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Early Intervention Speech Therapy

Autism and Early Intervention Speech Goals

Published September 29, 2009 10:30 AM by Stephanie Bruno-Dowling
Today’s post poses a question for all the speech-language pathologists out there who work with children in early intervention who have already been diagnosed as having autism. My question is this: when you are teaching these children to communicate, do you use sign language, pictures, words or a combination of either two or all three of them?

The reason for my question is because I recently spoke with a well-respected, seasoned colleague of mine who paid a visit to a local school in our area. While there, she attended an IEP meeting for one of our early intervention children on the verge of turning three. The IEP team wrote goals addressing all areas of need, one of them of course being speech and language. The speech goal included no mention of verbal techniques in the “methods” section of the IEP. The goal was focused only on sign language as the key system of communication to be used with this child. The therapist supported her goal by saying that sign language is “always accessible” and pictures are not.

My colleague is not a speech therapist; however she and the speech therapist who currently work with this child have already been using a dynamic approach to language. They have presented her with a combination of sign language, picture communication and verbal stimulation. The verbal is always there reinforcing the signs and pictures. The child has responded to ALL three methods. She has a handful of signs and pictures that she uses both in therapy and with her family at home and she has recently started to imitate modeled speech, although her ability to initiate verbal communication is very limited. At the delicate age of 35 months however the team felt that they needed to give her every opportunity to communicate in any way she could.

At the meeting, my colleague voiced her concerns and recommended that pictures and verbal stimulation be added to the IEP. The therapist informed her that she did not believe in a “whole language approach” to communication, but reluctantly agreed to add picture communication because the family specifically requested it because their child has recently responded to positively to picture cues.

So now that I have presented the scenario, what do you think and how do you address communication goals for young children in EI with the autism diagnosis? I am looking forward to hearing your feedback and will be writing a follow-up post regarding this topic in the near future!


On September 29 th 2009 we published a post entitled: Autism and Early Intervention Speech Goals . The

October 16, 2009 9:53 AM

I think what many are forgetting are the pre requisites to language.  To begin signing the child should have some type of imitation skills such as when singing finger play songs.  I involve all of my children with multi model approach.  This should not be confused with Whole language as mentioned by the SLP at the school.  I have bee working with a toddler  2.6 since 12 months of age and have used my animated vocals for animals sounds for example, large signs with hand over hand assistance from the EI , parent or other int he room and always have abook  with large graphic pictures.  She has now began her first words, is pointing and trying to make some signs (dyspraxia has interfered with her ability to make sighs ans speech movements.  Also we should not forget that many of our children have processing difficulties an d info should be given slowly and in the beginning in the most simple forms.  Use it all and don't    ' t forget those pre requisites and don't get stuck on one train of thought!

Adelaide, SLP - SLP, clinical, EI October 10, 2009 12:53 PM
Las Vegas NM

Multimodal is a safe bet.  I always emphasize visual, however.  Pictures, a PECs format + functional gestures paired with verbal input are the preferred way to go.  Did you know that there is a ratio of 5 to 1 re visual to auditory neurons in the brain?  I am always amazed at how well my students respond to Carol Gray's social stories (with pictures), Power Cards or Dr. Pat Mirenda's contingency maps.

Just signing is so limiting.  Very few people know signs and if the student has fine motor issues, it becomes even more challenging.

Ellen, Speech Pathology - Speech-Language Pathologist IV, high school October 8, 2009 11:42 AM
Kailua HI

Take a look at Dr. Calculator's article on Enhanced Natural Gestures.  It is really something to think about with children who are preverbal, or essentially nonverbal.  We use gestures naturally, and to capitalize on those gestures is an approach that parents and teachers can do on a daily basis - without having to really "think" about - because they automatically recognize the gestures when the child uses them, and this leads to the parents and teachers buying into the therapy model Calculator suggests.

Buy-in gives you more hands on deck, and more support.

Plus, these gestures don't require anyone to really "learn" sign language.  The gestures are fairly recognizable to the average guy in Wal-Mart.

Worth the effort, and well worth it to use as another tool in the box.

And of course, pair them up with verbal, pics, and whatever else is working for the child!

A. R., SLP October 7, 2009 11:47 AM

Wonderful article,thanks for putting this together! "This is obviously one great post. Thanks for the valuable information and insights you have so provided here. Keep it up!"

Dana Weber October 5, 2009 5:01 AM
New York NC

Wonderful article,thanks for putting this together! "This is obviously one great post. Thanks for the valuable information and insights you have so provided here. Keep it up!"

