Presenters: Akshaya R S and Sriram M

Reg no: A3320008

Course title: Language Disorders in Children
Topic: Prognosis and intervention of ASD – I and II

Prognosis and intervention – I

SLPs play a central role in improving not only language impairments associated with ASD
but also social communication and general functional communication related to personal and
health care needs. SLPs contribute to the independence and productivity of individuals with
ASD by ensuring effective functional communication systems or approaches (including
AAC) that allow them to attain and maintain maximum levels of functional communication.
Treatment for individuals with ASD typically includes:
Setting goals based on assessment data that target the core, associated, and secondary deficits
in ASD (e.g., feeding and swallowing disorders);
Focusing on initiating spontaneous communication in functional activities, engaging in
reciprocal communication interactions, and generalizing gains across activities,
environments, and communication partners;
Using a multimodal communication system (e.g., spoken language, gestures, sign language,
picture communication, speech-generating devices, and/or written language) that is
personalized according to the individual’s abilities and the contexts of communication; and

Measuring progress using systematic methods to determine whether an individual with ASD
is benefiting from a treatment program or strategy.
Evidence and Outcomes of Speech-Language Pathology Treatment
According to data from ASHA’s National Outcomes Measurement System (NOMS), 76.6%
of children with ASD receiving speech-language pathology services make clinically
meaningful progress on spoken-language expression and/or comprehension.
In a 2013 systematic review, Wong et al. concluded that the following are considered to be
evidence-based practices for the treatment of communication disorders in children,
adolescents, and/or young adults with ASD:
Visual support (children and young adults)
Parent-mediated/implemented interventions (toddler to school age)
Peer-mediated/implemented interventions (preschool to high school age)
Pivotal response training (toddler to middle school age)
Social skills training (children and young adults)

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Social narratives (preschool to high school age)
Picture Exchange Communication System (PECS; Bondy & Frost, 2001) (pre-school to
middle-school age)
Technology-assisted instruction (including video modeling) and speech-generating devices
(children and young adults)
Modeling (children and young adults)
Naturalistic intervention (toddler to elementary school age)
Scripts (preschool to high school age)
Wong et al. (2013) also considered the following behavioral interventions, or components of
behavioral interventions, to be evidence based:
Antecedent-based intervention
Reinforcement and differential reinforcement
Discrete trial training
Extinction
Functional communication training
Prompting
Time delay
Services Across the Lifespan
The symptoms of ASD affect individuals throughout the lifespan, impacting them differently
depending on the stage of life. Whereas (early) childhood services are critical, transitions
from preschool to school age and from adolescence to young adulthood present particularly
challenging communication issues for those with ASD.

ASD can affect success in postsecondary educational programs, employment, maintaining

relationships, and acquiring the skills necessary for independent living (Howlin & Moss,
2012; Zager & Alpern, 2010). Youth with ASD need access to timely services that are
community and evidence based. Communication services are a key support that can help
youth with ASD achieve education, employment, independent living, and community
integration goals as they transition to adulthood (Government Accountability Office, 2017).
The primary social communication impairments that accompany ASD continue into
adulthood; these social communication deficits result in a greater tendency for adults with
ASD to be overeducated for their jobs and have a lower employment rate. They are also more
likely to live with their parents (Poon, 2017).

Support Provided by SLPs for Individuals with ASD Transitioning in New Settings or
Stages of Life

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A growing number of youth and young adults with ASD are leaving school with substantial
service needs that will increase the demands on an already strained adult service system.
These needs will continue to grow in the coming years, as young people who are identified
with ASD in early childhood progress through school and into the adult services system.
Adults with ASD, including those with normal intellectual quotient (IQ), are significantly
disadvantaged for employment, social relationships, physical and mental health, and quality
of life (Howlin & Moss, 2012).
SLPs play a critical role in developing and assisting with medically necessary transition
services and supports, including the following:
Service provision for AAC devices (including updating an existing device) for the purpose of
communicating health concerns/needs and functional expression of wants and needs, thereby
enhancing life participation
Social communication treatment when addressed for the purposes of obtaining employment
and when an individual is in an employment setting
Transition planning to help an individual adjust to a new living situation for the purpose of
increasing independence, or when a parent or caregiver can no longer support them in an
existing home environment
Vocational support in employment programs to facilitate professional and social
communication, job readiness, and independence skills.
Sensory therapy:
Individuals with ASD have sensory challenges that may be related to repetitive and other
challenging behaviors. Indeed, sensory symptoms exhibited by young children, such as food
selectivity, covering their ears for certain sounds, and visual scrutiny of aspects of objects,
may be among the earliest differences families identify in their children’s development.
Sensory goals may be included in treatment objectives for students with ASD. Adult-directed
approaches provided through sensory-based interventions may be included in the context of
motor and behavioral therapies and in educational settings. Despite the increasing scientific
understanding of the neurobiological basis for sensory symptoms in individuals with ASD,
empirical interventions in common practice have modest evidence to support their general
use at this time. Commonly used sensory-based interventions, including brushing of the skin,
proprioceptive stimulation by using weighted vests, or kinesthetic stimulation (such as
swinging or use of specialized seating, such as a therapy ball, to modulate level of arousal),
are not yet supported in the peer-reviewed literature.
Proponents of sensory integration therapies distinguish them from interventions with sensory
modalities because of the active engagement with the child in skill building or
desensitization. The therapist explains the child’s behaviors and responses to caregivers in
sensory terms and provides them with strategies to help the caregivers accommodate the
child’s sensory needs to decrease functional impairment and tolerate environmental triggers.
Advocates of these interventions claim that dysfunction in integration of sensory input
contributes to inefficiencies in learning and to behavioral challenges and that therapeutic
approaches to sensory integration need to be considered separately from focal sensory-based
treatments. Although sensory-based therapies are among the most commonly requested

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therapies by caregivers, the evidence supporting their general use remains currently limited.
As with any other intervention, specific goals for sensory-based therapies should be
identified, and outcomes should be monitored so that the utility for any given child can be
documented.

A. Applied behaviour analysis:

The origins of ABA and its applications to the autism spectrum disorders (ABA) is based on
the operant conditioning principles most famously championed by B. F. Skinner. Operant
conditioning can be defined as the process through which the environment and behavior
interact to shape the behavioral repertoire of an organism or individual (Skinner, 1953).
ABA is defined as the direct application of behaviourism to the improvement of human
behavior Many of the behavioral hallmarks of autism have been addressed through strategies
based on applied behavior analysis (Baer, Wolf, and Risley, 1968). The three minimally
defining obvious characteristics of ABA are: applied, behavioral, and analytic.
In the behavioral context, Baer et al. (1968) established applied to mean that the behavior or
stimulus addressed was chosen because of its importance to humankind and society. In
addition, the applied nature of the behavior or stimulus of interest should be determined by its
context, and should be closely related to the subject being studied. Thus, in the ABA
program, it is important to establish a method by which the behavior of interest will be
measured and that which is reliable and agreed upon by multiple observers. There must be a
clear answer to the question regarding whose behavior was changed, the observer or the
observed.
Analytic refers to the notion that ABA requires a believable demonstration of the events
responsible for the behavior. An analysis of behavior is said to be achieved when an
experimenter can exercise control over the behavior (Baer et al., 1968).
Concepts and Application
A number of ABA concepts have been identified that address the social, communicative, and
behavioral deficits and excesses exhibited by many individuals with autism spectrum
disorder. These concepts can be classified as:
Consequence based and Antecedent based approaches.

❖ Consequence: Punishment and Punishment-Based Procedures

• Punishment procedures are those consequence-based procedures that decrease the future
likelihood of the target behavior. There are two broad classes of punishment: positive
punishment and negative punishment.
• Both classes of procedures result in the decreased likelihood of future target behavior. The
difference comes in the presentation or removal of a stimulus.
• In a positive punishment program, an aversive stimulus is presented (positive=presented)
contingent on the target behavior and results in a decreased likelihood of future responding.

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For example, A child slaps his classmate during class (behavior) and the teacher reprimands
him (aversive stimulus) in front of his classmates.

• In a negative punishment program, a stimulus is removed (negative=removed) contingent

on the target behavior, likewise resulting in a decreased likelihood of future responding. For
example, A child fights with her brother (behavior) and has her favorite toy taken away
(reinforcing stimulus removed).

❖ Consequence: Reinforcement and Reinforcement-Based Procedures

Reinforcement refers to the response-dependent presentation (positive reinforcement) or
removal (negative reinforcement) of a stimulus resulting in an increased likelihood of
responding.

 Positive reinforcement example: A father gives his daughter candy

(reinforcing stimulus) for completing the puzzle (behavior).

 Negative reinforcement example: John can get up from the dinner table
(aversive stimulus) when she eats 2 bites of her broccoli (behavior).

Reinforcers can be delivered immediately following a response, intermittently following

fixed or varied numbers of responses, or following specific time parameters (e.g., the first
response following 60 s). Alternatively, the reinforcers can be delivered in a delayed fashion
with a token, or other icon, used to help bridge the time gap (i.e., a token economy).

Within the context of autism, clinical issues targeted by reinforcement procedures include
appropriate communication, social interactions, and other academic, vocational, and
independent living skills.

