Autism Spectrum Disorders

CASE STUDY
HISTORY
Joey is a 6-year-old boy who was reported to have achieved early developmental motor milestones
within expected age ranges and his early developmental language milestones were within normal
limits as well (e.g., first words at 12 months, two word phrases at 15 months). However, his parents
reported that between 15 and 18 months he gradually stopped playing with his siblings and became
quieter. Also at this time he developed sleep difficulties and extreme tantrum behaviors including
banging his head. By 2 years of age, he was no longer talking and appeared to be "in his own little
world."
Joey began receiving speech/language therapy at age 2 years and his speech/ language therapist
suggested that he be evaluated for autism.
At the time of his diagnosis, shortly after he turned 3 years old, Joey had no speech and was not
pointing or gesturing to indicate his needs. His parents would need to hold things up and give them to
him to try to determine what he wanted or what was bothering him. Joey would not imitate actions of
others around him, nor did he engage in any pretend play or play with other children.
Joey made little eye contact and his parents reported that if they held his chin to try to force him to
look at them, he would look away. Joey did not offer comfort to others and would not accept comfort.
He had a limited range of facial expressions (smiling, scowling, and a "blank" look). Joey had no
interest in and did not respond to the approaches of other people. He would sometimes take his
mothers hand and lead her to what he wanted and put her hand on it. He used her hand as a tool in
other ways as well (e.g., when he would be upset and crying, he would use her hand to wipe his face
instead of his own).
Joey would repetitively pluck the fur off of his stuffed animals (going through two to three stuffed
animals per week) and pluck the fibers from carpets and afghans. He frequently went around the
house and collected everyones shoes and lined them up. He frequently mouthed objects and also
liked to lick windows and glass. Joey had odd hand mannerisms, twisting his hands in front of his face
and eyes. He was also frequently observed to walk on his toes while flapping his hands and spinning in
circles.
DIAGNOSIS
At the time of his initial evaluation he scored in the clinically significant range in all areas on
the Autism Diagnostic Interview-Revised)(ADI-R). He was also administered Module 1 of the Autism
Diagnostic Observation Schedule (ADOS) with scores consistent with Autistic Disorder as well. He was
not able to engage in standardized assessment of his intellectual ability at that time. A nonverbal
measure was attempted but rather than using the response cards to provide responses to test items,
he became fixated on them. Similarly, he became intensely interested in the spiral binding on one of
the stimulus books but was not interested in using the test materials as the examiner asked him to.
Joey was diagnosed with Autistic Disorder.
Teaching Students with Attention-Deficit/Hyperactivity
Disorder
Case #1: Melodie - Grade 1

Melodie, 6, moved into Metropolis Elementary from Los Angeles in January of her grade one
year. Her mother, a homemaker who appeared somewhat exhausted from managing
Melodie, met with Miss Fontaine, the Grade 1 teacher. She informed the teacher that
Melodie had been on Ritalin since Kindergarten and would need some special attention. She
and her husband, an engineer, were looking for any suggestions the school could provide in
managing Melodie at home as well. Miss Fontaine indicated that she would review Melodie's
file and asked Melodie's mother if she and her husband could come in to meet with her and
the school based team next week to discuss Melodie's program.
During the first week, Miss Fontaine made the following observations:
Melodie is cheerful and friendly. She seems keenly interested in pleasing the teacher
and her classmates.
Melodie appears to have a strong understanding of verbally presented information,
knows her colours and can count to 100.
Melodie's literacy skills are at the emergent stage - she cannot recall letter names
and does not appear to have any sight vocabulary.
Maintaining one to one correspondence with objects while counting is difficult for
Melodie.
Melodie completes 2 out of 20 questions when not medicated (she indicated that she
forgot to take her pill on Thursday morning); she completes entire sheet of 20
questions when she has taken her medication
During both individual and group instruction, Melodie frequently interrupts to ask
unrelated questions and change topics.
When interacting with peers, Melodie constantly changes topics and commonly
leaves an activity or game while others continue to play.
Information from Melodie's file indicated that she had received a psychological assessment
and had been identified as having AD/HD as well as learning disabilities. She had been
placed on a wait list for a special class placement in Los Angeles.
Miss Fontaine brought Melodie's case forward to the school based team meeting so that
planning could take place immediately. Mr. and Mrs. Marshall were invited and were able to
meet with the team on Thursday of the second week Melodie had been enrolled at the new
school.
At the meeting, the team agreed that acquiring literacy skills and helping Melodie to focus
on the topic at hand were the most important goals to begin with. The following plan was
developed.

Anderson: Excitement and Joy Through Pictures and Speech
by Sylvia Diehl
Anderson is a 3-year-old boy with ASD who was referred to a university speech and hearing center
by a local school district. He attended a morning preschool at the university center for one year in
addition to his school placement.
