are talking or listening to someone, it
  is nice to look at their eyes. This is how they
  know that you are talking or listening to them.

105
Social Stories Preschool and Early Elementary

• It is nice to have good personal space. This
  means I will not get too close to people. Good
  personal space is when you are not touching
  someone else and there is some space between you
  and other people.

• If I get too close to someone, I might be in
  their personal space. If I am in someones
  personal space, they might feel uncomfortable or
  mad. I will try to have good personal space and
  not stand or sit too close to people.

106
Social Stories Preschool and Early Elementary

• When I have something to say to a friend, first I
  need to get their attention. This way they will
  know that I have something to say.
• After I get my friends attention, they will know
  to listen to me.
• Written by Kristin Satzger

107
Social Stories Preschool and Early Elementary

• Sometimes other kids do things I dont like. They
  might not know that I dont like it. I need to
  use my words to tell people if I dont like what
  they are doing.

• If the person doesnt stop, tell the teacher or
  an adult.

108
Social Stories Preschool and Early Elementary

• Video Example Rules, Reading Story to Group

109
Play Activities designed to provide practice
opportunities Preschool and Early Elementary

• Simple turn taking games
• Asserting yourself my turn, Can I have it?
• Waiting for your turn
• Watching peers take a turn
• Staying engaged with activity to know when it is
  your turn
• Dealing with winning/losing Oh well, maybe next
  time, It was fun playing
• Ball toss/roll
• Gain peers attention first (say their name, find
  their eyes)
• Nonverbal communication (head nod to indicate you
  are ready)

110
Play Activities designed to provide practice
opportunities Preschool and Early Elementary

• Simple relay race
• Hand off object
• Ask peer for object
• Cheer for and watch your friends
• Group Art Projects
• Make something together or individually
• Gain peers attention to ask for materials
• Show peers what you did/made
• Games with matching pieces
• Gaining a peers attention
• Ask peers if they have the piece they need
• Make something together

111
Play Activities designed to provide practice
opportunities Preschool and Early Elementary

• Activity requiring 2 peers while others wait
• Ask a friend to be your partner
• Accept an offer to play
• Deal with possible rejection
• Watch others and wait for your turn
• Maintain spatial boundaries while waiting with
  peers
• Parachute Games
• Kids take turns being the leader (go, stop)
• Peers have to listen and watch the leader
• Ask friend to switch places with you
• Simple imagination skills (pretend we are in a
  tent, cave, etc.)

112
Play Activities designed to provide practice
opportunities Preschool and Early Elementary

• Simple Simon Says imitation game
• Encourages movement chosen by group members
• Keep eyes on peer/leader
• Leader watches to see if peers are imitating his
  actions

113
Play Activities designed to provide practice
opportunities Preschool and Early Elementary

• Videos
• Obstacle Course
• Simon Says

114
Play Activities designed to provide practice
opportunities Preschool and Early Elementary

• Free Play/Pretend Play Skills
• Remember what is expected for age/cognitive level
  (cooperative play, parallel play, etc.)
• Divide into small groups (2-3 kids per group)
• Provide themed materials (firehouse set,
  construction toys, zoo animals,
  kitchen/restaurant)
• Intrude as little as possible (provide play
  ideas, encourage child to include peer, ask peer
  what hes doing) then back off again
• Rules if needed Must play with a friend (not
  by yourself)

115
Play Skills Developmental Expectations (Gard,
Gilman, Gorman)
116
Play Activities designed to provide practice
opportunities Preschool and Early Elementary

• Video Construction Play

117
Preschool and Early Elementary Groups

• Use natural opportunities during the group to
  address more individual needs
• Personal space (Does Jacob like it when you get
  so close to him/hug him? Look at his face.)
• Sharing (That made Alex feel happy when you gave
  him a turn.)
• Body Awareness (When you are moving your body too
  much, your friends think you arent listening.)
• Understanding Others Feelings (Look at Bobby,
  his face looks sad. Do you know why he feels
  sad?)
• Perspective Taking (We werent on your vacation
  so we dont know what happened there, who you
  were with, etc.)
• Gaining Peers Attention (He didnt hear you. Say
  his name, use a louder voice, etc.)

118
Preschool and Early Elementary Groups

• Video Monkey Game, Goodbye

119
Preschool and Early Elementary Groups Community
Outings

• Community outings promote generalization of
  skills to a more natural setting
• McDonalds playland
• Ice cream
• Park/playground
• Butterfly Pavilion/museum/aquarium
• Continue to use consistent language from group
  teaching methods
• Bring visual supports as needed
• Review skills with child before outing (play with
  friends, share, use loud voice, etc.)
• Intervene with children individually as needed
  during outing
• OR, children take turns bringing a game/toy to
  group to share with friends

120
Preschool and Early Elementary Groups Example
Goals

• Will use strategies to gain a peer's attention
  (eye contact, body position, voice level, etc.),
  with moderate support, 4-5 times per group
  session for 3 consecutive sessions.
• Will initiate with peers (greetings, questions,
  comments), with moderate support, 4-5 times per
  group session for 3 consecutive group sessions.
• Will show listening skills (body positioning,
  commenting, etc.), with moderate adult cues,
  during 60 of opportunities for 3 consecutive
  sessions.
• Will express his feelings or opinion with peers
  and adults, with moderate adult support, 3-4
  times per group session for 3 consecutive
  sessions.
• Will maintain a short conversation with a peer
  (using comments or questions), with minimum adult
  support, 4-5 times per group session for 3
  consecutive sessions.