 Token economy: Token economies refer to the delivery of a conditioned reinforcer that
can later be exchanged for another reinforcer. Typical conditioned reinforcers include

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 tokens (hence, the term), points, and stickers. This type of reinforcement system has
several advantages, including the ability to implement it with relative ease in large-
group settings, and, in such settings, the ability to use uniform reinforcers for several
individuals.
Cooper et al. (2007) defined three components of a token economy:
(1) A list of target responses,
(2) tokens or points to be earned, and
(3) a menu of items for which tokens and/or points can be exchanged. The reinforcing value
of these tokens comes from the opportunity to exchange them for other, more salient
reinforcers (Rusch et al.).
Tarbox, Ghezzi, and Wilson (2006) used a token economy system to increase the eye
contact of a 5- year-old boy with autism. The study was conducted at a day treatment center
for children with developmental disabilities. During baseline, the child was given a verbal
prompt to attend to the tutor at the start of each instructional trial. The token reinforcement
condition was identical to baseline except that the child received a token (star sticker)
contingent on meeting the eye contact requirement. Once the child earned a predetermined
number of tokens, he could exchange them for a brief break from instruction. A schedule
thinning condition was added in which the number of tokens required to gain access to the
reinforcer was increased by a factor of five. In addition, a delay to reinforcement component
was added in which the child was required to wait before receiving the backup reinforcer.
Compared to baseline sessions, a substantial increase in eye contact was observed when the
token economy system was used.
• Extinction: it is based on the principle that when a response is not reinforced, the ignored
behaviour will be disappeared or decrease. While extinction can be an effective behavior
reduction technique, there are a number of considerations to take into account prior to
implementation. First, extinction procedures effectively reduce, if not eliminate,
individuals’ exposure to reinforcing stimuli. Second, extinction procedures do not teach the
individual any appropriate methods for recruiting meaningful reinforcers. And, third,
extinction procedures can result in an initial increase in target problem behavior (i.e., an
extinction burst occurs) and/or can result in variations in response topography, such as the
emergence of aggressive behavior (Lerman, Iwata, & Wallace, 1999).
• Shaping and chaining: - Shaping is the process of differentially reinforcing successive
approximations toward a desired response (Cooper et al., 2007). Shaping can be considered
a differential reinforcement procedure during which the target response is slightly altered as
the individual exhibits responses that are more and more similar to the desired terminal
response.
Behavioral chains are collections of discrete responses that are performed in rapid and
accurate sequences (Rusch et al. 1988). Reinforcement-based acquisition programs
sometimes focus on systematically and sequentially reinforcing each of the responses in a
chain to establish a particular skill. This process is described as chaining, with two types of
chaining (forward and backward).

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- In forward chaining, the responses in a behavioral chain are taught and reinforced in
their naturally occurring order (Cooper et al.). Reinforcement might initially be delivered
following the completion of Step 1. During the next phase of forward chaining,
reinforcement would be delivered following Steps 1 and 2, and so on until all responses are
exhibited in the correct order.
- Backward chaining consists of the teacher or therapist completing all but the last
response in a behavior chain, and providing the reinforcer contingent on the individual
completing the final response. In the next phase of backward chaining, the reinforcer would
be delivered after the individual had completed the next-tolast and final response, and so on
until all responses are exhibited in the correct order.
Ricciardi, Luiselli, and Camare (2006) used a shaping procedure to treat specific phobia
exhibited by a child with autism. In their study, an 8-year-old boy with autism was
differentially provided with reinforcement (access to preferred items) for closer and closer
approaches to phobic stimuli. Initially, the child was allowed ongoing access to the
preferred items, regardless of proximity to phobic stimuli. Preferred items were then only
allowed if the participant successfully approached and stayed within 5 m of the phobic
stimuli, then 4, 3, 2 m, and finally 1 m. The use of this shaping procedure successfully
resulted in the participant approaching phobic stimuli.
⧫ Antecedent Approaches to Treatment:
• Prompt procedures: Prompts have been defined by Cooper et al. (2007) as antecedent
stimuli that occasion specific responses and are supplemental to a behavioral treatment.
There are at least two broad categories of prompts: response prompts and stimulus prompts.
Response prompts such as physical guidance target behavior.
Stimulus prompts target the conditions that exist prior to the occurrence of a target behavior.
Stimulus prompts are often used as a means to occasion behavior. Once responding is more
frequent and reliable in the presence of naturally occurring stimuli, these auxiliary stimuli
can be removed.

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  Choice: Providing a choice within behavioral treatment programs has been
demonstrated to be an effective strategy for reducing problem behavior (e.g., Dibley &
Lim, 1999). Within the context of behavioral treatment, choice can be considered an
antecedent variable because it is in operation before the target response occurs and not
in response to a behavior.

ABA-Based Comprehensive Approaches to Autism Treatment: Intervention Programs

that Utilize Applied Behavior Analysis Procedures
• UCLA Young Autism Project/Lovaas Intervention:
The UCLA Young Autism Project (YAP) is an intensive home-based intervention program
for young children with autism developed by Ivaar Lovaas and colleagues. This intervention
is sometimes referred to as discrete trial teaching.
In the original YAP study, children in the intensive-treatment group received as much as 40 h
of intervention weekly for at least 2 years (Lovaas, 1987). The focus of therapy was on
increasing language, attending, imitation, social behavior, play, and self-care skills, and
decreasing disruptive behaviors. Intensive teaching was provided through a discrete trial
format. Children in the minimal-treatment group received similar services but for only 10 h a
week, and a third control group of children received an eclectic mix of interventions.
Compared to their baseline performance, children in the intensive-treatment group gained an
average of 37 IQ points over the course of the treatment, representing an average difference
of 31 points higher in comparison to the control group. In addition, 47% of the children in the
intensive group successfully completed first grade in a regular education setting. A follow-up
study was conducted with those children who successfully completed first grade without
support. At the age of 13, eight of these nine students were continuing to succeed in regular
education settings without support. This group continued to perform significantly higher than
the control group on measures of intelligence and adaptive abilities (McEachin, Smith, &
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Lovaas, 1993). Based upon the results of these studies and others, the UCLA YAP model has
been described as one of the most empirically validated interventions (Simpson, 2005).
• Pivotal response training (PRT)
PRT is a model that combines applied behavior analytic procedures and developmental
approaches to provide opportunities for children with autism spectrum disorders to learn
within natural environmental settings. PRT was developed by Drs. Robert and Lynn Koegel
at the University of California Santa Barbara.
The model focuses on pivotal areas, defined as those areas that, when targeted, result in
meaningful collateral changes in other areas of functioning and responding (Koegel &
Koegel, 2006). Pivotal areas that have been identified are:
(1) Motivation,
(2) Responsivity to multiple cues,
(3) Self-management,
(4) Self-initiations, and
(5) Empathy.
Motivational strategies that are applied in PRT include: following the child’s lead, using
preferred items and activities, teaching within natural contexts, providing clear instructions,
providing choices, reinforcement of attempts, varying and interspersing tasks, and using
naturally occurring reinforcers (Dunlap, Iovanne, & Kincaid 2008).
Instead of a focus on teaching discrete skills through repeated trials, PRT targets
developmental skills within natural environments. An emphasis is placed on family
involvement in the design and delivery of the intervention, data collection and monitoring,
and implementation of interventions in both home and school settings. To date, research on
PRT has demonstrated that this model can result in improvements in areas such as language
acquisition, play skills and social interactions, and decreases in challenging behaviors.
B. Peer-mediated interventions:
PMIs are considered Evidence based approaches by the National Professional Development
Center on ASD and the National Standards Project and found to be effective in remediating
social and communication deficits for children with ASD.
PMI is used to teach typically developing peers ways to interact with and help learners with
ASD acquire new behaviors, communication, and social skills by increasing social
opportunities within natural environments. The peers are systematically taught ways of
engaging learners with ASD in social interactions in both teacher-directed and learner-
initiated activities.
The goals of PMIs are to increase social competence as a foundation for forming
relationships. Stichter and Conroy (2006) defined peer-related social competence as the
ability to engage in reciprocal interactions and form relationships with peers. Thus, PMI is a
logical and appropriate choice to build social competence and communication for children
and youth with ASD.

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General Approaches of Peer-Mediated Interventions:
DiSalvo and Oswald (2002) described three basic intervention approaches for PMI to
increase social behaviors of children with ASD:
(1) manipulation of the situation or contingencies to promote interaction,
(2) peer instruction in initiation and social interaction strategies to promote interactions, and
(3) target child instruction in initiation strategies, with a fourth option of a combination of
approaches.
The authors reported on various structures to support interaction including arrangements that
structure the environment/contingencies and instruction for children and peers to include:
(a) integrated play groups
(b) peer buddy, peer tutoring, and peer network approaches
(c) pivotal response training and peer initiation training
(d) group-oriented contingencies
(e) target child initiation training Sperry, Neitzel, and Engelhardt-Wells (2010) prescribed a
model for using PMIs based on behaviorism and social learning theory.
Steps of this model include
(1) selecting four to five peers that exhibit good social and communication skills, are well
liked by peers, and have a positive social interaction history with the child with ASD,
(2) training and supporting peers in understanding similarities and differences of children
with ASD including specific children with whom they will be engaged,
(3) training peers in specific strategies (e.g., playing behaviors, providing assistance,
keeping interactions going, engaging in conversations) with direct instruction and practice
to learn strategies,
(4) implementing structured teaching sessions with the peers and the participants with
ASD with prompting and feedback from the teacher/provider,
(5) implementing PMI in naturalistic classroom and school settings (i.e., arranging
schedules to include peer-mediated learning activities, having materials and visual cues
available, identifying responsible staff, planning for prompting and reinforcement), and
(6) extending initiations and opportunities across the day.
These steps outlined in the model from Sperry and colleagues incorporate evidence-based
practices based on evidence from three decades of PMI research.
Evidence-Based Practices and Strategies Used in Peer-Mediated Intervention
Wong et al. (2013) published a synthesis of EBP for children and youth with ASD. From
their review of literature published between 1990 and 2011, 27 practices were reported as
providing sufficient evidence to be considered best practice. PMIs and social skills
interventions were included. These practices included some of the routinely used PMI

