Better interventions for non-verbal autistic children

Child autism teaching
Children can learn new play skills and ways to interact with the world by watching and imitating other people, and so we think this might help turn on the brain systems involved in social cognition, including the motor resonance system.
Dr Joe McCleery
70 million people worldwide are estimated to have autism, including 600,000 in the United Kingdom alone. The charity Autistica published a consultation this month which found that of these, 24 per cent of children with autism do not speak at all, or produce minimum verbal output. This inability to communicate verbally can often persist into adulthood, in spite of professional interventions aimed at supporting speech and language development.

A University of Birmingham paper which appeared this week in the journal Frontiers in Neuroscience considers the state of current research and considers the effectiveness of the different intervention techniques which may be used. The report goes on to discuss how approaches could be altered or invented to improve the quality of life of children with autism.

Speaking to ScienceOmega.com, lead author of the review study Dr Joe McCleery, a lecturer in developmental neuroscience in Birmingham’s School of Psychology, explained why there is both room for improvement and reason to be optimistic…

What do we know about the underlying causes of non-verbality in children (and adults) with autism?
Unfortunately, very little is about this population and why they don’t develop speech while other children on the autistic spectrum do. One potential factor is that there are so many other challenges for these children. They tend to exhibit more behavioural difficulties, and because of the fact that they can’t communicate it is often difficult to conduct tests using traditional brain imaging methods. There is a push now, from Autistica and other organisations, for more studies to look at brain structure and brain function, because this is a poorly understood area.

We know that non-verbal or minimally verbal autistic children are at higher risk for seizure disorders, which may affect temporal and medio-temporal brain regions involved in language and memory function, for example. This is probably a contributory factor in some (but not all) of these children.

We also know that some of these children and adults experience co-morbid genetic syndromes like Fragile X syndrome. Fragile X and some other conditions affect intellectual development overall. Most of the time it’s not just a language delay, it’s a general intellectual delay, but we’re trying to improve the language skills of these children because we know their importance.

More research is needed, but not just in neurobiology. There also needs to be more work on how we characterise the difficulties experienced and how we develop methods for assessing strengths and weaknesses and verbal and non-verbal capacity.

What attempts have been made in the past to support language development in these individuals?
The key approaches have been sign language, picture-based communication training, and methods designed to improve motivation and success. It’s been hypothesised that learned helplessness plays a role in some children’s difficulties. Traditional interventions have asked these children to produce full words or clear approximations of words, but they struggle very hard and sometimes produce only simple speech sounds. Taking that into account, some practitioners provide access to toys, foods or other rewards simply for trying to make sounds close to the target sound.

Despite strong reason to believe that sign language should work, there is evidence that it does not work very well for these children. The data show that they don’t learn many signs and, while at first they seem to learn to talk, they are producing only very basic sounds. Although that’s a good start, the majority never go beyond that – other kinds of intervention are needed.

Picture-based communication training and play-based, motivationally-oriented strategies that use explicit teaching have been found to improve both communication and speech skills in minimally verbal children, but there is room for improvement. We don’t know exactly how many of those children go on to become fully verbal versus only being able to speak in phrases for the rest of their lives. We do know that children who aren’t speaking at all when they start this intervention process – who are literally not saying anything or maybe using one word – often do not make notable gains, even following the best interventions available.

Why was this survey of the literature necessary?
This is what I would call a summary review. We take the general findings of all the research in this field and summarise them in a way that tells a story about the current state of the literature, the current state of the development of certain interventions, and how this relates to theoretical models about motor functioning, motor development, motor resonance and motor mirroring in language development in typical children and in children with autism.

A key point is that it’s not enough to have a theory about what might work. You have to test that theory with these children and show that they improve. We provide an overarching framework for linking theory to intervention, but also for linking tests of intervention to actual treatment recommendations.

How are you planning to build on the findings to improve interventions? Are results already being seen?
With funding from Autistica, we are conducting a pilot randomised controlled trial (RCT) on an intervention called reciprocal imitation training, with the intention of going into a full-scale RCT. This therapy targets motor activities, imitation of action, gestures and speech. The hypothesis is that this intervention, which teaches the child to imitate in a play context, gets them to pay attention and gets them more interested in people.

Children can learn new play skills and ways to interact with the world by watching and imitating other people, and so we think this might help turn on the brain systems involved in social cognition, including the motor resonance system. This is being tested in kids who are non-verbal and minimally verbal, in toddlers who are not talking at all and toddlers who are talking a little bit.

A couple of other things are in the planning stages. One is an efficacy versus effectiveness study. For now it is confined to a laboratory environment but we are discussing with Autistica the best ways to transfer it into community environments such as schools, preschools or speech pathology clinics. Then we can assess not just whether kids can learn this way but whether they can learn this way in the real world.

What do you hope will be the outcome of improved support for non-verbal autistic children, now and in their adult lives?
We’d like to improve quality of life. Speech and language functioning helps you to communicate your thoughts and desires. It gives you increased capacity for extended relationships with people outside your family, and an increased capacity to contribute to society and be practically and financially independent. Allowing people the opportunity to communicate their needs, be involved in what other people are saying and contribute to discussion can make a big difference.

Discussions are ongoing with Autistica about how we might integrate new theoretical angles into existing effective practices, in order to improve them and improve outcomes for the children. We’re looking at ways to incorporate hand banging and other strategies to maximise their effect, so as well as developing new interventions we can integrate our findings into existing frameworks.

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