II Developing an Intervention Program for the Non-Verbal Child with Autism:

After considering the previous questions, an intervention program can then be developed to address the child's communicative needs at this preverbal level. It should include the following essential communication elements:

• Developing communicative intent:

Following the establishment of such pre-linguistic skills as attending and maintaining eye contact, a non-verbal child with autism can be taught communicative intent in several ways:

• Cause/effect reasoning: Cause/effect reasoning helps develop communicative intent, because it teaches the child that doing one action can cause another to happen. It is important for the child to develop an understanding of cause/effect reasoning through a variety of experiences, such as playing with pop-up/musical toys that are activated by the push of a button, climbing up on a chair to get a cookie off of the counter, being rewarded for specific desired behaviors, etc.
• Joint activity routines: Highly predictable routines including movement routines, such as blowing bubbles, blowing up a balloon and letting it go, "Here Comes the Spider" tickle game, food making routines, such as making Kool-Aid or chocolate milk, play routines with simple toys, can establish anticipatory behaviors in the child. The child's ability to anticipate the outcome of these highly predictable joint activity routines ensures an understanding of cause/effect. Joint activity routines are a highly effective teaching strategy for children with autism, as they provide learning through a strength feature of autism, a preference for routines. Joint activity routines allow for the child and adult to engage in meaningful, natural social communicative interactions within the routine of an activity. Another positive outcome in using joint activity routines is that they teach the child that he can share experiences with others through the communication embedded in these routines (2).
• Delay responses to anticipated wants/needs: At times it may be easy to anticipate and respond to the wants and needs of the non-verbal child, even though the child may not exhibit intentional communication. However, because the goal of the intervention program is to develop meaningful communication skills (i.e. purpose, intent, and desire), it is important to remember to expect the child to communicate. Even though the adult may know what the child wants, it is important to delay meeting the child's wants and needs so that he is placed in situations which require him to interact with others to get his wants and needs met.

• Establishing an efficient and appropriate way (form) to communicate:

After determining the child's form of communication, (i.e. motoric, gestural, etc.) it is important to consider if a more efficient form can be used to express the same functions (uses) of language. For example: if the child jumps up and down excitedly in the general area of a desired item, a more efficient way to "request" desired items should be considered. This piece of the intervention process is two-fold: a) determining which visual representation system is best understood by the child (i.e.: objects, photographs, realistic drawing, line drawings, written words); and b) using this information to determine an appropriate alternative communication system for the child. The following visual representation systems are listed in hierarchical order, from concrete to more abstract.

• Visual Representation Systems:

Real objects: The child uses various real objects to communicate (e.g., gives his parent shoes to indicate that he wants to go outside).

Miniature real objects: The child understands that a miniature object represents the full-sized object (e.g., a miniature cup is representative of a real cup).


"True Object Based Icons (T.O.B.I.s)"

True Object Based Icons (T.O.B.I.s): A T.O.B.I. can be a line drawing, scanned photograph, etc., which is cut out in the actual shape or outline of the item it represents. Symbol shape, which the child can both see and feel, appears to assist the child in more readily understanding a 2-dimensional representation system (1). T.O.B.I.s tend to be somewhat larger than typical 2-dimensional visual representation systems and when initially introduced, may be 3 inches in size or larger (1).

Photos: The child understands that a photograph of an action or object is representative of the real object, action or event.

Real drawings: The child understands that a real drawing of an action or object is representative of the real object, action or event.

Line drawings: The child understands that a simple line drawing of an action or object is representative of the real object, action or event.

Written word: The child understands that the written word is representative of the real object, action or event. The written word should accompany all visual representation systems, as many children with autism, even at the non-verbal level, exhibit emerging literacy skills.



• Alternative Communication System:The following are various alternative communication systems that may be tried with the non-verbal child with autism. (list does not represent any type of hierarchy):

Gestural: This is an alternative communication system that is important to establish in the non-verbal child with autism. It does not require any type of visual representation system. A gestural system can include pointing and/or looking to desired items: the child shaking his head "no"; pushing something away to protest or reject; and hand-waving for greetings.

Object exchange: An object exchange system is based on the child giving an object to another person to indicate that he wants something. That is, the child exchanges objects to request, one of the functions of communication. For example if the child wants more milk, he gives his cup to someone to indicate this request.

Picture point system: This system requires the child to point to various visual representation systems to communicate. Visual representation systems that can be used: photos, real drawings, line drawings, written words.



Picture Exchange Communication System (PECS): PECS allow the child to spontaneously initiate a communicative interaction by actually exchanging, or giving a visual representation system to another person (3). In this alternative communication system, the child quickly learns the cause and effect of communication. In addition, by physically exchanging a visual representation system with another person, the child develops a concrete understanding that communication is an actual exchange of information between two or more people (e.g., the child hands a picture of a swing to an adult to indicate that he would like to swing). The PECS program is composed of various phases or levels, starting with simple, concrete communicative exchanges and moving to more abstract communication. For example, the beginning child starts very concretely exchanging one item to make a request. As he advances, his exchanges become more communicatively complex, developing higher level social communication functions, such as commenting. Visual representation systems which can be used: miniature objects, T.O.B.I.s, photos, real drawings, line drawings, written words.

Electronic/alternative keyboards or computers: Some non-verbal children with autism exhibit reading and writing skills to effectively communicate as both speaker (expressively) and listener (receptively). They can use various electronic or alternative keyboards for communication (e.g., a child can type out a communicative request to "listen to music" on an AlphaSmart, an electronic keyboard). Visual representation system which can be used: written words.

Voice Output Communication Aids (VOCAs): Using VOCAs, non-verbal children with autism can express themselves by pushing a button, which plays a pre- recorded message on a communication device . A visual representation system, which the child understands, should be positioned on the "button(s)" of the voice output communication aid/device. Many children with autism spectrum disorder are motivated to communicate by use of these devices, particularly by the auditory feedback immediately given as their communicative message. Use of VOCAs have proven effective in teaching children the cause/effect of language through activities which are stimulating to them (e.g., Use of the Big Mack for a child to request highly desired sensory activities such as "chase me"; "tickle me"; "hug me"; "listen to music").

While VOCAs have many positive qualities, caution should be taken when using them to initially teach communication functions / purposes. VOCAs can be overly motivating and stimulating for some children. In these cases, the VOCAs tend to function as repetitive and stimulating high interest item rather than as communication devices. The child will repeatedly push down the button(s) on the device for the self-motivation that he receives from the auditory feedback, rather than for the cause/effect of the communicative message. When this occurs, a different alternative communication system is suggested to initially teach the child the purpose of communication. After the child learns the purpose of communication, use of a VOCA might then be explored. Visual representation system which can be used: real objects, miniature real objects, T.O.B.I.s, photos, real drawings, line drawings, written words.