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strategies such as modeling, naturalistic intervention, prompting, reinforcement, scripting,
self-management, social narratives, structured play groups, and task analysis.
The majority of studies on PMIs have included training peers, sometimes participants
with ASD independently or concurrently, and teachers and interventionists to prompt
specific skills or competencies in order to increase social and communication skills. The
most effective approaches have used behavioral techniques such as positive
reinforcement, modeling, shaping, fading, redirection, prompting, and extinction to teach
peers and participants with ASD (Corbett et al., 2014, as cited in Chang & Locke, 2016;
Camargo et al., 2014).
Specific skill categories taught using PMIs have included:
(1) social skills instruction to increase knowledge of the rules of social engagement and
interactions (White, Koenig, & Scahill, 2010; Wood, Fujii, Renno, & Van Dyke, 2014);
(2) teaching specific social communication strategies such as instructing peers and
participants with ASD to use requests and share toys and games, comments about
play/activities of self and others, niceties (e.g., saying please and thank you), and play
organizers (e.g., joining in game rules) (Kamps et al., 2014);
(3) teaching communication partners and participants joint attention within naturally
occurring activities and routines (Kasari, Freeman, & Paparella, 2006; Schertz, Odom,
Baggett, & Sideris, 2013); and
(4) pivotal responses targeted in PRT including giving clear instructions, using of child-
selected stimulus materials, teaching self-initiations, interspersing maintenance items,
using of natural reinforcers, and reinforcing attempts.
Several researchers have emphasized that “Peer models may need more structured
training to help them intentionally think about, plan, and create opportunities for social
interactions to promote social initiations when they interact with children with ASD”
(Chang & Locke, 2016).
Settings for PMI
PMI studies generally include structured arrangements within social activities and
naturally occurring social times that provide multiple opportunities for social interaction
between participants with ASD and typically developing peers. These settings or social
structures often include social skills and play groups/center time with classmates using
age-appropriate toys and games (Hundert, Rowe, & Harrison, 2014; Kamps et al., 2014),
lunch groups (Koegel, Fredeen et al., 2012), and recess groups (Lang et al., 2011; Mason
et al., 2014), all including peer training and demonstrating positive outcomes in
increasing social interaction and communicative behaviors for participants. In some
studies, the activities were specifically designed and controlled to provide teaching
opportunities and feedback such as pull-out social groups or therapy sessions.
Some PMI Studies:
Two early reviews on PMI included Choi (2007) reporting on peer training methods for
children and adolescents with ASD based on reviews of 45 studies and Chan et al. (2009)
reporting on 42 studies, including 172 participants and 396 peers. Publication dates
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ranged from 1985 to 2008, with only five published between 2004 and 2008 (Chan et al.,
2009). Choi concluded from the review and reported findings (McGrath, Bosch, Sullivan,
& Fuqua, 2003) that it is more effective and efficient to teach children with ASD to be
responsive to peers than to be the initiators of interaction. Similarly, Chan et al. reported
peer initiation to participants with ASD as the most common intervention. Techniques for
instructing peers to maintain interactions included prompting play and communication
(Chung et al., 2007); repeating and expanding verbalizations and making requests (Sasso,
Mundschenk, Melloy, & Casey, 1998); responding to children’s attempts to communicate
(Garrison-Harrell et al., 1997); and PRT (Koegel et al., 1999; Pierce & Schreibman,
1997).

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A number of key findings supported from the research are outlined below.
First, typically developing peers are a recommended component to interventions
addressing social competence for children and individuals with ASD (Camargo et al.,
2014; Watkins et al., 2015). Chang and Locke (2016) suggest that the benefits of PMIs
include typically developing peers that can model appropriate social behaviors, peers that
are readily accessible in school settings to act as intervention agents, and peers that
provide multiple opportunities for children with ASD to practice their new skills.
A second finding is that training children with ASD to respond and initiate to their peers
can provide powerful changes in their ability to socialize and communicate.
A third finding is that setting matters. Social skills interventions and PMIs conducted in
the setting in which the students will use the skills promote higher maintenance and
generalization (Bellini et al., 2007; Camargo et al., 2014). Inclusive settings may have
added value for PMIs (Koegel, Kuriakose et al., 2012). In addition, implementation of
PMIs may have more powerful effects and generalized outcomes when implemented in
multiple general education settings (e.g., classroom, lunchroom, playground; Camargo et
al., 2014; Harper et al., 2008; Kamps et al., 1997, 2002). Kasari and Patterson (2012)
concur that the intervention setting matters, suggesting that toddlers may respond
differently to different interventionists (i.e., therapists and parents) and settings and
developmental differences may further impact responsiveness to treatment.

C. DIR/Floortime

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DIR/Floortime is the application of the Developmental, Individual-differences, and
Relationship-based (DIR) model that focuses on the child’s developmental abilities in the
context of his or her individual processing profile and interactions with the family
(Greenspan & Wieder, 2006, 2007).
The components of the DIR model are:
a. Development, which emphasizes the child’s developmental level in developing a
treatment plan;
b. Individual-differences, which focuses on the child’s unique needs; and
c. Relationship-based, which describes the learning relationships that the child has with
their caregivers.
This model focuses on the individual’s social and emotional development, sensory
processing, and motor planning skills by working with the individual’s strengths and
weaknesses at each stage of development to build healthy foundations for social,
emotional, and intellectual abilities (Greenspan & Wieder, 2006; Masse, McNeil,
Wagner, & Chorney, 2007).
As a comprehensive framework, DIR Model typically involves an interdisciplinary team
approach including speech and occupational therapy, mental health professionals (e.g.
social worker, psychologist, child psychiatrist), educational programs, and, where
appropriate, biomedical intervention. After carefully assessing the child’s functional
developmental level, individual differences and challenges, as well as relationships with
caregivers and peers, the interdisciplinary team will, together with the parents, develop an
individualized functional profile that captures each child’s unique developmental features
and serves as a basis for creating an individually tailored intervention program.
The child’s functional emotional skills are assessed and used as a foundation for teaching
new skills. Additionally, the child’s sensory modulation abilities and motor planning
skills are also taken into consideration for developing interactions. This model is based on
the foundation of increasing positive social interactions to develop more complex skills.
In this model, there is an emphasis on creating meaningful interpersonal relationships
between the adult and child (Wagner, Wallace, & Rogers, 2014).
As stated by Greenspan and Wieder (1999), “the primary goal of DIR-based intervention
program (sometimes referred to as Floortime) is to enable children to form a sense of
themselves as intentional, interactive individuals, develop cognitive language and social
capacities from this basic sense of intentionality, and progress through the six functional
emotional developmental capacities.” There are critical milestones that are central to the
DIR/ Floortime approach. They include:
(1) self-regulation and interest in the world,
(2) developing relationships and attachment with others,
(3) reciprocal communication,
(4) complex communication,

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(5) emotional ideas (e.g., pretend play, identifying emotions, perspective taking), and
(6) emotional thinking (e.g., connecting one’s actions and feelings, understanding the
relationship between self and others).
These milestones progress sequentially and are important for individuals to develop
communication, thinking, and emotional coping skills (Metz et al., 2005).
Floortime is one component of the DIR model and refers to the specific technique of
getting on to the floor to work with the child and build his or her skills. The technique
emphasizes a child-lead approach and joining the child in his or her world to promote
their functional emotional developmental capacities. It is a child-lead intervention in
which the role of the caregiver is to develop the child’s skills by following the child’s
lead.
During Floortime sessions, the adult follows the child’s interests and uses their
interactions to promote the child’s progression through socialization skills (Wieder &
Greenspan, 2003). Foundational skills such as joint attention, engagement, basic gestures,
and problem solving are emphasized to promote development of more complex skills.
The primary objective of DIR/Floortime is to encourage parents to meet their child at the
child’s developmental level (Greenspan & Wieder, 2007). Dedicated DIR/Floortime
sessions are encouraged throughout the day. In addition to Floortime sessions, parents are
also encouraged to utilize natural opportunities to implement DIR/Floortime strategies
throughout the day, such as during the morning routine and meal times. DIR/Floortime
therapists work with caregivers in the family’s home, in clinics, or in the child’s school
setting in order to provide the caregivers with as much support for the child as possible
(Wagner et al., 2014).
Research studies:
In a pilot study by Solomon, Necheles, Ferch, and Bruckman (2007), the DIR/Floortime
approach was found to be effective at increasing social communication skills. The study
participants included 68 children aged 18 months to 6 years old who completed an 8–12
months program of 15 h per week of 1:1 interaction with their parents. About 45% of
children made good to very good clinically significant developmental progress.
Importantly, parents were found to be effective at implementing the intervention. This
study provided preliminary support for the use of DIR/Floortime as a cost-effective
intervention for young children with ASD.
Another pilot study by Pajareya and Nopmaneejumruslers (2011) examined the efficacy
of DIR/Floortime in preschool children in Thailand. Thirty-two children and their parents
were enrolled in the study. Parents were trained by the researchers on how to implement
DIR/ Floortime sessions. After implementing the intervention for about 15 h each week
over 3 months, the children in the DIR/Floortime group made significantly greater gains
on measures of emotional development (e.g., engagement, social-emotional reciprocity,
communication) and decreases in ASD symptom severity when compared to a typical
treatment group.
Casenhiser, Shanker, and Stieben (2013) conducted a randomized controlled trial to
evaluate the efficacy of a DIR-based intervention. The intervention group received 2 h of

