Prelinguistic communication complexity predicts expressive language in initial minimally verbal autistic children.

BACKGROUND: Prelinguistic communication complexity refers to the use of different communication forms such as eye gaze, gestures and vocalisations and the degree to which these forms are coordinated and how directed to a communication partner. To date, little is known about the relationship between prelinguistic communication complexity and expressive language in minimally verbal autistic children. AIMS: To test the hypothesis that prelinguistic communication complexity predicts expressive language 12 months later in autistic children and explore whether there are any differences in specific prelinguistic intentional communicative behaviours that are related to later expressive language levels. METHODS & PROCEDURES: This longitudinal study examined 37 minimally verbal autistic children (29-71 months old). The Communication Complexity Scale (CCS) was used to measure participants' prelinguistic communication behaviours, which were extracted from a semi-structured play interaction at Time 1. The Chinese Communicative Development Inventory (CCDI) was used to examine participants' expressive language at Time 1 and Time 2 (12 months later). According to Time 2 vocabulary size, participants were divided into two groups: Low CCDI, between 0 and 62 words, and High CCDI, more than 100 words. Linear regression was used to examine the relationship between early prelinguistic communication complexity and later expressive language. Binary logistic regression was used to determine which of the early communication behaviours were uniquely significantly related to later expressive language levels. OUTCOMES & RESULTS: There was a significant positive relationship between prelinguistic communication complexity and expressive language 12 months later, even after controlling for age and concurrent language. Findings revealed a group difference in the frequency of gesture and vocalisation combinations between the Low and High CCDI groups at Time 1. Gesture-vocalisation combinations also predicted better expressive language levels at Time 2. CONCLUSIONS & IMPLICATIONS: Our findings suggest that it may be beneficial to incorporate different complex communication behaviours into prelinguistic intervention targets for minimally verbal autistic children. The CCS hierarchies can be used as a reference for the intervention goals of minimally verbal autistic children. These findings highlight the importance of targeting gesture and vocalisation combinations when autistic children transition from single prelinguistic communication behaviours to multimodal behaviours. WHAT THIS PAPER ADDS: What is already known on this subject Children use eye gaze, gestures and vocalisations to communicate with others before they learn spoken language. There is strong evidence suggest that the frequency of prelinguistic communication predicts later linguistic achievements in autistic children. However, less is known about whether prelinguistic communication complexity also predicts later language and which specific behaviours are most predictive of language outcomes. What this study adds Minimally verbal autistic children who exhibit more complex prelinguistic communication behaviours have better expressive language 12 months later. Gestures combined with vocalisations predict better expressive language in minimally verbal autistic children. What are the clinical implications of this work? When identifying intervention targets for minimally verbal autistic children, the clinicians may reference the prelinguistic communication behaviours from the CCS. The gesture and vocalisation combinations are the key behaviours when targets transit from single form to two-form behaviours.

Phonemic Feature Scoring as a Tool for Progress Monitoring During Language Interventions for Children With Autism and Minimal Verbal Skills.

PURPOSE: An increasing number of studies focus on verbal treatments for children with autism and minimal verbal skills. However, clinical tools for progress monitoring during interventions are lacking. The aim of this clinical focus article is to provide illustrations on the utility of a phonemic feature scoring system as a progress-monitoring tool, focusing on benefits and limitations as well as indications for use. METHOD: Current practices for progress monitoring during language interventions with children with autism and minimal verbal skills are reviewed. A phonemic feature scoring tool is provided to aid clinicians in assessing the accuracy and consistency of expressive word productions. The authors illustrate the use of phonemic feature scoring as a progress-monitoring tool for two children with autism and minimal verbal skills, contrasting the phonemic feature scoring system to correct/incorrect, phoneme-level, and whole-word scoring. RESULTS: Case 1 demonstrates a scenario where the child's speech intelligibility is low and clinical use of the phonemic feature scoring system captures discrete changes in speech production progress not represented by correct/incorrect, phoneme-level, and whole-word scoring. However, Case 2 represents a situation where once a child's speech intelligibility improves, the phonemic feature scoring system is no longer needed, and correct/incorrect scoring may be sufficient. CONCLUSION: The phonemic feature scoring system allows clinicians to track phonemic feature changes in word productions and provides detailed progress monitoring information, leading to adaptations of the intervention for each individual.

A Chinese version of the communication complexity scale (CCS): psychometric evaluation in children with minimal verbal skills.