<a href="">Speech Writing</a>

Jean Ette October 5, 2009 4:42 AM
New York NY

My experience with the  young ones and the  primary students, has been that a multi-modal approach works(visual,auditory,kinesthetic). No two autistic kids are exactly alike. Last year I used PROMPT in school on a first grader. It worked beautifully. However no one else wanted to learn so we used PECS and some standard signs as well.

Currently my graduate school classes promote a total language approach to communication.

Mary, EI and Elementary - Speech Specialist, School October 3, 2009 10:55 PM
Long Beach CA

As a practicing SLP in the field of autism for 34 years, it is my belief that using several systems simultaneously gives the child multiple cues and ways of responding. Using multiple cues and reinforcer is also advocated in the pivotal response approach.  

I have combined verbal, sign, pictures and melodic intonation therapy with students well into their teens and have seen increases verbalization. Sign should always be combined with verbal unless there is some really unique auditory processing problems. The following article addresses a review of the topic in a variety of studies and the pros and cons of the various systems. The jury is still out on whether there is 1 system preferable to another. Mirenda, P. (2003) Toward Functional Augmentative and Alternative Communication for Students with Autism: Manual signs, Graphic Symbols, and Voice Output Communication Aids. Language, Speech, and Hearing Services in Schools, 34, 203-216.

Anita Marcott, SLP/ASD October 3, 2009 1:48 PM
South Lyon MI

I believe you must try various combination communication approaches with children with autism.  I have found that using more than one approach (PECS, basic signs, ABA) usually helps increase communication in children with autism.  It's also important to make sure the child  hears the verbal name of the picture/sign.  

Paty October 3, 2009 12:25 PM

The picture component addresses the interaction part of communication. PECS is ideal for this; not just picture pointing & naming but the exchange component. It can establish requesting for some children. I give you this picture; I receive this object. Verbalization should accompany gesture, sign &/or pictures. Isn't verbal communication the goal?

Randi Finkelstein October 2, 2009 7:10 PM

Ah, YIKES! Can we talk about the spch path that said she did not believe in using pictures? Where did this girl go to school? Anybody in their right mind would know that using as much stimulation as possible is the way to go. The kid just turned 3 and there is no main "learning modality" that is firmly established. Why would you not use pictures?

And another thing, why would she say that she didn't or wouldn't use pictures as part of a therapy approach IN FRONT OF PARENTS AND ADMINISTRATORS? Why would she set herself up that way? OMG, someone from administration needs to talk to this therapist and tell her that there are certain things that you do NOT say in a staffing. This is one of them!

Bob Roza, Spch. Path - President, Integrative Spch. Inc. October 2, 2009 11:54 AM
Westchester IL

Tuesday's post discussed the various ways speech therapists can treat young children in early intervention

October 2, 2009 10:55 AM

I too found it hard to believe that anyone in this day and age would focus solely on sign language.  Certainly sign should be a component of a total communication approach, but I almost always use all three communication systems, as well as sometimes voice output devices (which expand the functionality of pictures).

The kids on the autism spectrum are so different, and I, for one, often can't predict by the age of 3 what they are going to be doing ultimately for communication.  To lock a child into only sign language, which most people in the wider environment won't understand, is a severe limitation indeed!  One of the basic tenet of AAC these days is that any AAC user needs a variety of communication systems, because none will always work.

I was at a presentation this weekend about AAC in the schools given by Stephen Calculater.  He was talking about the use of "enhanced gestures."  It's not a term I have run across before, but apparently uses natural gestures and makes them more salient so they can become an effective communication system.  It sounds like some of the baby sign systems that are being popularized.  Anyway, it seems to me that it might be a very good system for some kids with ASD.

David Harper, , SLP Home-based October 1, 2009 10:47 PM
Superior WI

I suggest using the term "total communication" for goals for any young child with a significant disability, since nobody can predict with certainty how a 3 year old will look a year from now. Clinically, TC may allow for non-verbal as well as verbal modes of communication, as well as AAC. It is the most functinal approach that will win out.

L P October 1, 2009 7:14 PM

Use all three.  Pictures have advantages over spoken words and sign language.  Spoken words and sign language is transient, once spoken or signed it is gone.  Children are able to use pictures expressively and receptively. pictures are not transient, they are static.  Children with ASD often have fine motor issues and would not be able to sign language expressivley.  