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 coaching and therapy each week, while a community therapy group received various
services for around 4 h each week. The study examined the quality of social interaction
(i.e., engagement in play), ability to engage in and initiate joint attention, degree of
enjoyment in interaction, and language ability. Fifty-one children aged 2–4 years were
given treatment over 1 year. The children in the DIR based intervention group made
significantly greater gains in social interaction skills over the community treatment group.
Specifically, the DIR-based intervention group showed greater improvements in
enjoyment of interactions, engagement in interactions, and initiation of joint attention.
A major limitation of DIR/Floortime is the intensive nature of the intervention. DIR/
Floortime requires caregivers to spend significant time with their children conducting
Floortime sessions; as such, families must be highly motivated and able to dedicate the
time to implement the intervention (Masse et al., 2007). While this intervention lacks
sufficient research evidence, there are components of DIR/ Floortime that are part of
traditional behavioral therapy which may benefit children with ASD.
The DIR/Floortime model incorporates several teaching methods including incidental
teaching, optimizing interactions, and shaping and reinforcement techniques. The
difference between DIR/Floortime and ABA-based interventions is that DIR/Floortime
does not use discrete trials to teach skills. Although DIR/ Floortime emphasizes child-
lead interactions, the parent is able to incorporate several teaching methods that are used
in traditionally behavioral approaches. Additionally, while the focus of DIR/Floortime is
to develop social-emotional skills, there are components that may promote the
development of the child’s motor, cognitive, and language skills (Wagner et al., 2014).
 WORKING WITH FAMILIES
Families play a key role in effective treatment for children with ASD. The impact of having a
child with ASD on other family members and on society is considerable. Parents of children
with ASD report more stress and increased costs than do parents who do not have a child
with ASD. More than half of families report that a parent needs to cut back on work or stop
working because of the care needs of the child.
The largest societal costs associated with ASD are special education, residential care, and lost
days of caregiver work. Peer support for families of children with ASD is associated with less
parental stress, less negative mood, and more positive perceptions. Parents who understand
more about their child’s ASD can advocate for more intensive and appropriate services. Best
practice includes giving families contact information for a family support group at the time of
diagnosis.
This support may be a local group that provides face-to-face interaction and community
activities or an online community. Many families may not have the time or inclination at the
time of diagnosis to communicate with other families affected by ASD but may find the
support useful later when they are facing the transitions of preschool, adolescence, or
adulthood.
National support groups that address a wider community of children and youth with special
health care needs (such as Family Voices and Parent2Parent), autism-specific national
support organizations (such as Autism Speaks and the Autism Society), and local
organizations are effective in helping families obtain information and feel supported.

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 Conclusion: Interventions for individuals with ASD should be lifelong, with
multidisciplinary services that are evidence based and found to be effective, including
applied behavior analysis, educational programs, speech therapy, occupational therapy,
social skills training, and physical therapy.

References:
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children with autism spectrum disorders: Static versus dynamic assessment. Advances in
Speech Language Pathology, 9(4), 297–311.
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Law, J., & Camilleri, B. (2007). Dynamic assessment and its application to children with
speech and language learning difficulties. Advances in Speech Language Pathology,
9(4), 271–272. https://doi.org/10.1080/14417040701516522

Asperger, I., Diagnostic, S., Asds, T., Video, A., Autism, T., Checklist, B., Abc, T., Autism,
T., Screening, S., Assq, C. T., Abc, T., Admin, A., Description, T., Asds, T., Syndrome, A.,
& Quotient, A. S. (2008). ASD Specific Screening Tools.

Matson, J. (2005). Applied Behaviour Analysis for Children with Autism Spectrum Disorders.
In Journal of Materials Processing Technology (Vol. 1, Issue 1).

Matson, J. (2017). Handbook of Treatments for Autism Spectrum Disorder. In ProQuest

Dissertations and Theses.

Leaf, J. B. [Ed]. (2017). Handbook of social skills and autism spectrum disorder: Assessment,
curricula, and intervention. In Handbook of social skills and autism spectrum disorder:
Assessment, curricula, and intervention.

Mukherjee, S. B., Aneja, S., Sharma, S., & Sharma, M. (2019). Diagnostic Accuracy of
Indian Scale for Assessment of Autism in Indian Children Aged 2–5 Years. Indian
Pediatrics, 56(9), 831–836. https://doi.org/10.1007/s13312-019-1608-1

Greenspan, S., Wieder, S., & Ph, D. (2014). What is the DIR/Floortime Model? The
Interdisciplinary Council on Developmental and Learning Disorders.
http://www.stanleygreenspan.com/swf/The DIR Floortime Model.pdf

Wieder, S., & Foundation, P. (2015). THE DEVELOPMENTAL , INDIVIDUAL-

DIFFERENCE , RELATIONSHIP-BASED ( DIRTM ) MODEL THE DEVELOPMENTAL ,
INDIVIDUAL-DIFFERENCE ,. May.

Kaminker, M. K., Savard, L., & Albrecht, M. (2015). Selected Assessment Tools for
Evaluation of Children With Autism Spectrum Disorder in School-Based Practice. Academy
of Pediatric Therapy Fact Sheet, 1–15. https://pediatricapta.org/includes/fact-sheets/pdfs/15
Selected Assess Tools for ASD.pdf

Chakraborty, S., Thomas, P., Bhatia, T., Nimgaonkar, V. L., & Deshpande, S. N. (2015).
Assessment of severity of autism using the Indian scale for assessment of autism. Indian

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Journal of Psychological Medicine, 37(2), 169–174. https://doi.org/10.4103/0253-
7176.155616

Arun, P., & Chavan, B. S. (2018). Development of a screening instrument for autism
spectrum disorder: Chandigarh Autism Screening Instrument. The Indian journal of medical
research, 147(4), 369–375. https://doi.org/10.4103/ijmr.IJMR_1968_16

Wong, C. M., & Singhal, S. (2014). INDT-ASD: An autism diagnostic tool for Indian
children - Developmental pediatrician’s perspective. Indian Pediatrics, 51(5), 355–356.
https://doi.org/10.1007/s13312-014-0407-y

Asokan, S., Meera, S., & Shivashankar, N. (2016). INCLEN Diagnostic Tool for the
assessment of Autism Spectrum Disorder: A new tool in the speech-language pathologist′s
armoury. Journal of Indian Speech Language & Hearing Association, 30(1), 7.
https://doi.org/10.4103/0974-2131.196245

Chakraborty, S., Bhatia, T., Sharma, V., Antony, N., Das, D., Sahu, S., Sharma, S., Shriharsh,
V., Brar, J. S., Iyengar, S., Singh, R., Nimgaonkar, V. L., & Deshpande, S. N. (2021).
Psychometric properties of a screening tool for autism in the community-The Indian Autism
Screening Questionnaire (IASQ). PLoS ONE, 16(4 April 2021), 1–16.
https://doi.org/10.1371/journal.pone.0249970

Kishore MT, Menon DK, Binukumar B. Development of a scale for identifying autism
spectrum disorder during early childhood. Indian J Psychiatry 2018;60:438-44

Owens, J. R., Metz, D.E., & Farinella, K.A. (2015). Introduction to communication disorders
- A lifespan evidence-based perspective. Upper Saddle River; NJ: Pearson Education Inc.

18
 Language Disorders in Children

Topic: ASD Prognosis and intervention II– Social-communication, emotional regulations

abilities and transactional supports, responsive teaching, relationship development
intervention, Hanen approach, Treatment and Education of Autistic and Related
Communication Handicapped Children, Picture Exchange Communication System, Com-
DEALL, SCERTS approach, and diet management;

Presenter: Sriram M- I M.Sc. (Speech Language Pathology)

Social Communication Emotional Regulation Abilities and Transactional Supports

(SCERTS):

Introduction:

SCERTS Model is a comprehensive, multidisciplinary approach to enhance communication

and socioemotional abilities of children from early intervention to the early school years
(Prizant, Wetherby, Rubin, & Laurent, 2013). The model prioritizes Social Communication,
Emotional Regulation, and Transactional Support as the primary developmental dimensions
that must be addressed in a comprehensive program designed to support the development of
children with ASD. As the model addresses core deficits or challenges definitive of ASD, it
can be applied flexibly to a range of children who have varying degrees of disability (i.e.,
mild to severe) in cognitive, communicative, sensory processing, and regulatory capacities.

The ultimate goal of communication intervention for children with ASD is to help the
children interact with others in their natural environments. As an alternative to behaviourally
based approaches, the SCERTS approach is based on social interaction, developmental, and
family system theories.

The SCERTS approach addresses a child’s social communication abilities and social
relationships as the primary focus of intervention.

The SCERTS approach uses the following methods:

 Following the child’s lead

 Offering choices and alternatives within the child’s daily routines and activities

 Responding to the child’s intent and reinforcing communication attempts

 Modeling a variety of communication functions at the child’s level

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  Elaborating the child’s verbal and non-verbal communication attempts (Prizant &
Wetherby,2006)

In this approach, the communication partners embed learning sequences within the child’s
everyday activities. Embedding instruction increases the generalization of the targeted
behaviours and encourages the involvement of the child’s parents, classroom, teachers,
siblings, and peers. Because intervention aims to improve both the quality and quantity of
interactions, the practitioner in a SCERTS intervention uses both frequency counts and
behavioural rating systems to document child and communication partner objectives.
Through SCERTS intervention approach there is an effort to increase the child’s independent
functioning and self-regulation. To accomplish this, intervention often focuses on natural
routines that have a beginning, middle and end.

The Domains in SCERTS:

I. SOCIAL COMMUNICATION (SC)

It is now well documented that positive long-term outcomes for children with ASD are
strongly correlated with the achievement of communicative competence those children who
display a greater capacity to establish and follow the attentional focus of their communicative
partners are more likely to initiate bids for communication, use more contingent language and
acquire conversational skills, use more sophisticated gestures and symbolic language,
recognize and repair communicative breakdowns, and respond to contextual and
interpersonal cues (Carpenter &Tomasello,2000; Wetherby, Prizant, & Hutchinson, 1998).

