- 33 Downloads
Short Description or Definition
Speech/communication impairments are among the core features of autism spectrum disorders (ASD). Although enormous variability in the development of speech and language is observed in individuals with ASD, even those who have high cognitive and language abilities exhibit some type of communication disability. Deficits can occur at the nonverbal level (e.g., gestures, facial expressions, eye gaze), paralinguistic level (e.g., prosody, intonation), and linguistic level (e.g., language, speech). Communication deficits in the social use of speech and language are particularly salient. Research suggests that a subset of children with ASD also have grammatical deficits similar to children with specific language impairment. In addition, speech sound disorders are evident in a subset of children with ASD. Approximately 20–40% of individuals with autism never develop spoken language, and about 20% exhibit a loss of language skills as toddlers, also known as language regression.
Aspects of communication that are relatively preserved in individuals with ASD include segmental phonology (i.e., the system of speech sounds), syntax, and morphology (i.e., the form or structure of language). Areas of relative difficulty include nonsegmental speech production (e.g., prosody, intonation, stress patterns, vocal quality), semantics (i.e., meaning), and pragmatics (i.e., social use of language).
The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5; American Psychiatric Association 2013) includes four categories of communication disorders: language disorder, speech sound disorder, childhood-onset fluency disorder, and social (pragmatic) communication disorder. Speech/communication disabilities can be associated with developmental disabilities and syndromes, such as autism spectrum disorders.
Speech/communication disabilities are core features of ASD. According to Fombonne’s (2009) review, the prevalence for all autism spectrum disorders (previously referred to as pervasive developmental disorders) is estimated at 60–70 per 10,000.
Natural History, Prognostic Factors, Outcomes
Communication delays and deficits are often the first indicators of ASD. For example, children later diagnosed with ASD show a lack of interest in faces, voices, and social interactions as infants. Later in development, children with ASD may fail to understand or produce communicative gestures (e.g., pointing) and may be delayed in babbling, vocalizing, and speech development. Lack of communication skills is one of the most significant stress factors for families of children with ASD.
The speech/communicative outcomes of individuals with ASD are extremely variable. About 20% of children with ASD exhibit a regression in speech and language skills during their second year of life. About 40–50% never develops functional speech except for perhaps a few single words (although this percentage may be decreasing due to the positive effects of early identification and intervention). Little is known about the communication skills of nonverbal individuals with ASD because research has focused on verbal individuals.
Those individuals with ASD who do develop speech are often significantly delayed and do not speak until well into their preschool years. High-functioning individuals with ASD may have IQs in the normal range and appear precocious in their vocabulary size and ability to speak in detail on certain topics. Despite these strengths, this population continues to struggle with the comprehension and production of social and nonliteral communication.
Several characteristics have been linked to better communicative outcomes. For example, children with ASD who produce and imitate words, exhibit pretend play with objects, communicate with gestures, and show evidence of joint attention have greater rates of vocabulary growth and overall language skills. Negative prognostic indicators include a regression in language skills after a period of development and severe receptive language impairment. Children with lower IQs also tend to have poorer communicative functioning. Even for individuals with high cognitive and language abilities who attend college and are able to live independently, ASD is a lifelong disability that affects social communication and functioning.
Clinical Expression and Pathophysiology
Early Communication Development
Communication is a broad term that encompasses numerous modes of sending and receiving messages, including gestures, body language, facial expressions, language, and speech. Typically developing children exhibit social communicative behaviors beginning in infancy. For example, they turn toward human voices, are fascinated by faces, smile to hold an adult’s attention, vocalize, and demonstrate joint attention (e.g., paying attention to the same object as another person). In the first year of life, typically developing infants express a range of communicative intents, such as requesting, greeting, and protesting. For individuals with ASD, communication deficits are apparent almost from birth. One of the first signs of ASD is a lack of responsiveness to social interactions. For example, infants later diagnosed with ASD were described by their parents as uninterested in human voices or faces. They rarely smiled at others, vocalized in a communicative manner, or engaged in social games such as “peekaboo.” In addition, 1-year-olds who were later diagnosed with ASD exhibited a lack of joint attentional behavior and paid less attention to people in their environment. The communicative intents of children with ASD are primarily to regulate their environment (e.g., getting others to do things for them) rather than for social purposes. They may exhibit unusual gestures, such as pulling an adult’s hand toward a desired object (rather than pointing at the object or verbally requesting it). Other symptoms of communicative deficits include delayed development of pointing gestures, a lack of typical imitation skills, and deficits in pretend and imaginative play. In the second year of life, the receptive language abilities of children with ASD are depressed relative to their expressive abilities. The gap tends to narrow over time, with receptive and expressive language abilities becoming more similar by ages 3–4. Parents of children with ASD report becoming seriously concerned about their children’s development during the toddler years, particularly due to their children’s receptive and expressive language delays. Children with ASD are generally late to begin talking and develop speech and language at a slower rate than typical children. When they do speak, children with ASD are less spontaneous in their communication, and verbal expression is sparse. They also exhibit deficits in social communication, including following politeness rules, turn taking, and engaging in conversation.