History
Birth and Development
Anderson was a full-term baby delivered with no complications. Anderson's mother reported that as
a baby and toddler, he was healthy and his motor development was within normal limits for the major
milestones of sitting, standing, and walking. At age 3 he was described as low tone with awkward
motor skills and inconsistent imitation skills. His communication development was delayed; he began
using vocalizations at 3 months of age but had developed no words by 3 years.
Communication Profile at Baseline
Anderson communicated through nonverbal means and used communication solely for behavioral
regulation. He communicated requests primarily by reaching for the communication partner's hand
and placing it on the desired object. When cued, he used an approximation of the "more" sign when
grabbing the hand along with a verbal production of /m/.
He knew about 10 approximate signs when asked to label, but these were not used in a
communicative fashion. Protests were demonstrated most often through pushing hands. Anderson
played functionally with toys when seated and used eye gaze appropriately during cause-and-effect
play, but otherwise eye gaze was absent. He often appeared to be non-engaged and responded
inconsistently to his name.
Assessment
The Communication Symbolic and Behavior Scales Developmental Profile (CSBS DP; Wetherby &
Prizant, 1993) was used to determine communicative competence. This norm-referenced instrument
for children 624 months old is characterized by outstanding psychometric data (i.e.,
sensitivity=89.4%94.4%; specificity=89.4%). Although Anderson was 36 months old, this tool was
chosen because it provides salient information about social communication development for children
from 6 months to 6 years old.
Intervention
Anderson's team and family members developed communication goals that included spontaneously
using a consistent communication system for a variety of communicative functions and initiating and
responding to bids for joint attention. Research suggests that joint attention is essential to the
development of social, cognitive, and verbal abilities (Mundy & Neal, 2001).
Because Anderson could not meet his needs through verbal communication, AAC was considered.
He had been taught some signs but did not use them communicatively. More importantly, his motor
imitation skills were so poor that it was difficult to differentiate his signs. His communication partners
would need to learn not only standard signs, but Anderson's idiosyncratic signs. Therefore, the
Picture Exchange Communication System (PECS; Bondy & Frost, 1994) was chosen to provide him
with a consistent communication system. Additionally, a visual schedule was used at home and
school to aid in transitions and to increase his symbolization.
Incidental teaching methods including choices and incomplete activities were embedded in home
and preschool routines. In addition, a variety of joint activity routines (e.g., singing and moving to
"Ring Around the Rosie" or "Row Your Boat" while holding hands) that were socially pleasing to
Anderson were identified. These were infused throughout his day in various settings and with
various people. Picture representations of these play routines also were represented in his PECS
book.
Research
Several evidence-based strategies were chosen to support intervention, including PECS (Carr &
Felce, 2007; Ganz & Simpson, 2004; Temple, 2007), visual supports (Bryan & Gast 2000; Krantz,
MacDuff, & McClannahan, 1993), and incidental teaching (Cowan & Allen, 2007; Miranda-Linne &
Melin, 1992).
Outcomes
By the end of the year, a video taken at preschool showed that Anderson was spontaneously using
PECS for requests and protests. He was using speech along with his PECS requests in the "I want"
format. He also used speech alone for one-word requests and for automatic routines such as
counting or "ready, set, go." He shared excitement and joy in several joint activity routines with
various people and referred to their facial expressions for approval and reassurance.
Sylvia Diehl, PhD, CCC-SLP, is an assistant professor in the Communication Sciences and
Disorders Department of the University of South Florida, where she teaches courses in
augmentative and alternative communication, language disorders, autism, and developmental
disabilities. Contact her atdiehl@cas.usf.edu.
Tait: Communicating Emotions
by Jane Wegner
Tait is a 12-year-old boy who was diagnosed with ASD at age 2. Tait is generally healthy although
he has recently been diagnosed with rheumatoid arthritis and is sensitive to pain. He has difficulty
with small spaces and "bottlenecks" where many people are congregated. Tait participates in special
education at a local elementary school. His strengths include being curious, social, and visually
astute. His challenges include communication, impulsivity, and behavior that may include tantrums,
aggression, and property destruction. These challenges have made it difficult for Tait to participate in
activities with peers.
Communication Profile
Tait has a positive-behavior support team and receives speech-language intervention at the
Schiefelbusch Speech-Language-Hearing Clinic. He is a multimodal communicator whose verbal
communication is not understood by most people. He uses a Palm 3 (Dynavox Technologies),
pictures, idiosyncratic signs, gestures, and some words to communicate.