The “SC” component of the SCERTS Model directly addresses the core challenges in social
communication faced by children with ASD. Although there is great heterogeneity in
children with ASD, research over the past 2 decades has identified core challenges that fall
into 2 major areas:

(1) The capacity for joint attention, which underlies a child’s ability to coordinate and share
attention, share emotions, express intentions, and engage in reciprocal social interactions, and

(2) The capacity for symbol use, which underlies a child’s understanding of meaning
expressed through conventional gestures, words, and more advanced linguistic forms, and the
ability to engage in appropriate use of objects leading to imaginative play (Wetherby, Prizant,
& Schuler, 2000).

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Capacity for joint attention

A child’s ability to consider the attentional focus of another and to draw another’s attention
toward objects and events of mutual interest is a foundation for the development of language,
social-conversational skills, and social relationships. Moreover, these early capacities are
strongly related to the ability to interpret and share emotional states and intentions, and to
consider another’s prior experiences and perspective in relation to events or conversational
topics (Carpenter &Tomasello, 2000; NRC, 2001).

At pre-linguistic stages of language acquisition, joint attentional capacities are manifest in the
ability to orient to a social partner, to coordinate and shift attention between people and
objects, to share and interpret affect or emotional states, and ultimately, to use gestures and
vocalizations paired with physical contact or gaze to deliberately affect (i.e., communicate
with) another person.

A child’s ability to monitor the social environment through social referencing (i.e., shifting
gaze) and to share affect typically precedes the developmental milestone of intentional
communication, which is then followed by an expanded ability to express intentions across
communicative partners and for a range of communicative functions or purposes.

Prior to the development of language, a child’s capacity for joint attention also underlies the
ability to communicate not only for need-based instrumental purposes (eg, requesting or
protesting by using push away or giving gestures), but also for more social purposes.

As a child makes the transition to language, the capacity for joint attention facilitates the
development of a more sophisticated and explicit system of communication. There is a rapid
expansion of vocabulary and linguistic concepts, and emergence of more sophisticated
sentence structures for the purposes of sharing intentions and emotions (Wetherby et al.,
2000).

At more advanced stages of language acquisition, the emergence of more sophisticated joint
attention capacities supports communication about past and future events and enables
children to consider what is novel, interesting, and important to their listener based on their
listener’s attentional focus, interests, and knowledge of prior events (Carpenter &Tomasello,
2000)

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The core challenge in the capacity for joint attention impacts 4 critical developmental
capacities in the social-communicative profile of children with ASD, resulting in a number of
significant developmental challenges and limitations:

1. Limitations in coordinating attention and affect result in difficulties in

(a) orienting and attending to a social partner;

(b) shifting gaze between people and objects in order to monitor another’s attentional focus
and intentions;

(c) sharing emotional states with another person;

(d) following and drawing another person’s attention toward objects or events for the purpose
of sharing experiences; and

(e) participating in reciprocal interactions over multiple turns in social exchange.

2.Limitations in sharing intent (Prizant & Wetherby, 1987) result in difficulties in

(a) directing signals to others to express intentions;

(b) gaining another’s attention when initiating either gestural, vocal, or linguistic
communication,

(c) communicating intentionally at a rate necessary to maintain reciprocal interaction, and

(d) persisting and repairing communicative breakdowns when they occur.

3. A restricted range of communicative functions resulting in a reduced frequency of

communication for more social purposes (Wetherby, 1986) such as for social interaction or
calling attention to oneself, or for joint attention such as commenting on and sharing
experiences, and expressing emotions; and

4. Difficulties inferring another’s perspective or emotional state—resulting in

(a) problems in monitoring the appropriateness of verbal and nonverbal discourse;

(b) selecting appropriate topics;

(c) providing sufficient background information; and

(d) reading and responding appropriately to others’ emotional expressions.

Capacity for symbol use:

22
Challenges in the capacity for symbol use impact 3 critical developmental capacities in the
social-communicative profile of children with ASD, resulting in a number of significant
limitations:

1. Limitations in the use of conventional hand gestures (Eg: showing, waving, and
pointing) and other nonverbal conventional communicative means (Eg: head nods and
headshakes) resulting in a reliance on primarily concrete, pre-symbolic motor-based gestures
(Eg: manipulating a caregiver’s hand, leading another toward a desired item, and re-enacting
desired actions). Additionally, the use of socially undesirable communicative means or
challenging behaviors for communication (Eg: screaming, aggression, tantrums), often
observed in children with ASD, may be a direct consequence of these limitations, as they are
used in lieu of more conventional gestures for protesting or establishing social control.

2. Unconventional vocal development, which may be marked by a paucity of vocal

communication or the use of difficult to read, unconventional sounds.

3. Unconventional verbal behaviour such as the use of immediate or delayed forms of

echolalia, perseverative speech, or incessant questioning (Rydell&Prizant,1995; Schuler &
Prizant, 1985;

4.Limitations in functional object use and symbolic play, as marked by difficulties using
objects appropriately, which may be due in part to limitations in motor planning and in
imitating the nonverbal behaviors of others, as well as limitations in the underlying symbolic
capacity to represent social events, to “role-play,” and to elaborate on play schemes
(Wolfberg, 1999).

II. EMOTIONAL REGULATION:

Emotional regulation is a core process underlying attention and social engagement, and is
believed to be essential for optimal socio-emotional and communication development, and
the development of relationships for children with and without disabilities (Prizant & Meyer,
1993).

Cicchetti, Ganiban, and Barnett (1991) defined emotional regulation as “the intra and extra
organismic factors by which emotional arousal is redirected, controlled, modulated, and
modified to enable an individual to function adaptively”.

23
Through the process of emotional regulation children strive to maintain an optimal state of
arousal that matches the social and physical demands of their environments and that allows
them to respond adaptively (DeGangi, 2000).

Arousal has been defined as a continuum of physiological states or biobehavioural states

ranging from sleep to wakeful (Lester, Freier, & LeGasse, 1995).

Modulation abilities (i.e., the efficient and appropriate transition along the continuum of
arousal states) enable children to transition along this continuum in accordance with internal
and external factors. Factors influencing the ability to transition along the continuum include,
but are not limited to, environmental characteristics (e.g., types and intensity of
environmental stimulation), social context, (e.g., availability of familiar communicative
partners), and internal or constitutional variables (e.g., illness, level of fatigue, and pain).

It has been well documented that children with ASD have significant difficulties with arousal
modulation, and therefore, emotional regulation, due to neurophysiological factors. This may
take the form of a low threshold for physiological and emotional reactivity, resulting in being
“at risk” for experiencing heightened states of arousal and emotion (i.e., hyper-reactivity),
causing anxiety, agitation, and a limited ability to be “available” for learning and interacting.
In these heightened states of arousal, children often exhibit flight, fright, and fight reactions,
which are frequently misinterpreted and treated as “behaviour problems.”

Social-communicative and language difficulties experienced by children with ASD

significantly impact their arousal modulation abilities and behavioural organization, and
therefore, their emotional regulation, in reference to the development of both self- and mutual
regulatory abilities. Regarding self-regulation, difficulties with symbolic capacities, may
impact negatively on the development of “inner language.”

It has long been understood that inner language (Vygotsky, 1978), or the ability to represent
events in memory and problem solve through inner symbolic means, serves an important
cognitive function of organizing experience and behaviour, thinking about and learning from
past events, and planning for future events.

With limited ability to use inner language for these cognitive functions, it is less possible to
plan for dysregulating and potentially threatening events, or to reflect on past events in a
manner that supports emotional regulation when faced with stressful events.

24
These difficulties may contribute to the unpredictable reactions to daily events observed in
many children with ASD.

III. TRANSACTIONAL SUPPORT:

Due in large part to the difficulties in social communication and emotional regulation, the
majority of children with ASD require a variety of supports to participate optimally in
interpersonal interactions and relationships, and to understand and derive enjoyment from
everyday activities.

Supports are also needed to maximize learning in educational settings and participation in
daily living activities and events. The notion of transactional support in the SCERTS Model
emphasizes that supports must be flexible and responsive to different social contexts and
learning environments, and to the changing needs of children and families.

Most important, however, is that both children and family members develop a sense of
confidence and competence in utilizing and responding to supports.

Transactional support is addressed in 3 major domains in the SCERTS Model which are:
Interpersonal support, educational support, and family support

I. Interpersonal support:

Interpersonal support focus on the following:

1. Identify specific features of communicative partners’ interactive styles and language use
that either support or are barriers to successful interactions (e.g., expression of emotion,
language complexity and style, vocal volume, rate, physical proximity, physical contact, use
of visual supports). An optimal style is one that provides enough structure to support a child’s
attentional focus, situational understanding, emotional regulation, and positive emotional
experience, but that also fosters initiation, spontaneity, flexibility and self-determination

2. Coordinate efforts across different partners in developing strategies to use more those
specific features that support more successful interaction.

3. Design and implement learning experiences with peers so that the child with ASD may
benefit optimally from good language, social, and play models. Design motivating activities,
organize supportive environments, and incorporate visual supports. Teach both typical
children and children with ASD specific strategies for success in daily interactions.

25
II. Educational and learning supports: Focuses on

1. Design and implement visual and organizational supports for:-

a. Expanding and enhancing the development of a child’s expressive communication system,

either as a primary modality or as an augmentative system that is one part of a child’s
multimodal communication system;

b. Supporting a child’s understanding of language as well as others’ nonverbal behaviour;

c. Supporting a child’s sense of organization, activity structure, and understanding of time;

and

d. Supporting the development and use of cognitive-linguistic emotional regulatory strategies.

e. Adapt and/or modify curriculum goals that are primarily language-based to enable the child
to succeed to the extent possible.