PURPOSE: This study aimed to evaluate the reliability and validity of the translated Chinese version of the Communication Complexity Scale (C-CCS) in a Chinese sample of preschool-aged children with minimal verbal skills. METHODS: A total of 120 children with autism spectrum disorders or children with developmental delays aged 2 to 5 years with minimal verbal skills (i.e., produced less than 20 functional words) were recruited to complete the C-CCS. First, we tested the protocol with 20 children and shortened it based on their results. Second, the interrater reliability, test-retest reliability, and concurrent validity for 100 participants were examined. C-CCS scores were compared with scores from the Chinese Communicative Development Inventories (CCDI) for concurrent validity. RESULTS: Ten C-CCS interactive scripts were administered to 100 participants. Intraclass correlation coefficients (ICC) between independent observers were high. The ICCs for overall optimal scores, optimal BR scores and optimal JA scores were 0.978, 0.971 and 0.977 respectively. Agreement for scores within scripted opportunities and communication level were high-Kappa coefficients 0.869 and 1.000 respectively. The test-retest reliability was high (r = 0.911). A moderate correlation was found between the C-CCS and the CCDI (r = 0.401). CONCLUSIONS: The results indicate that C-CCS could be used as a measurement tool in research and clinical practice to describe communication levels in children with minimal verbal skills in China.

The Chinese version of the Communication Complexity Scale was developed through a rigorous cultural adaptation process.The evidence shows that the Chinese version of the Communication Complexity Scale is a reliable and valid tool for children with minimal verbal skills in China.The Chinese version of the Communication Complexity Scale can be used in research and clinical practice to assess the general level of social communication skills of Chinese children who mainly communicate using preverbal communication and develop intervention programs.

The role of service providers' linguistic backgrounds on assessment of multilingual children.

INTRODUCTION: Cultural and linguistic competencies play a critical role in speech-language pathology services when working with people from diverse linguistic backgrounds with communication disorders (CD; Hopf et al., 2021). The personal experiences of speech-language pathologists (SLPs) influence their cultural and linguistic competence skills. Training programs that consider these personal factors might address the unique needs of the SLPs based on their experiences. The current research explores the connection between the linguistic backgrounds of the SLPs and the challenges and needs they reported while assessing multilingual children with CD. METHOD: This study uses a survey method for documenting and comparing 105 SLPs with varying linguistic backgrounds - monolingual, bilingual, and multilingual - on their reported challenges and needs associated with evaluating communication abilities in children from multilingual families with CD. RESULTS: Although all the SLPs worked with children from multilingual families, their linguistic backgrounds introduced differences in their clinical assessment opinions. Across all SLPs in the study, common challenges were the limited availability of interpreters, dedicated assessment materials, multilingual clinical supervisors, and pre-professional training opportunities. CONCLUSION: This study provides valuable information on the effects of linguistic backgrounds on the clinical opinions of SLPs and alludes to the importance of personal experiences on clinical practices. Future research that examines other personal factors and their effects on the SLPs' clinical opinions and practices will help the development of evidence-based cultural and linguistic competence training programs.

The Influence of Communication Sample Length on Reliability and Convergent Validity of Vocal Measures Derived From the Communication Complexity Scale.

PURPOSE: This study examines the effects of communication sample length on the reliability and convergent validity of six vocal measures for children with autism spectrum disorder (ASD) with minimal verbal skills. The results are expected to inform recommendations for the length of communication samples for clinical and research purposes. METHOD: Participants included 31 children with ASD (24 boys and seven girls; M age = 6;7 [years;months], SD = 17 months) with minimal verbal skills. We coded six vocal measures that focus on vocalizations and early word productions from the Communication Complexity Scale (CCS) scripted administration protocol. To evaluate reliability of different sample lengths, we calculated intraclass correlation coefficients between the full CCS sample and 1-, 3-, 7-, 10-, and 20-min samples. To examine convergent validity, we calculated correlations between the six vocal measures for each sample length. RESULTS: When coded from 10-min samples from the beginning of the CCS, all of the vocal measures exhibit adequate reliability with the full CCS sample. Some vocal measures exhibit adequate reliability with samples as short as 3 min. For convergent validity, all of the correlations between the vocal measures exceed .40 and are statistically significant for the 10-min samples except for some of the correlations with the proportion of communicative vocalizations. Similar results were found for other sample lengths. CONCLUSION: Findings support coding 10-min segments from the CCS scripted administration protocol to evaluate the vocal development skills of children with ASD with minimal verbal skills. SUPPLEMENTAL MATERIAL: https://doi.org/10.23641/asha.20999938.

Successes and Challenges in Treating Severe Communication Disorders.

This article summarizes research focusing on communication skills of people with intellectual and developmental disabilities (IDD) who communicate primarily without speech, sign language, or augmentative communication. Importantly, developmental theories were emphasized as useful for interpreting communication in children and adults. These studies led to research aimed at developing improved assessments and interventions for individuals with IDD, who may have a variety of diagnoses. Future research is needed to facilitate more widespread use of these tools by clinicians and researchers.