121
Late Elementary Groups

• ASD Supports
• Schedule (written and/or pictorial)
• Higher-level Social Stories
• Conversation practice with support
• Age appropriate motor/sensory play
• Social Thinking focus
• Straightforward feedback about how actions/words
  affect others

122
Possible Skills to Address Late Elementary Groups

• Age appropriate play
• Expanded comments (I did that too)
• Topic maintenance
• Asking questions to show interest (who, where,
  when)
• Appropriate touch
• Personal space in public places
• Greetings/Small Talk

• Flexibility for play and conversation topics
• Reading peers cues
• Eye contact/body language
• Entering a group of peers
• Dealing with bullies
• Providing only relevant details- keep it short
• Determining if someone if listening/interested in
  what you are saying

123
Social Stories Late Elementary

• If I talk for a long time and tell long stories,
  my friends might get bored.
• (draw in talk bubble)

• I will try to only say 2 or 3 things at a time.
  This way my friends will be able to listen to me
  and will not get bored. This will also give my
  friends a turn to talk.

124
Social Stories Late Elementary

• When our friends are telling us stories, we can
  ask them questions to show we are interested. We
  could ask

125
Social Stories Late Elementary

• There are some things I really like to talk
  about. But my friends might want to talk about
  something different.

• Its nice to say something short about what I
  like, and then I can talk about other things. I
  could ask my friends What do you like to do?

126
Late Elementary Groups

• Conversation practice Talk Time
• Visual support- dry erase board
• Generate good topics (that most kids your age
  like to do or talk about)
• Topic maintenance (out in space)
• Small talk (Whats up, Hows it going?)
• Commenting about your own experiences
• Asking questions to show interest
• Keeping it short

127
Play Activities Late Elementary Groups

• Sport activities (versions of basketball, soccer)
• Gain peers attention
• Stay with group
• Winning/losing
• Flexibility with rules
• Charades, Outburst, Hangman
• Chance to be a leader
• Nonverbal communication (charades)
• Group participation (making guesses)
• Dealing with yelling (OK time to be loud)

• Card/Board Games- Uno, Trouble
• Waiting turn (with a quiet body)
• Not bossing peers about their turn
• Coping with losing (Oh well, maybe next time)
• Appropriate joking, competition (He really got
  you that time!)

128
Late Elementary Groups

• Community Outings
• Snack bar at Target
• Ice Cream
• Bowling
• Park (sports)
• Museums/Aquarium/etc.
• Other ideas
• Holiday parties- children plan party together
• Games, food, decorations, music
• Peers bring toys/games to share
• Talk to child about what most kids his age
  might like to play
• Child can explain game to peers

129
Late Elementary Groups Example Goals

• Will initiate conversation with peers on an
  appropriate topic, with minimum cues, 3-4 times
  per group for 3 consecutive sessions.
• Will maintain a conversation on a peer's chosen
  topic, using comments or questions, 3-4 times per
  group session for 3 consecutive sessions.
• Will show awareness of whether peers are
  interested/listening to his stories and comments,
  with moderate cues, 3-4 times per group session
  for 3 consecutive sessions.
• Will use eye contact and body positioning when
  initiating conversation or play with peers,
  independently, during 80 of opportunities for 3
  consecutive sessions.
• Will keep his narratives short with only relevant
  details, with moderate adult support, 3-4 times
  per session for 3 consecutive sessions.
• Will acknowledge how a peer is feeling (or
  whether a peer is interested in what he is
  saying), with moderate adult support, 3-4 times
  per session for 3 consecutive sessions.

130
Adolescent Groups

• ASD Supports
• Written Schedule if needed
• Written handouts with skill description
• Comic Strip Conversations
• Video Analysis/Feedback
• Straightforward feedback from therapists (be
  blunt!)
• Focus on age appropriate skills and life skills

131
Possible Skills to Address Adolescent Groups

• Using body language to show you are listening
• Reading peers body language/facial expressions
• Topic maintenance
• Maintaining conversations with comments/questions
• Keeping it short with relevant details

• Ending a conversation Phone Skills
• Entering a group of peers
• Small Talk
• Teenage Talk
• Age Appropriate Interests/Hobbies
• Bullying
• Hygiene/Appearance
• Friends verses acquaintances
• Topic flexibility

132
Teaching Tool Comic Strips

• For use with older or high functioning (literate)
  students
• Based on Carol Grays concept of Comic Strip
  Conversations
• A visual and written way to teach skills
• Use of thought bubbles in addition to
  characters talking to each other
• Depict facial expressions and body language
• Increasing the successful social exchanges a
  student will have by reviewing different
  scenarios and how to respond
• Easy to create on your own
• Fun and motivating for students

133
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134
Teaching Tool Written Handouts or Scripts

• Effective for higher-level students who do not
  need a visual representation to learn new skills
• Teach higher-level conversational skills,
  community skills, life skills
• Provide specific scripts for different
  scenarios so students have appropriate choices of
  what to say or ask
• Increasing the successful social exchanges a
  student will have by reviewing different
  scenarios and how to respond
• Still explaining why something is important
  (teaching social thinking!)
• Can be sent home for practice and reviewed bef