Assessment
Tait's communication was assessed with the SCERTS Assessment Process (SAP; Prizant,
Wetherby, Rubin, Laurent, & Rydell, 2006) in spring 2007. As a criterion-referenced, curriculum-
based tool, the SAP determines a child's profile of strengths and needs based on his or her
developmental stage in the domains of social communication and emotional regulation. Tait was in
the Language Partner stage of communication. We collected data in three contexts: school, home,
and an intervention session in the Schiefelbusch clinic.
Social Communication
Tait's strengths in the area of social communication included engaging in reciprocal interactions,
sharing attention to regulate the behavior of others, and using several modes of communication. His
needs in social communication included sharing a range of emotions with symbols and sharing
intentions for joint attention by commenting on objects, actions, events, or requesting information
across partners and contexts.
Emotional Regulation
Tait's emotional regulation strengths included responding to assistance from a familiar partner that
he trusted, recovering from extreme dysregulation with support from a familiar partner, and using a
behavior strategy (holding a block of wood) to remain focused and calm in some familiar
environments. His needs in the area of emotional regulation were seeking assistance with emotional
regulation from others, responding to assistance across contexts, and responding to the use of
language strategies across environments.
Transactional Support
Transactional support was strong in some areas. For example, all of Tait's partners wanted him to
learn and communicate more conventionally and he had consistent, responsive communication
partners at home. Tait needed the same responsive style across all partners and the consistent use
of visual and organizational supports as well as his AAC system to enhance learning and
comprehension of language and behavior.
Intervention
Goals included:
Increased use of emotion words on the AAC device.
Commenting on objects, actions, or events.
Choosing what he needs to calm himself from choices offered (from an adaptation of the 5-
point scale by Buron and Curtis, 2003).
Transactional goals included:
Using augmented input (Romski & Sevcik, 2003) with redirection, expansion, and modeling
by Tait's partners.
Providing a binder with a schedule and social stories (Gray, 1995) for preparation for
activities.
Making an AAC device always available and using an interactive diary developed by his
mother.
These supports were implemented in activities of interest to Tait such as holidays, his life in photo
albums, tools, and events at home.
Outcomes
In the past two years, Tait has made many communication gains. His AAC device has more than
200 pages of icons, which he accesses independently to express feelings. He has told us when he is
angry, happy, sad, frustrated, and sick, and he engages in reciprocal exchanges, commenting on the
shared object or event of interest. He has started to mark tense when he comments by using the
"later" and "past" icons on his device to clarify his message. He is able to indicate to his partner what
he needs to calm himself when choices are offered. In addition, he has more communication
partners who are responsive and able to provide him with the learning supports he needs.
Find Out More
View an article and video about Tait.
J ane Wegner, PhD, CCC-SLP, is a clinical professor and director of the Schiefelbusch Speech-
Language-Hearing Clinic at the University of Kansas. She teaches courses in AAC and autism
spectrum disorders and directs the "Communication, Autism, and Technology" and "Augmentative
and Alternative Communication in the Schools: Access and Leadership" projects. Contact her
atjwegner@ku.edu.
Sam: From Gestures to Symbols
by Emily Rubin
Sam is a 16-year-old young man with ASD and significant cognitive delays. As part of professional
development training for his educational team, this speech-language pathology consultant followed
him for 12 months. Sam now attends a public school special day class that offers frequent instruction
in varied settings to foster independence in the community.
History
Birth and Development
Sam was born six weeks premature following his mother's hospitalization for pre-term labor. His birth
history was significant for low birth weight (2 lbs., 10 oz), respiratory distress, intraventricular
hemorrhage, and a neonatal hospital stay of six weeks. He began receiving intervention services at
12 months of age to address speech, language, social-emotional, and cognitive delays. To date,
evaluations yield developmental age equivalents up to the 24-month level. Since birth, Sam's history
is unremarkable for significant medical concerns and he is in good health. He has passed hearing
screenings and wears corrective glasses.
Communication Profile at Baseline
At 14 years, 8 months of age, Sam spontaneously shared his intentions through nonverbal means,
which included facial expressions (e.g., looking toward staff to request a snack), physical gestures
(e.g., pulling his teacher's hands to his head to request a head massage), and more conventional
gestures (e.g., pointing to request and a head shake to reject). He also used unconventional
nonverbal signals that included biting his hand to share positive and negative emotions and pinching
to protest. Sam occasionally used a few verbal word approximations (e.g., "no," "yes," "more," and
"balloon"), the sign for "help," and picture symbols on a voice output device. However, he typically
used these symbols passively, most often in response to a direct verbal prompt from his social
partner (e.g., "Do you want more?").
Assessment
At baseline, the SAP was administered to gather information about functional abilities in daily
activities through observation and a comprehensive caregiver questionnaire. Given his baseline
presentation, the SAP placed him at the Social Partner Stage, a stage that is relevant for individuals
using pre-symbolic communication. With this profile, functional educational goals based upon parent
priorities and evidence-based supports were determined.