Alternative receptive language assessment modalities and stimuli for autistic children who are minimally verbal.

LAY ABSTRACT: It is difficult to measure language comprehension abilities in autistic children who have limited expressive language skills. Results from available assessments may underestimate autistic children's receptive language skills. The primary purpose of this study was to compare alternative modalities and stimuli used to measure receptive vocabulary skills in autistic children who are minimally verbal. This study compared participants' outcomes on three different receptive vocabulary assessment conditions: an assessment that used a low-tech stimulus book, a touchscreen assessment, and an assessment that used real-object stimuli. Twenty-seven students between the ages of 3 and 12 who had minimal verbal skills and a diagnosis of autism spectrum disorder participated in this study. Results showed that participants' scores in the real-object assessment condition were significantly higher than in the low-tech condition and marginally higher than scores in the touchscreen condition. These results suggest real-object stimuli may provide a more robust measure of autistic children's receptive vocabulary skills than traditional low-tech picture stimuli. Although many direct standardized assessments use picture stimuli to measure word understanding, when assessing autistic individuals who have limited expressive language, real objects can be used in replacement of, or in addition to, picture stimuli.

Narrative Analysis in Adolescents With Fragile X Syndrome.

This study analyzed narratives of male and female adolescents with fragile X syndrome (FXS). The impact of structural language, cognition and autism symptomatology on narrative skills and the association between narratives and literacy were examined. Narratives from 32 adolescents with FXS (24 males, 8 females) were analyzed for macrostructure. Relationships between narrative macrostructure, language scores, cognitive scores, Childhood Autism Rating Scale-Second Edition scores and literacy skills were examined. Males produced more simplistic narratives, whereas the females' narratives were more complex. Language scores predicted narrative scores above and beyond nonverbal cognitive skills and autism symptomatology. Narrative scores correlated with literacy scores. Narrative skills in FXS are predicted by language skills and are correlated with literacy skills. Investigation into narrative interventions in FXS is needed.

Effectiveness of Responsivity Intervention Strategies on Prelinguistic and Language Outcomes for Children with Autism Spectrum Disorder: A Systematic Review and Meta-Analysis of Group and Single Case Studies.

We conducted a systematic review to identify randomized controlled trials (RCTs) and single case research design (SCRD) studies of children with autism spectrum disorder that evaluate the effectiveness of responsivity intervention techniques for improving prelinguistic and/or language outcomes. Mean effect sizes were moderate and large for RCTs (33 studies; g = 0.36, 95% CI [0.21, 0.51]) and SCRD (34 studies; between-case standardized mean difference = 1.20, 95% CI [0.87, 1.54]) studies, respectively. Visual analysis (37 studies) revealed strong evidence of a functional relation for 45% of the opportunities and no evidence for 53%. Analyses of moderator effects and study quality are presented. Findings provide support for responsivity intervention strategies with more robust support for context-bound outcomes than more generalized outcomes.

Predicting progress in word learning for children with autism and minimal verbal skills.

BACKGROUND: Approximately 30% of children diagnosed with autism remain minimally verbal past age 5. Interventions are often effective in increasing spoken communication for some of these children. Clinical and research decisions would be facilitated by identifying early indicators of progress in interventions. The purpose of this study was to investigate the relationship between speech sound measures obtained from the early phases of treatment and later treatment outcomes in children with autism and minimal verbal skills. METHODS: Twenty-three children (18 boys) between 5 and 9 years of age participated. We compared scores reflecting the phonemic features of word attempts produced during probes, and the number of correct words after 4 weeks of intervention to later word learning outcomes. RESULTS: Correlational and hierarchical regression analyses showed that both predictors were positively correlated with outcomes, but the phonemic scores were more strongly related than number of correct words. CONCLUSION: We conclude that phonemic scoring may be a useful measure to determine proximal gains in a spoken word learning intervention. Proximal measures are particularly helpful when trying to decide if the current course of intervention should be maintained or altered. TRIAL REGISTRATION: https://register.clinicaltrials.gov/prs/app/action/LoginUser?ts=2&cx=-jg9qo3 .

Rethinking Measurement Standards of Autism Symptomology in Adolescents with Fragile X Syndrome.

Accurate representation of autism spectrum disorder (ASD) in fragile X syndrome (FXS) is necessary for the field. We examined classifications of ASD using three approaches-Autism Diagnostic Observation Schedule (ADOS-2; Lord et al. 2012), Childhood Autism Rating Scale (CARS2-ST; Schopler et al. 2010), and Vineland Adaptive Behavior Scales (VABS-II; Sparrow et al. 2005)-in 45 adolescents with FXS. Maladaptive items from the VABS-II plus a maternal interview were matched with Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5; American Psychiatric Association 2013) criteria for ASD. Results indicated discrepant classifications. The ADOS-2 yielded the highest rate of comorbid autism (71%); CARS2-ST and VABS-II/DSM-5 yielded lower rates (38% and 42%, respectively). A singular measure of autism symptomology is insufficient to characterize autism in FXS.