2. Design living and learning environments to support social communication and emotional
regulation.

III. Family support (i.e., support to parents, siblings, extended family members)

1. Provide families with educational support including information, knowledge, and skills to
understand the nature of their child’s disability and to support their child’s development.
Support that is provided, must be based on family priorities, and offered through a variety of
options such as educational support activities (e.g., lectures, discussion groups), direct
training of skills, observation of educational/treatment programming, and interactive
guidance in natural activities

2. Provide emotional support in one to one and group settings to:

a. Enhance the family members’ abilities to cope with the stresses and challenges of raising a
child with ASD

b. Help parents to identify their priorities, and develop appropriate expectations and realistic,
achievable goals for their child’s development and for family life.

IV: RESPONSIVE TEACHING (RT):

Responsive Teaching is a comprehensive developmental intervention designed to be used
with children up to six years of age who have, or are at-risk for, developmental and social
emotional problems.
26
Responsive Teaching supports and enhances parents’ role in children's development and is
grounded in contemporary child development theory. It aims to help children learn and use
the pivotal behaviours that child development experts believe to be the processes that
children use to attain higher levels of competence:
• Cognition
• Communication
• Social-emotional functioning
• Motivation

Responsive Teaching includes four curriculum components:

• Intervention goals and objectives
• Intervention topics to help parents understand the desired pivotal behaviours
• Responsive teaching strategies
• Family action plans

These Responsive Teaching curriculum is designed to encourage parents to use Responsive

Teaching strategies in each interaction they have with their children to help them develop
cognitive, language and social-emotional skills.

One study looked at Responsive Teaching for parents and 20 young children aged two to five
years who had pervasive developmental disorders including Autism (Mahoney and Perales
2005). Both children and their parents had weekly 1-hour sessions over a period of 8 to 14
months.

It was found that the mothers' responsiveness to their children increased, as were the
children's social cognitive and communication functioning and scores on standardized
measures of social-emotional functioning. The authors did note that the study did not meet all
the criteria that would qualify Responsive Teaching as an evidence-based treatment, and that
further rigorous research was required

This concludes SCERTS and its four domains.

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 Hanen’s Approach

The Hanen's Parental Programme is one of a number of programmes concerned with the early
reciprocal interactions between parents and their children. It works on the premise that
children with communicative delays have less well-developed dialogue skills and are less
able to benefit from their linguistic environment than children with typically developing
language. The parent is encouraged to enhance the quality of interaction in spontaneously
occurring events using a number of techniques (Manolson 1992, Tannock and Girolametto
1992)

Hanen Parent Programme:

The 11-week programme included eight weekly group sessions and three home visits and was
carried out by two trained therapists. The group sessions were for parents only, lasted 2 hours
15 minutes and followed the Hanen published programme. A typical session included
reviewing the previous week, the presentation of new information, videotapes and role-play
to illustrate key techniques and for discussion.

Carryover activities relating to the content of the session were assigned. The three home
visits provided parents with the opportunity for individual consultation and feedback about
their own and their child’s progress through the use of videotapes. The parent and child were
briefly recorded during free play and the tape was then subsequently reviewed by the parent
and speech and language therapist to provide immediate feedback on the use of techniques
introduced in the programme.

It was recognized that Hanen sessions were longer but, for the group sessions, the time
allocated to any one family was about 30–45 minutes. The primary difference between these
two styles of intervention is that in the direct clinic approach, is that the focus is on the
child’s language, whereas in the indirect HPP the focus is much more on the parents’
language and interaction style.

The Hanen center (www.hanen.org) offers five different programs for parents, namely: It
takes two to talk, More than words, TalkAbility, Target word and I'm Ready!

Parents learn some very concrete and practical ways to encourage their child’s
communication development. Parents report significant improvements in their child’s
communication, interaction and play skills as a result of taking the program.

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The It Takes Two to Talk Program is based on some well-researched principles of
intervention:

 Putting the family front and centre

It is a family-centred program, in which parents are involved in their child’s intervention in

ways that strengthen their ability to help their child.

Parents learn what to do to help their child learn and develop, and the earlier parents are
involved in their child’s intervention, the better the child’s outcome.

 Therapy is part of everyday family life

It makes use of everyday activities and interactions within a family’s life. When children
learn to communicate in their natural environment in real-life situations with their caregivers,
they are more motivated to communicate and are better able to apply their newly-learned
skills to other situations.

 Learning to communicate takes place within parent-child interactions

Interaction between adult and child that is the catalyst for the child’s language learning.

This theory is based on the belief that children’s language learning is fostered when the adult:

 Is very responsive to the child’s communication efforts; and

 Simplifies and fine-tunes what she says to the child so that the child can understand
and learn from it.

 Being responsive to the child is the key

It teaches parents to be responsive to their child. Being responsive means:

1. Responding promptly (often within 1-2 seconds of a child doing or saying something)

2. Responding positively – responding in a way that shows the child the parent is really
interested in what she or he is saying

3. Sticking with what the child is “talking” about and not trying to get him interested in
something else (e.g., if the child is showing the parent how he can drive his toy car
along the kitchen floor, the parent then talks about what he is doing with the car, not
the colour of the car or about the toy train)

29
Benefits of Taking the It Takes Two to Talk® Program
The various benefits of the program are as follows:

Practical strategies you can use in everyday situations

The It Takes Two to Talk Program shows how to use your natural, day-to-day life with your
child to help him develop language skills. You’ll discover simple things you can do during
everyday activities like meal time, story time and bath time to create enjoyable learning
opportunities for your child.

It Takes Two to Talk translates the research on early language intervention into concrete
strategies that are easy for parents to understand and to put into practice. The program offers
you many opportunities to practice and discuss each strategy you learn so that you’ll be
comfortable and confident using them at home.

Here’s an example of an It Takes Two to talk strategy that can be used during any activity to
encourage your child to start conversations:

“OWL to Let Your Child Lead”

Observe
Wait
Listen

Research has shown that children learn language best when they are allowed to lead a
conversation and communicate about what interests them. The OWL strategy will help you
follow your child’s lead so that he’ll be more likely to stay in the interaction with you and get
the practice and feedback he needs to build his communication skills.

R. Repeat what you say and do

O. Offer opportunities for your child to take his turn
C. Cue your child to take his turn
K. Keep it fun! Keep it going!

The R.O.C.K. strategy can be used during any activity we do with the child to foster longer,
more meaningful interactions and improved social skills.

“Shoot for the SSTaRS”

A child hears thousands of words in a day. When helping children learn new words, it’s
important to make the word sparkle – so we have to highlight it somehow. To make new

30
words sparkle during book reading, we can use the following strategy of Shoot for the
SSTARS:

Stress the new word to focus the child’s attention

Show the child what the word means
Tell the child what the word means
And
Relate the word to the child’s personal experiences and knowledge, as well as to other
words and situations
Say it again – and read the book again

Based on Hanen’s programme there are various strategies that are empowered and explained
to parents.

 To look and observe at what their child likes and dislikes- what toy the child likes to play,
favourite food, physical play, who does your child like to be with the most
 Recognize the child’s sensory preferences

The sights, sounds, smells, feelings and movements that their child enjoys or dislikes are
called sensory preferences.

It will show them where to start in helping their child learn to communicate. When the child
receives information through preferred sense, he may be able to pay attention and longer and
learn more. The parents are asked to choose activities that are motivating and pleasurable.

 Understanding the child’s learning style- rote learners, gestalt learners, visual learners,
auditory learner or hands-on learners. This will help the parent to stimulate the child in
which the child prefers learning.
 To highlight and make the parent understand what communication is- interaction occurs
when the parent and their child do things together and respond to one another, and also
for the parent to give opportunities to make the child initiate and participate in social
interactions.
 To ask the parent to play the helper/teacher role- ask once and wait. Then to ask again,
adding help; Partner role- to play peak a boo and taking turns; Cheerleader role-
encourage and motivate the child for the child to understand what he/ did is right and will
repeat to do things again in order to get appreciation

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 Interacting with other people.

Communicating in new ways-pictures or gestures:

Pick a way for child to communicate-picture, point to things, use hand signs

Understanding the connect between what the parent’s say and what’s happening in their
child’s world:

 The parent can improve the way the child communicates by

 Turning echoes into spontaneous speech

 Turning gestures into signs, speech or picture communication
 Turning picture communication into verbal communication
 Turning single word communication into short phrases

 Help the child improve his understanding of events such as past and future, feelings,
comparisons, how to behave or problem solve, other people’s point of view.
 To make the play interactive and interesting

To make the child reach out and request for toys

 To use the four ‘I’ way to follow your child’s lead

1. Include your child’s interests

2. Interpret
3. Imitate
4. Intrude

 To give cues the child, take a turn

 Questions – ask to keep the child involved in the conversation
 To give comments
 To help the child understand what parents say

And to Say less and stress, Go slow and show!

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 Picture Exchange Communication System (PECS)

Introduction:

PECS was developed in 1985 as a unique augmentative/alternative communication

intervention package for individuals with autism spectrum disorder and related
developmental disabilities.

First used at the Delaware Autistic Program, PECS has received worldwide recognition for
focusing on the initiation component of communication. PECS does not require complex or
expensive materials. It was created with families, educators, and resident care providers in
mind, so is readily used in a range of settings.

PECS begins by teaching an individual to give a picture of a desired item to a

“communicative partner” who immediately honours the exchange as a request. The system
goes on to teach discrimination of pictures and how to put them together in sentences. In the
more advanced phases, individuals are taught to answer questions and to comment.