Research
The SAP was derived from longitudinal descriptive group research. It enables providers to select
educational objectives that are predictive of gains in language acquisition and social adaptive
functioning (Prizant et al., 2005). Sam's educational team selected objectives shown to predict an
individual's symbolic growth, such as increasing his rate of spontaneous communication and his
range of communicative functions. The team worked to move him beyond requesting objects to
requesting specific people and actions. The SAP also facilitated the selection of evidence-based
supports such as AAC when developing educational accommodations to address these objectives.
Intervention
Sam's Individualized Education Program objectives shifted from those for passive responses (e.g.,
responding to questions such as "Where did you go?") to initiating communication using AAC (e.g.,
requesting help or other actions, expressing emotions, and making choices of coping strategies).
Throughout the day, Sam accessed an emotion necklace of laminated cards. On the front of each
card was a graphic symbol representing an emotional state (e.g., happy, angry, and sad). On the
back were symbols representing words Sam could use to request actions from others (e.g., "high
five" for happy). This support fostered symbolic requests for communicative functions that Sam
already exhibited spontaneously using nonverbal means at baseline (e.g., expressing emotion by
biting his hand and looking toward staff).
During language art centers, Sam engaged in activities designed to elicit more sophisticated
requests for preferred actions. Rather than identifying pictures, he could choose a preferred sensory
activity, such as a head massage, a back rub, or tickling. Color-coded symbols paired with sentence
templates allowed Sam to create his own sentences for functions already exhibited spontaneously
using nonverbal means at baseline (e.g., requesting comfort by pulling his teacher's hands toward
his head).
Outcomes
Sam's first quarterly review occurred around his 15th birthday. Observations and videos revealed a
higher rate of spontaneous bids for communication and the emergence of symbols to express
emotion (e.g., "happy" and "mad"), request coping strategies (e.g., "head squeezes" and "high
fives"), and form simple sentence structures (e.g., "Jim squeeze head" and "Karen rub back"). By six
months post-intervention, Sam began to take turns, requesting interaction using subject + verb
sentences and then responding to interaction. His teacher might request that "Sam rub back" and
Sam would oblige. At 12 months post-intervention, Sam continues to expand his symbolic language
skills and recently began to generalize his sentences to include names of his peers.
Emily Rubin, MS, CCC-SLP, is director of Communication Crossroads, a private practice in Carmel,
Calif. She is an adjunct faculty member at Yale University, where she has served as a member of its
Autism and Developmental Disabilities Clinic. She is a co-author of the clinical manual for the
SCERTS Model, a comprehensive educational approach for children with autism spectrum
disorders. Contact her at Emily@CommXRoads.com.


Interagency Autism Coordinating Committee
ASHA Provides Input to Interagency Autism Coordinating Committee
by Ann-Mari Pierotti
The Interagency Autism Coordinating Committee (IACC) was established in accordance with the
Combating Autism Act of 2006 (P.L. 109-416.) The committee coordinates all efforts within the
Department of Health and Human Services (HHS) concerning autism spectrum disorder (ASD). The
IACC includes both members representing federal agencies and the public to ensure that
perspectives and ideas are represented and discussed in a public forum.
The IACC mission is to:
Advise the Secretary of Health and Human Services regarding federal activities related to
ASD.
Facilitate the exchange of information and coordination of activities related to ASD among
the member agencies and organizations.
Increase public understanding of the member agencies' activities, programs, policies, and
research by providing a public forum for discussions related to ASD research and services.
ASHA staff has been attending the IACC's meetings, which include presentations and discussions
on a variety of topics such as activities and projects of the IACC, recent advances in science, and
autism policy issues. Catherine Gottfred, 2008 ASHA president, submitted comments to the IACC on
Dec. 12, 2008 emphasizing the critical role of the speech-language pathologists with respect to
assessment and treatment of ASD. During this comment period, ASHA informed the committee of
ASHA's policy documents related to the role of the SLP with respect to autism. These documents
include a position statement, technical report, guidelines, and a knowIedge and skills statement and
are available online.
Additionally, ASHA staff provided input to the IACC as the agency developed its 2010 Strategic Plan
for Autism Spectrum Disorder Research. ASHA's comments focused on the need for:
Screeners with high sensitivity and specificity that identify early signs of behavioral,
cognitive, and communication impairments that are critical to accurate and early diagnosis.
Evidence-based comparative effectiveness research that identifies effective treatments.
Research that will provide clear indications regarding which services and support strategies
or combinations are most effective.
Research to assess the efficacy of behavioral treatment approaches to determine which
intervention(s) yield clinically significant improvements in speech, language, and social
communication.