Later Language, Speech, and Communicative Development
Language consists of three primary domains: form, content, and use. Form involves the structure of language (i.e., phonology, syntax, morphology), content involves the meaning of language (i.e., semantics, vocabulary), and use refers to the social use of language (e.g., pragmatics). Effective communication involves the interaction of these three domains. For example, language produced by typical individuals is most often syntactically correct, meaningful, and socially appropriate. In addition, effective communicators can decode other’s communication in terms of its form, content, and use. In individuals with ASD, the domains of language can be dissociated, negatively impacting communication. Specially, the form of language may be preserved (e.g., syntax, morphology, phonology), but the meaning, and especially social use of language, is impaired. More details on the language, speech, and communication characteristics of individuals are included below.
Language Form (Phonology, Morphology, Syntax)
The language form of individuals with ASD who communicate verbally is relatively unimpaired compared to the language domains of content and use. In general, development of language form in children with ASD follows the same sequence as for typically developing children. Syntactic errors that are observed seem to be related to semantic or pragmatic difficulties. In general, the development of language form is commensurate with nonverbal mental age, although a more restricted range of syntactic constructions may be produced. A subgroup of children with ASD may exhibit grammatical deficits similar to children with specific language impairment. This subgroup of children is likely to omit certain grammatical morphemes such as articles, auxiliary and copula verbs, and verb tense markers (e.g., past tense, third person singular).
Language Content (Vocabulary, Semantics)
Language content involves the rules for relating words to meaning. Individuals with ASD exhibit both strengths and impairments in this language domain. For example, research suggests that overall vocabulary knowledge may be a relative strength in individuals with autism spectrum disorders (ASD). In addition, children with ASD use semantic groupings (i.e., word relationships) in typical ways for categorizing and retrieving words. Despite these strengths, notable deficits and unusual characteristics are apparent. For example, the acquisition of words that refer to mental state or emotional concepts may be especially impaired. Individuals with ASD may have difficulty generalizing the meanings of words to new contexts (e.g., understanding that the word “dog” can refer to many animals, not just the family pet). In addition, they often have difficulty comprehending vocabulary in nonliteral language (e.g., slang, figures of speech, proverbs, metaphors).
Individuals with ASD may produce speech that appears to be irrelevant to the current communicative context. These utterances are referred to as idiosyncratic or metaphorical language. For example, Kanner (1946) described a child with ASD who would yell, “Don’t throw the dog off the balcony!” whenever he was about to throw something. His parents reported that several years earlier, they had been staying in a hotel with a balcony and warned the child not to throw his stuffed toy dog over the railing. Kanner emphasized that this type of utterance was not irrelevant or meaningless. Rather, individuals with ASD attach unique meanings to these “figures of speech” based on specific past experiences.
Language Use (Pragmatics, Social Use of Language)
The social use of language is particularly impaired in individuals with ASD, including for individuals with IQs in the normal range. Deficits in social communication are evident almost from birth, as children with ASD are less responsive to voices and faces. Social skills are learned and applied in transactional contexts, that is, during interactions between communication partners. The deficits in social communication in individuals with ASD result in less social experience, contributing to impaired development and learning. For children who develop verbal language, the speech acts they do exhibit are primarily for regulating their environment and the behaviors of others, rather than for social purposes. Later in development, engaging in conversation appears to be especially difficult. Deficits in eye gaze, intonation, topic maintenance, understanding the communicative intent of others, and providing the appropriate amount of information are apparent. In general, individuals with ASD exhibit impairments participating in communicative interactions that involve joint reference or shared topics and perspectives.