The Six Stages of PECS are as follows:

PHASE I:
How to Communicate
Students learn to exchange single pictures for items or
activities they really want.

PHASE II
Distance and Persistence
Still using single pictures, students learn to generalize this
new skill by using it in different places, with different
people and across distances. They are also taught to be
more persistent communicators.
PHASE III
Picture Discrimination
Students learn to select from two or more pictures to ask for
their favourite things. These are placed in a communication
book—a ring binder with Velcro strips where pictures are

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stored and easily removed for communication.
PHASE IV
Sentence Structure
Students learn to construct simple sentences on a
detachable sentence strip using an “I want” picture
followed by a picture of the item being requested.

Attributes and Language Expansion

Students learn to expand their sentences by adding
adjectives, verbs and prepositions.

PHASE V
Answering Questions
Students learn to use PECS to answer the question, “What
do you want?”
PHASE VI
Commenting
Now students are taught to comment in response to
questions such as, “What do you see?”, “What do you
hear?” and “What is it?”. They learn to make up sentences
starting with “I see”, “I hear”, “I feel”, “It is a”, etc.

COM-DEALL:

Introduction:

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Communication DEALL is a Developmental Eclectic Approach to Language Learning, an
indigenously developed intensive early intervention program for children with neuro-
developmental communication disorders such as those with Autism Spectrum Disorders
(ASD), Specific Language Impairment (SLI), and Developmental Verbal Dyspraxia (DVD);
which aims at maximizing their potential through intensive preschool intervention (Karanth,
Shaista, & Srikanth, 2010).

The intervention is provided by a multidisciplinary team of speech-language pathologists,

occupational therapists and developmental educators. The primary goal of the intervention for
children with developmental disabilities in the communication DEALL program has been, to
integrate them in regular schools to the extent possible, with adequate preparation in the
preschool years.

Theoretical Framework of COM-DEALL:

The theoretical framework within which the program has been developed is that ASD is
primarily a pervasive developmental disorder, most possibly of neurological causation, that
affects many developmental domains.

The triad of characteristics seen in these children such as poor communication, social skills
and prerequisite learning behaviour (PLB) such as eye contact, attention, sitting tolerance and
compliance, are seen as being linked to more basic difficulties in sensory motor processing.

The intervention program addresses the needs of each child by enabling the child to stabilize
pre requisite learning behaviour, as well as acquire age appropriate developmental skills
across several domains, with specialized input from a multidisciplinary team of
interventionists.

The program provides intervention for 3 h a day, 5 days a week over a period of 10 months
from June every year to April of the subsequent year, with two short vacations in October and
December.

Unlike the better known western early intervention programs which provide intervention
based on behavioural and psychological models, it specifically targets developmental issues
in the areas of motor, communication, cognitive, social and emotional skills, while
incidentally addressing the behavioural issues. Initiated in 2000, the program is increasingly
showing positive results.

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Diagnostic Sources of Approach:

The Communication DEALL Developmental Checklist (CDDC) This checklist can be used
for assessing developmental skills in eight important domains, in children below 6 years of
age. The skills that the Communication-DEALL checklist evaluates are: Gross Motor skills
(GM), Fine Motor skills (FM), Activities of Daily Living (ADL), Receptive Language
(RL), Expressive Language (EL), Cognitive Skills (CS), Social Skills (SS)and Emotional
Skills (ES).

Development of each item was rated on a five-point rating scale as follows:

 NR No response (not known)

 0 Not Acquired

 1 Acquired but lost

 2 Acquired but inconsistently present

 3 Acquired and consistently present, but only in specific situations.

 4 Acquired and consistently present across all situations

A maximum score of 182 per year indicated normal development. Communication-DEALL

program for children with communication disorders, specifically for those with ASD is an
effective early intervention program. However, it needs further strengthening, particularly in
the stabilization of prerequisite learning skills.

Early intensive intervention for children with ASD based on models such as the Applied
Behaviour Analysis model and the Floor Time model have been reported to produce positive
outcomes. However, these are not easily accessible in countries like India due to lack of
trained manpower and high costs. The indigenously developed Communication DEALL
model is designed to meet the requirements of the socio-economic conditions in India and is
replicable.

Treatment and Education of Autistic and Related Communication Handicapped

Children (TEACCH):

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History of the TEACCH Approach:

The TEACCH Autism Program is a clinical, training, and research program based at the
University of North Carolina – Chapel Hill. TEACCH was developed by Dr. Eric Schopler
and Dr. Robert Reichler in the 1960s. It was established as a state wide program in 1972
and has become a model for other programs around the world. 

TEACCH uses a method called “Structured TEACCHing.” This is based on the unique

learning needs of people with ASD, including: 

 Strengths in visual information processing 

 Difficulties with social communication, attention and executive function 

Structured TEACCHing provides strategies and tools for teachers to use in the classroom.

These help students with autism to achieve educational and therapeutic goals.  

The Structured TEACCHing approach focuses on:  

 External organizational supports to address challenges with attention and executive

function  

 Visual and/or written information to supplement verbal communication  

 Structured support for social communication 

This method supports meaningful engagement in activities. It also works to

increase students’ flexibility, independence, and self-efficacy.   

TEACCH programs are usually applied in a classroom setting. TEACCH-based home

programs are also available. Parents work with professionals as co-therapists for their
children so that they can continue to use TEACCH techniques at home. 

Structured TEACCHing strategies can be used alongside other approaches and therapies.

Structured TEACCHing uses organization and supports in the classroom environment to help
students learn best.

This includes: 

1. Physical organization  

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 2. Individualized schedules 

3. Work (Activity) systems 

4. Visual structure of materials in tasks and activities 

TEACCH methods are used by a variety of autism professionals: 

 Special education teachers 

 Residential care providers 

 Psychologists 

 Social workers 

 Speech therapists 

To become trained, professionals must go through a certification program offered by the

TEACCH Autism Program in North Carolina. Trainings are offered both online and in-
person on the TEACCH campus. The program includes two certification
levels, Practitioner and Advanced Consultant. 

A 2011 review of more than 150 autism-intervention studies found that the TEACCH
program had the strongest evidence of educational benefits of any recognized program. These
benefits included improved learning (cognition) and motor skills.

Other studies found benefits of using TEACCH strategies in residential and employment
programs for adults with autism.

Diet management in Autism Spectrum Disorder (ASD):

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Autism, as it is classically defined, occurs on a spectrum and is often referred to as autistic
spectrum disorder (ASD) or simply autistic disorder. This is a lifelong complex
neurobiological disorder that affects practically every aspect of the diagnosed person’s life.
The Centres for Disease Control and Prevention recently reported prevalence rates of 1 in 150
children diagnosed with autism (http://www.cdc.gov/mmwr/PDF/ss/ss5601.pdf). Although
there is controversy regarding whether this is an actual rise in the number of cases or a result
of increased publicity and better diagnostic measures, it remains clear that autism is a
disorder that produces major challenges for families and society at large. To date, there is no
clear etiology or known cure.

The Gluten-Free Casein Free (GFCF) Diet:

The Gluten-free casein-free diet (GFCF) Diet, one of the most popular, yet currently
scientifically unproven, interventions for ASD is the GFCF diet. A number of theories have
been used to explain the rationale for this diet that eliminates gluten (found in wheat, rye, and
barley) and casein (the main protein in dairy products) (Elder, 2014).

It is hypothesized that some autistic symptoms (e.g., stereotypical and ritualistic behaviours,
perseveration, excessive activity, speech and language delays, and oddities) may be the result
of opioid peptides formed from the incomplete breakdown of foods containing gluten and
casein. Increased intestinal permeability, also referred to as the “leaky gut syndrome,” allows
these peptides to cross the intestinal membrane, enter the bloodstream, and cross the blood–
brain barrier, affecting the endogenous opiate system and neurotransmission within the
central nervous system.

This may help explain why many children with autism have associated GI symptoms,
including diarrhoea, constipation, abdominal pain, and gastroesophageal reflux. Furthermore,
because many of these children cannot adequately express their pain or GI discomfort
verbally, they may react with extreme behaviours (e.g., screaming, aggression, self-abuse).

Considerations When Implementing the GFCF Diet:

Many children with ASD have seriously restricted food repertoires that make it difficult to
eliminate foods containing gluten and/or casein. Therefore, it is critical that those seeking to
implement the diet obtain dietary histories and work collaboratively with families to tailor
each child’s diet to his or her preferences and needs. Reports of bone loss in children who
have been on the GFCF diet strongly suggest that nutrition status should be monitored and

39
that, in some cases, supplemental vitamins and minerals may be indicated. Parents should
also be encouraged to keep daily dietary records to share with their nutritionist and/or
healthcare provider. Finally, parents of school-age children must communicate closely with
school personnel and other caretakers to ensure that dietary restrictions are maintained while
the child is not at home. Special occasions and school parties must be planned for in advance
and alternative experiences and/or GFCF food substitutes made available.

Decision Making to Differentiate Pros and Cons by the Family for GFCF Diet:

Families of individuals with ASD often feel an urgency to make treatment decisions since
they are ultimately responsible for the welfare of individuals with ASD. While research
efforts related to use of the GFCF diet in autism have recently provided some preliminary
evidence, there is much to learn and many questions left to answer. Until more is known,
parents will continue facing challenges as they try to determine what is best for the person
with ASD and the family as a whole.

Professionals in a position to assist with decision making might consider the following
questions to help families weigh pros and cons related to the GFCF diet:

1. Does the family have the resources to purchase foods in the GFCF diet that are often
more expensive, and are these foods readily available?

2. Has the family considered the extra time and effort that may be needed to prepare
the diet?

3. Is there a commitment by at least 1 family member to keep accurate daily records of

food intake and behavioural changes?