Diane Milewski, autism - slp October 1, 2009 5:56 PM
Haverhill MA

I would tend to agree with the above comments.  A child of this age who is beginning to speak shouldn't be limited to learning sign alone.  About the comment that pictures aren't accessable?  Even if an agency can't afford to purchase a program such as Boardmaker, SLP's these days can always turn to the internet and do a search for pictures they may be looking for.  I know there are sites out there specifically for SLP's if you do a search that post free pictures.  I would think that sign alone is more limiting since not many people this child would encounter in the school or community setting would be versed in sign.  This therapist may fear that pictures may limit verbal output, but haven't we all learned by now from the research that pictures promote verbalizations.  I agree with the above SLP's that a combination of sign, pics, and verbalizations be used

Nicole Rehrauer, , Speech-Language Pathologist Fair Park Elementary October 1, 2009 3:46 PM
West Bend WI

I have worked with many children on the spectrum diagnosed before the age of 3, and they have all been so different from one another. Yet,  I use pictures, signs, and verbal with all children at least at some point.  There are benefits to each- pictures paired with verbal allow a child to hear a word (build receptive vocab) as well as see a picture which does not move or go anywhere- it is "static" which allows the child increased time to PROCESS the word and picture together.  Its like teaching italian- the word is easier to learn if a picture goes with it each time you hear it.  Pictures also draw in a child's attention, and I hold a picture to my mouth while saying the word so a child can see the meaning, hear the word, and see how my mouth moves to create the word.  It draws a child's eye gaze to my face.  The benefit to signing is that can be done anywhere, and children may imitate a motor action- for some kids this was their first way of communicating even after years of PECS training!! I always pair verbal to allow them to learn the receptive meaning if for no other reason, but many will imitate sounds/words after some time in intervention if capable.  

jennifer October 1, 2009 3:36 PM

I couldn't believe what I was reading!  I worked with the autistic population for ten years in a collaborative therapy model approach and ALWAYS used a combination of all three modes to achieve optimum results (and that was BEFORE it became popular!).  I'm curious to know if the therapist who opposed the "whole language approach" was an "old school/pull-out approach" therapist.  I just can't imagine newer graduates being blind to the obvious benefits of approaching therapy in a multi-modal fashion.  The whole point in this particular situation was to help the child communicate effectively with a VARIETY of audiences, not just an audience who understands sign language!

Mary October 1, 2009 3:32 PM

I think it really depends on the child, although I initially start by trying all three and always use the verbal whether or not I learn towards signing or pictures.  There are benefits to both.  For example, the signing can help build a child's imitation skills and like speech a separate and specific motor movement represents a specific object (unlike picture exchange).  However, for a child with limited attention to others and motor planning difficulties (often present in kids on spectrum), pictures may be a more viable form of communication, at least initially.  Of course, it also depends on the family and their preference and how much time they are willing to spend on it.  Sign is tyipcally easier to incorporate while pictures takes time.  

Marni October 1, 2009 3:16 PM

Was there nothing on the IEP about using signs paired with verbalizations?  I believe it is negligent to concentrate on signs without verbalizations, especially since the child is already beginning to talk. Signs should be a means toward an end, not the end itself.  Studies have shown that signs paired with verbalizations will help increase verbalizations.  The early childhood years are the best time to work on talking,  and it's also the time to make the talking functional, so that the child does not become cue dependent.  

Regarding signs versus pictures, I believe both are good to use.  Not everyone the child encounters will know sign, but I don't think pictures encourage vocalizations as much.  It makes sense to concentrate on all three.

Rhonda Banford, Speech-Language Pathologist - Private Practice October 1, 2009 2:16 PM
Chesterfield MO

i just received training for the Early Start Denver Model at the MIND Institute.  It is an amazing program for children on the spectrum and would incorporate all three modes of communication but frame it in a "playful" setting with the child.  It not only focuses on receptive and expressive communication, but also on social skills, imitation, behavior,  cognition, etc.  I would highly recommend anyone who is working with a child 2-5 on the spectrum to look into the ESDM program by Sally Rogers.

kristi Howard September 30, 2009 7:36 PM
woodland CA

I use signs and verbalizations ALL the time with my 0-3 children.  I haven't used pictures, but that is only because I am just getting into the early intervention scene and have not had a chance to try them.  My kids respond so well to the combination of speech/signs.  I can't imagine only focusing on one, but I am sure every case is different and one should not assume that all 3 methods should be use with every child.

Katie September 30, 2009 10:00 AM

I use all three...both in 0-3 and 3-5 year olds....I love tamara kaspar and Nancy Kaufman's K &K Sign and Say cards...which pair signs and verbal...great conference, btw!

I think all of the options (sign, pics, and verbal) should be used especially for a child this age!

Lisa September 29, 2009 8:14 PM

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About this Blog

    Stephanie Bruno Dowling, M.S. CCC-SLP
    Occupation: Speech-Language Pathologist
    Setting: Early Intervention in Delaware County, PA
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