Among individuals with ASD who speak, articulation skills are a relative strength and are generally commensurate with mental age, although there may be a higher incidence of residual speech distortion errors on sounds such as /r/, /l/, and /s/ in adults. Despite strengths in speech sound development, paralinguistic aspects of speech (e.g., intonation, prosody) and vocal quality may be atypical, causing communication difficulties. For example, prosody and intonation may be monotonous, inappropriate, or overly dramatic. In addition to expressive deficits, individuals with ASD may have difficulty interpreting the prosody and intonation of others leading to misinterpretation of sarcasm, etc.
Echolalia is the repetition, with similar intonation, of words or phrases spoken by another person. Echolalia can be immediate (e.g., a child repeats, “Are you hungry?” when an adult asks him that question) or delayed (e.g., a child says, “You look sleepy,” to indicate that it is bedtime). Echolalia was once considered to be aberrant, undesirable behavior. Now it is recognized as serving various communicative functions. Echolalia is more common in children with less language ability and tends to decline as language develops. Other populations of children, including typical children, also produce echolalic utterances, although not to the extent observed in children with ASD.
It has frequently been noted that children with ASD appear to reverse the pronouns in their utterances. For example, they may say, “Pick you up!” instead of, “Pick me up!” These errors are thought to be a result of echolalia.
Evaluation and Differential Diagnosis
As stated earlier, impairments in communication, particularly for social purposes, are core features of ASD. Therefore, all individuals with ASD will have communication needs, although they will vary depending on the age, level of functioning, and individual characteristics of each person. For very young children, assessment will include evaluation of preverbal communication abilities, including gestures, eye gaze, joint attention, vocalizations, responsiveness to communication, and communicative functions. Observations during play or activities of daily living are important for gaining information about children’s communicative behavior and their caregivers’ interactional style. The use of checklists while observing the child in naturalistic interactions is common and may be the only feasible method of assessment for many children with ASD who have difficulty participating in structured test formats (see Paul and Norbury 2012).
A variety of parent report/interview assessment tools are available, including the Receptive-Expressive Emergent Language Test, Third Edition (REEL-3; Bzoch et al. 2003) and the Vineland Adaptive Behavior Scales, Third Edition (Vineland-3; Sparrow et al. 2016). Other assessment tools include direct observation of the child and may include more structured interactions or elicitation of particular behaviors. Examples include the Communication and Symbolic Behavior and Play Scales-DP (CSBS; Wetherby and Prizant 2003), the Peabody Picture Vocabulary Test, Fourth Edition (PPVT-5; Dunn 2019), and the Preschool Language Scale, Fifth Edition (PLS-5; Zimmerman et al. 2011).
In verbal children, language samples may be collected for assessing the expression and use of language in naturalistic settings. Specific areas to assess include responsiveness to speech, mean length of utterance (a measure of syntactic development), word use, echolalia, pronoun use, and pragmatics. Pragmatic analysis may include the range of communicative functions (e.g., directing others, reasoning, empathizing), discourse management, register variation (e.g., politeness), presupposition (e.g., providing enough background information), and manner of communication.
For individuals with ASD who have higher cognitive and language abilities, and who can participate in formal testing situations, a variety of standardized language assessments are available (see Paul and Norbury 2012). Assessments that focus on pragmatic language or verbal reasoning may be the most useful in identifying core deficits. It is important to supplement standardized testing with informal observations within a variety of naturalistic contexts in order to capture deficits in social communication.
For individuals with ASD who are nonverbal, it is important to assess the various ways that they do communicate. In addition, their ability to use augmentative and alternative communication (AAC) may also be evaluated.
Speech can be assessed through procedures common to the evaluation of any client with a suspected speech sound disorder, depending on the ability of the individual with ASD to participate in a standardized assessment. Common tests include the Arizona Articulation Proficiency Scale, Fourth Edition (Arizona-4; Fudala and Stegall 2017) and the Goldman-Fristoe Test of Articulation 3 (GFTA-3; Goldman and Fristoe 2015). Also, speech can be evaluated through more naturalistic sampling procedures (e.g., recording an inventory of a client’s phonetic repertoire during spontaneous speech).
