Kasari, C., Kaiser, A., Goods, K., Nietfeld, J., Mathy, P., Landa, R., . . . Almirall, D. (2014). Communication interventions for minimally verbal children with autism: A sequential multiple assignment randomized trial. Journal of the American Academy of Child & Adolescent Psychiatry, 53(6), 635-646. https://doi.org/10.1016/j.jaac.2014.01.019.
Reviewed by Sunbul Rai, MSc, BCBA, ASAT Extern
and
Karen Fried, PsyD, BCBA-D, ASAT Board Member
Why research this topic?
Autism spectrum disorder (ASD) includes substantial communication challenges that can have a tremendous impact on the quality of life of individuals with ASD. This is especially true for the 25- 30% of children with ASD who continue to be minimally verbal following intervention (speaking fewer than 30 words to communicate). To enhance or replace spoken language, research has examined different augmentative or alternative communication (AAC) systems including gestures, sign language, picture exchange (such as the Picture Exchange Communication System, or PECS) and speech-generating devices (SGDs such as an iPAD or DynaVox). Studies show that ABA methods can be used to teach minimally verbal children with ASD to use PECS to make requests. However, there is currently limited evidence that instruction in PECS improves other aspects of communication (e.g., using spoken language for a variety of purposes). Regarding other AAC systems, such as SGDs, there have been promising case reports of effectiveness but no studies with strong scientific design. The current study aims to use a strong design to test novel interventions and SGDs for minimally verbal children with ASD.
What did the researcher do?
The researchers combined two developmental/behavioral interventions, Joint Attention Symbolic Play Engagement and Regulation (JASPER) and Enhanced Milieu Teaching (EMT), referring to the combination as JASP+EMT. JASPER focuses on developing prelinguistic gestures (joint attention, requesting) and play skills within the context of child-led, play-based interactions. EMT uses backand-forth interaction and systematic modeling and prompting to promote spontaneous, spoken communication. Sixty-one minimally verbal children with ASD, aged 5-8 years, participated in the study. In Stage 1, participants were randomly assigned to either JASP+EMT or JASP+EMT+SGD (i.e., enhanced by an SGD in the form of an iPad or DynaVox). Participants received the intervention for two 1-hour sessions per week for 12 weeks. Measurements included total number of spontaneous communicative utterances, total number of novel words and total comments (taken from a natural language sample scored by raters who were blind to the intervention group the child was in). Stage 2 was also 12 weeks long. “Early responders” to Stage 1 intervention received the same intervention in Stage 2. “Slow responders” to Stage 1 intervention received an intensified intervention in Stage 2, either an additional hour per week of JASP+EMT, or the incorporation of an SGD, or an extra hour per week of JASP+EMT+SGD. Parents observed intervention during Stage 1 and received direct training on intervention procedures in Stage 2. The study included repeated outcome measures (baseline, weeks 12, 24, and 36).
What did the researchers find?
The researchers found more communication improvements on all outcome measures for the group that began with JASP+EMT+SGD than for the group that began with JASP+EMT only. Specifically, the participants in the JASP+EMT+SGD group demonstrated an increase, not just in requesting, but in number of spontaneous communicative utterances, number of novel words and total comments. Ninety-two percent of their spontaneous communicative utterances were spoken utterances. Adding SGD in Stage 2 for “slow-responders” to JASP+EMT was less beneficial than having SGD from the start of intervention. Quality of intervention, defined as implementing the procedures as intended, was higher when trained professionals delivered the intervention than when parents did so.
What are the strengths and limitations of the study?
This study delivered a strong scientific design, with random assignment to intervention groups, observations of communication by blinded raters, and repeated measures of outcome. The children’s responses to Stage 1 of the intervention were specifically and operationally defined as either “early responders” or “slow responders” so that Stage 2 of the intervention could be adapted while still systematically examining the contribution of the SGD. Limitations included having a sample size that was only two-thirds of the recruitment target. However, the sample size was still considered large for a randomized trial in ASD research. Parents’ ability to implement the intervention as intended is also a concern. Another limitation is that all participants had at least two years of prior intervention per parent report, but the nature of that intervention was not specified including presence or absence of previous AAC intervention. It was also not stated whether participants were receiving additional interventions during the course of the study.
What do the results mean?
The current study indicates that child-led interventions plus SGDs are a potentially effective tool for increasing a range of spontaneous communication skills in minimally verbal, school-aged children with ASD. The current study delivered effective intervention at a low intensity (2 to 3 hours per week). To increase the utility of this intervention, an important area for future research is to investigate communication gains when intervention occurs at a higher intensity and to improve the parent training procedures so that parents implement the interventions more successfully. Finally, SGD options are not necessarily equivalent. An area for future research is to compare and contrast the SGD options for minimally verbal, school-aged children with ASD so that qualified professionals can make the best decisions for each learner.
Citation for this article:
Rai, S., & Fried, K. (2016). Research review: Communication interventions for minimally verbal children with autism: A sequential multiple assignment randomized trial. Science in Autism Treatment, 13(3), 7-9.
