Abstract
This chapter reviews the major in-person therapies for autism. It begins with standard therapies like general speech-language therapy, applied behavioral analysis (ABA/DTT), and more naturalistic alternatives (DSP/DIR/Floor Time). It discusses how these therapies approach language and what the data show about their efficacy. It then turns to additional/supplemental strategies, including those that seek to boost attention to speech and others that use visual strategies like the picture exchange communication system (PECS). The chapter then describes other systematic approaches to instruction—direct instruction and precision teaching—discussing how these potentially contribute to language instruction. It concludes with a discussion of the shortcomings of the in-person methods, including limitations in eliciting appropriate practice, challenges providing appropriate feedback, deficiencies in curriculum coverage (particularly grammar and pragmatics), and difficulty providing effective instruction to non-speaking, nonverbal individuals.
TopIntroduction
In the previous chapters, we discussed core characteristics of autism that impede the acquisition of language. Here is a quick recap:
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The core characteristics amount to diminished attention to speech and to speakers and to diminished motivation to interact with people.
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Just how diminished this attention and motivation is varies from individual to individual and is tightly correlated with degrees of language impairment.
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The linguistic challenges range from difficulties acquiring vocabulary, to difficulties with grammar and syntax, to difficulties with the social aspects of language (e.g., pragmatics), to difficulties with comprehension.
Difficulties with speech articulation and with speech prosody (tone of voice) can also occur in autism, but they are not the focus of this book. Our focus, rather, is on language problems that affect all mediums of language (spoken, written, signed).
Given all this, what are the best therapeutic approaches? One strategy is to address the underlying problems head on; another is to bypass them. In the first category are interventions directly targeting the diminished attention to speech and the diminished motivation to interact. In the second category are interventions that bypass the attention and motivational problems. In short, the therapist might either
As we will see below in our discussion of therapies for autism, most interventions take some combination of these approaches—though they vary in their goals and priorities. There is, however, one general consensus among autism professionals: namely that individuals with autism need early, intensive interventions of at least 25 hours a week (see, e.g., Myers et al., 2007). While the recommended intervention goals include a variety of areas (behavior, life skills, social skills), pre-eminent among them is language.
We begin by discussing the standard in-person language therapies used in autism and their efficacy: we call these “in-person” therapies to distinguish them from the technology-mediated therapies discussed in the next chapter. Then we turn to other (in-person) language remediation/teaching tools and programs that, while less standard as treatments for autism, may still have some applicability and promise. Finally, we discuss ways in which all of these tools come up short, noting additional features that effective autism therapies should ideally include.
Key Terms in this Chapter
Picture Exchange Communication System (PECS): A system of communication that involves small, laminated pictures (including photographs) or icons, often customized to the child’s particular interests and sometimes captioned with printed words. In PECS training, instead of prompting a child to produce a targeted spoken or signed response, the therapist prompts him to select and hand over (“exchange”) a targeted picture or sequence of pictures.
Direct Instruction: A behaviorist approach akin to ABA, involving structured learning environments and explicit, systematic, sub-task-by-subtask instruction. Direct Instruction is typically done in classroom settings and focuses on academic skills, though it includes a language teaching curriculum.
Discrete Trial Training (DTT): A form of ABA that involves direct, one-on-one, therapist-led instruction. DTT typically involves highly structured environments—e.g., with the child and therapist sitting opposite each other at a table.
Applied Behavioral Analysis (ABA): A behaviorist intervention commonly used in autism, involving structured learning environments and explicit, systematic, subtask-by-subtask instruction. ABA sessions are designed to teach positive behaviors and eliminate negative ones, with reinforcements (carefully chosen rewards) for correct responses, modeling of correct responses as needed, and gradual fading of prompts/cues and reinforcements.
Function Words: Words that serve primarily a grammatical rather than a semantic function. Function words include articles (“a” and “the”), and connecting words like “and,” “but,” and “if”. Function words are difficult to teach, especially in isolation.
Milieu Training: A more naturalistic training alternative to DTT. Milieu training is less teacher-directed and more child-centered and child-initiated. It is well suited to real-world routines like meals or preparations for outings.
Contemporary ABA (CABA): A form of ABA that combines Discrete Trial Training with training sessions conducted in naturalistic environments.
Floor Time: An early variant of the DSP model. Floor Time involves the parent joining the child in his play activities, following his attentional lead, commenting on the objects and activities of play, and concocting attention-getting scenarios or playful obstructions to inspire the child to use language.
Precision Teaching (PT): Akin to Direct Instruction, but with the additional instructional goal of fluency. Fluency, which is based on the speed and accuracy of the students’ responses, is considered by PT practitioners to be a key ingredient of mastery.
Developmental Social Pragmatic (DSP) Model: A child-directed, play-based intervention that views fostering positive relationships and enhancing social motivation and social connection as the best ways to encourage linguistic expression. DSP views language as developing naturally, even in autism, and merely in need of motivating environments in order to emerge in full.