For individuals with ASD, research has demonstrated that a range of approaches are effective for promoting communication abilities (cf. ASHA 2017). Common approaches range from naturalistic (e.g., Floor Time, Greenspan et al. 1998) to highly structured, behavioral interventions (e.g., Lovaas et al. 1989). The incorporation of peers as models and/or trainers is also common. According to the National Research Council (2001), educational interventions for individuals with ASD should begin as early as possible, programming should be intensive with repeated and planned teaching opportunities, teacher-student ratios should be low, mechanisms for ongoing assessment and program evaluation should be in place, and family involvement and training is important. In addition, intervention for individuals with ASD should include spontaneous and functional communication, social skills, play skills, peer interactions, generalization of skills to natural contexts, mechanisms for addressing challenging behaviors, and promoting functional academic skills when appropriate.
For young children in the beginning stages of language development, the goals of intervention include rewarding efforts for communication and speech, expanding vocabulary and communicative functions, encouraging multiword utterances, expanding sentence types, developing emergent literacy, teaching functional use of imitation, and capitalizing on memorized forms. Various evidence-based approaches to facilitating language may be implemented, including prelinguistic milieu teaching, focused stimulation, and conversational recasting. In addition, approaches that focus on parent training, such as It Takes Two to Talk, More Than Words or Talkability (developed by The Hanen Centre), have been shown to be effective.
For nonverbal individuals with ASD, the use of augmentative and alternative communication (AAC) strategies is common for facilitating communication. AAC approaches include sign language, Picture Exchange Communication System (PECS), communication boards, and voice output devices. For individuals who are literate, written language can be an effective means of communication and can be used for compensatory purposes (e.g., using a script or communication checklist for functioning within various situations). For example, Social Stories (Gray 1993) employ a story format using visual materials to improve an individual with ASD’s social understanding of various situations. Technology (e.g., texting, social networking) may assist individuals with ASD in social communication without the stress of face-to-face interactions. Comprehension monitoring strategies for older individuals with ASD with higher cognitive and language abilities (e.g., checklists) may also be effective.
In general, intervention for individuals with ASD needs to address core deficits in communication and social skills.
References and Readings
- American Speech-Language-Hearing Association. (2017). Autism. Available from www.asha.org/Practice-Portal/Clinical-Topics/Autism/. Accessed 26 June 2017.
- Bzoch, K., League, R., & Brown, V. (2003). Receptive-expressive emergent language test (3rd ed.). Circle Pines: American Guidance Service.Google Scholar
- Dunn, D. M. (2019). Peabody picture vocabulary test (5th ed.). Bloomington, MN: NCS Pearson.Google Scholar
- Fudala, J. B., & Stegall, S. (2017). Arizona articulation proficiency scale-fourth revision. Los Angeles: Western Psychological Services.Google Scholar
- Goldman, R., & Fristoe, M. (2015). Goldman-Fristoe test of articulation 3. Bloomington: Pearson.Google Scholar
- Gray, C. (1993). The social story book. Arlington: Future Horizons.Google Scholar
- Greenspan, S. I., Wieder, S., & Simons, R. (1998). The child with special needs: Encouraging intellectual and emotional growth. Reading: Addison-Wesley.Google Scholar
- National Research Council. (2001). Educating children with autism. Washington, DC: National Academy Press, Committee on Educational Interventions for Children with Autism, Division of Behavioral and Social Sciences and Education.Google Scholar
- Paul, R., & Norbury, C. (2012). Language disorders from infancy through adolescence: Listening, speaking, reading, writing, and communicating (4th ed.). St. Louis: Elsevier.Google Scholar
- Sparrow, S., Cicchetti, D., & Saulnier, C. (2016). Vineland adaptive behavior scales (3rd ed.). Minneapolis: Pearson Assessment.Google Scholar
- Tager-Flusberg, H., Paul, R., & Lord, C. (2005). Language and communication in autism. In F. R. Volkmar, R. Paul, A. Klin, & D. Cohen (Eds.), Handbook of autism and pervasive developmental disorders (Vol. 1, 3rd ed., pp. 335–364). Hoboken: Wiley.Google Scholar
- The Hanen Centre. http://www.hanen.org/. Accessed 15 Aug 2019.
- Wetherby, A., & Prizant, B. (2003). Communication and symbolic behavior scales developmental profile. Baltimore: Paul H. Brookes.Google Scholar
- Zimmerman, I. L., Steiner, V. G., & Pond, R. E. (2011). Preschool language scales (5th ed.). Bloomington: Pearson.Google Scholar