4. Are there adequate plans regarding how to ensure dietary compliance at home and,
when applicable, at school?

5. Is there another parent or professional who has implemented the diet and who can
offer practical advice for preparing and implementing the GFCF diet?

6. Are there clinicians and/or researchers in the family’s geographical area who might
assist in systematically evaluating the GFCF diet?

Three additional considerations specific to the children themselves are as follows:

40
1. What is the overall health status of the child?

2. Is there a plan for regular monitoring, including weights?

3. Does the child have a limited food repertoire that, if further limited by the GFCF
diet, might result in a dangerously compromised nutrition status?

Other Diets:

Ketogenic Diet:

The ketogenic diet is a high-fat, low-protein, and low-carbohydrate diet that is designed to
elicit biochemical changes that are typically associated with starvation (Freeman et al., 1998).
This biochemical response results in the replacement of glucose with ketones as the primary
source of fuel for the brain (Hartman, Gasior, Vining, & Rogawski, 2007). The use of the
ketogenic diet to control seizures is well established and has been supported by earlier
research (Groesbeck, Bluml, & Kossoff, 2006; Kinsman, Vining, Quaskey, Mellits, &
Freeman, 1992; Neal et al., 2008).

Related to ASD, the majority of studies that have positive effects on ASD type symptoms
have focused on mouse models (Ahn, Narous, Tobias, Rho, & Mychasiuk, 2014; Ruskin et
al., 2013). However, there is still inadequate evidence to support the effectiveness of this diet
for humans with ASD (Castro et al., 2015). A final concern is that use of this diet is related to
known health risks such as slow growth, skeletal fractures, and kidney stones (Groesbeck et
al., 2006).

Restricted and Supplementing Diets:

The restrictive diets, i.e., the elimination of ingredients from an individual’s diet, have their
place in treatment. They are routinely prescribed for physical disorders including food
allergies and sensitivities, inflammatory bowel disorders, seizures, and fungal and viral
infections (Srinivasan, 2009).

Because individuals with ASD are more prone to these conditions, restrictive diets may be
appropriate to ease the pain and suffering of these comorbid conditions, thereby improving
overall quality of life. However, eliminating certain ingredients from a diet brings the risk of
an imbalance in the diet. For example, removal of dairy from a diet due to casein allergy may
cause calcium deficiency.

41
Since efficacy research does not yet support a clear connection between dietary interventions
and/or supplementation and the core symptoms of ASD, the most relevant use of diet and
supplementation is to address comorbid symptomatology. Of the well-established comorbid
symptoms, those that are related to feeding and gastrointestinal concerns are the most
pertinent to a discussion of diet and/or supplementation use.

Specifically, feeding and gastrointestinal (GI) function are diet-related concerns that have
been documented since Kanner (1943) noted food and feeding issues in the form of food
intolerance in his study group of children with ASD. More recently, Ming, Brimacombe,
Chaaban, Zimmerman-Bier, and Wagner’s (2008) study of 160 children with ASD found half
suffered long-term food intolerance, and in 25%, the onset occurred in infancy with infant
formula intolerance.

It is important to know about the gastro-intestinal abnormalities that need to be

acknowledged by the clinician before looking to start a dietary intervention and/or
supplemental addition for an individual with ASD.

GI Abnormalities in Autism:

There is growing interest in GI abnormalities associated with autism. A number of

researchers have proposed that abnormal intestinal permeability in children with ASD results
in the absorption of larger peptides, the products of incomplete breakdown of proteins such as
gluten or casein. This assumes that peptide fragments act as endogenous opioids, cross the
blood–brain barrier, and result in the behaviours often observed in ASD.

Thus, the “opioid theory” may explain the physiology and psychology of ASD and effect for
the GFCF diet. Several studies have reported significant GI dysfunction in children with
autism, which may result from gluten or casein sensitivity.

Ashwood and colleagues found distinct mucosal pathologies in children with ASD and GI
symptoms. They noted the apparent positive effect in the colonic mucosa between children on
and off the GFCF diet and recommended further study.

Wakefield et al demonstrated irregularities in the absorptive properties of the mucosa of the

intestinal wall in children with autism.

42
In a second study, more than 93% of their sample (n =60) had GI symptoms, including
abdominal pain, constipation, diarrhoea, and bloating. Horvath and co-workers used
endoscopy with biopsy to examine the upper GI tract of a convenience sample of 36 children
diagnosed with autism who were experiencing abdominal pain, chronic diarrhoea, bloating,
night time awakening, or unexplained irritability. They found reflux esophagitis in all 36
children, and 24 had chronic duodenitis.

Black et al reviewed medical records and concluded that, in general, there were no
associations among GI inflammation, celiac disease, food intolerance, recurrent GI
symptoms, and the development of autism.

However, they acknowledged that GI symptoms may be present in a certain subgroup of

individuals with autism. Once again, this highlights the variability in this population and the
importance of further characterization.

Relationship Development Intervention (RDI):

Relationship Development Intervention (RDI) is a family-based, behavioral treatment which

addresses the core symptoms of autism. It focuses on building social and emotional skills.
Parents are trained as the primary therapist in most RDI programs.

RDI helps people with autism form personal relationships by strengthening the building
blocks of social connections. This includes the ability to form an emotional bond and share
experiences with others (Gutstein, Burgess, & Montfort, 2007).

Dynamic Intelligence

RDI builds on the idea that “dynamic intelligence” is key to improving quality of life for
individuals with autism.

Dynamic intelligence means the ability to think flexibly:

 Understand different perspectives

 Cope with change

 Integrate information from multiple sources (e.g. sights and sounds)

43
There are six objectives of RDI:

1. Emotional Referencing: the ability to learn from the emotional and subjective
experiences of others

2. Social Coordination: the ability to observe and control behavior to successfully

participate in social relationships

3. Declarative Language: the ability to use language and non-verbal communication to

express curiosity, invite others to interact, share perceptions and feelings and coordinate
your actions with others

4. Flexible Thinking: the ability to adapt and alter plans as circumstances change

5. Relational Information Processing: the ability to put things into context and solve
problems that lack clear cut solutions and have no “right and wrong” solutions

6. Foresight and Hindsight: the ability to think about past experiences and anticipate future
possibilities based on past experiences

RDI involves a step-by-step approach to build motivation and teach skills. The teaching plan
is based on the child’s current age and ability level.  The parent or therapist uses a set of step-
by-step, developmentally appropriate goals

The initial goal is to build a "guided participation" relationship between parents and child,
with the child as a "cognitive apprentice." Once this relationship is in place, the family
advances through a series of developmental goals for their child. The goal of this process is to
improve “neural connectivity,” or brain function.

Parents, teachers and other caretakers continue to use the principles of RDI in the child’s
daily life. They use positive reinforcement to help the child improve social skills, adaptability
and self-awareness.

Who provides RDI?

Parents and caregivers of people with autism usually serve as the primary therapist in an RDI
program. Parents can learn the techniques of RDI through training seminars, books and other
materials. They may choose to work with an RDI-certified consultant, as well.

44
Classroom teachers and behavioral therapists may also use RDI. Some specialized schools
offer RDI in a private school setting.

How does RDI work?

The RDI consultant may begin by doing an assessment to learn how the child interacts with
parents or teachers. The consultant will then create a teaching plan and goals based on the
person’s development and abilities. The plan will include working on communication styles
that best suit the child.

At the start, RDI involves one-on-one work between the parent and child. The parent or
therapist applies stepwise, developmentally appropriate objectives to everyday life situations.

For instance, at first parents may limit how much they use spoken language. This encourages
the child and parent to focus on eye contact and non-verbal communication.

As the child’s abilities increase, the goals and teaching plan change to meet his/her needs.

Next, the child begins spending time with a peer who shares similar social and emotional
skills. This may be referred to as forming a “dyad” (meaning two children).

Gradually, additional children join the group. They meet and play in a variety of settings with
the guidance of a parent or therapist. This allows them to practice forming and maintaining
relationships in different contexts.

What is the intensity of most RDI programs?

Families often use the principles of RDI in their day-to-day lives. Each family will make
choices based on their child. Most families spend at least a few hours per week using RDI
strategies

References:

 Prizant, M. B., Wetherby, M. A., Rubin, E., & Laurent, C. (2013). Social
Communication, Emotional Regulation, and Transactional Support (SCERTS). Infants
and Young Children, 16(4), 296–316. https://doi.org/10.1007/978-1-4614-5301-7-6
 Karanth, P., Shaista, S., & Srikanth, N. (2010). Efficacy of Communication DEALL —
An Indigenous Early Intervention Program for Children with Autism Spectrum Disorders.
Indian Journal of Pediatrics, 77, 957–962 https://doi.org/10.1007/s12098-010-0144-8

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 Elder, J. H. (2014). The Gluten-Free, Casein-Free Diet in Autism: An Overview With
Clinical Implications. Nutrition in Clinical Practice, 23(6), 583–588.
https://doi.org/10.1177/0884533608326061
 Gutstein, S. E., Burgess, A. F., & Montfort, K. (2007). Evaluation of the Relationship
Development Intervention Program. Autism, 11(5), 397–411.
https://doi.org/10.1177/1362361307079603
 Owens, J. R., Metz, D.E., & Farinella, K.A. (2011). Introduction to communication
disorders - A lifespan evidence-based perspective. Upper Saddle River; NJ: Pearson
Education Inc.
 Matson, J. L. (2018). Handbook of Treatments for Autism Spectrum Disorder.
SPRINGER INTERNATIONAL PU.
 http://www.hanen.org
 http://www.autismspeaks.org
 http://www.autismtruths.org

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