Measuring Change in the Communication Skills of Children With Austim Spectrum Disorder Using the Communication Complexity Scale.

Changes in minimal verbal communication by children with autism spectrum disorder (ASD) were measured with the Communication Complexity Scale (CCS) and other communication assessments. The CCS measures complexity of preverbal and beginning verbal communication used to communicate behavior regulation and joint attention. The purpose was to investigate if the CCS was responsive to changes associated with a behavioral intervention aimed at improving communication skills. Changes were detected with CCS scores, rates of initiating joint attention, and the Mullen Scales of Early Learning (MSEL) Expressive Language subscale. Significant changes in CCS scores were also detected for a subgroup of participants who did not show significant changes on the MSEL Expressive Language subscale, demonstrating that CCS scores are sensitive to changes associated with a behavioral intervention.

Language Development From Early Childhood to Adolescence in Youths With Fragile X Syndrome.

Purpose The aim of this study was to investigate language growth in individuals with fragile X syndrome (FXS) from early childhood to adolescence and the influence of maternal responsivity on language growth. Method We conducted a longitudinal analysis of language development in 55 youths (44 males, 11 females) with FXS. Data collection spanned the ages of 11-216 months. We measured expressive and receptive vocabulary with standardized tests. The number of different words and mean length of utterance were obtained from language sample analyses of mother-child interactions. We also measured maternal comments (responsivity indicator) produced during the language samples and child nonverbal IQ. Results Growth models indicated that rates of number of different words and receptive vocabulary were related to maternal commenting. Mean length of utterance did not change significantly over time. Expressive vocabulary measured with a standardized test grew, but the growth was not related to maternal commenting. Nonverbal IQ was related to all language outcomes at age of 10 years and to changes over time in vocabulary. Visual analysis indicated that the highest scores on standardized tests were produced by girls; however, measures derived from language sample analyses appeared similar for boys and girls. Language models for boys only were similar to the total sample models with lower scores at age of 10 years for some outcomes. Conclusion Results of persistent language impairments for most youths with FXS suggest the need for continued, focused interventions aimed at improved language productions in addition to a responsive environment. Supplemental Material https://doi.org/10.23641/asha.13022825.

Communication Assessment for Individuals With Minimal Verbal Skills: A Survey of Current Practices and Satisfaction.

Purpose There are few tools developed specifically to assess communication in people with minimal verbal skills. The literature suggests that "gold standard" assessment practice includes a combination of three components: observation, direct assessment, and indirect assessment. The purpose of this study was to describe the assessment methods practitioners and researchers currently use to measure communication skills in individuals with minimal verbal skills. We also wanted to gain information about professionals' satisfaction with their current assessment methods, as well as the factors they consider when selecting assessments for this population. Method A 24-question survey, composed of forced-choice, multiple-choice, Likert-type, and open-ended questions, was disseminated online using LimeSurvey. A total of 217 individuals responded to the survey. Results from the questionnaire were analyzed using qualitative and quantitative methods. Results The number and type of assessments used varied. Observation was the assessment method identified most frequently. Nineteen percent of the respondents reported using the gold standard approach (i.e., observation + direct + indirect). Many respondents were dissatisfied with some or many aspects of their current assessment method. Respondents who used the gold standard approach reported that their assessment method assisted in setting goals significantly better than those who did not use this approach. Comprehensiveness of skills assessed as well as ease and comfort level of the examinee were key factors in assessment selection. Conclusions Results from this survey suggest the need to continue to promote using multiple forms of assessment for individuals with minimal verbal skills. In addition, it points to the need to develop additional effective assessment methods for individuals with minimal verbal skills.

Developmental Trajectory of Communication Repair in Children with Fragile X Syndrome.

BACKGROUND & AIMS: The development of communicative competence requires both language and social skills. The ability to repair following a communication breakdown is critical for continued conversational interchange and to ensure comprehension of bids for communication. Repair demonstrates adequate language and social skills. Children with Fragile X Syndrome (FXS) have difficulty with language development and social skills, which may result in delays or deficits in repair. Repair may be additionally impaired in children with FXS and co-morbid autism. This study examined the development of repair in children with FXS from toddlerhood into middle childhood. METHODS: Fifty-five children with FXS and their biological mothers participated. Data were collected during in-home visits approximately every 18 months. Videotaped mother-child interactions were collected, as well as standardized assessments of language, social skills, and autism symptomology. RESULTS: Children with FXS acquired the ability to repair at 90% mastery by three-and-a-half years of age. Multilevel logistic regressions predicting probability of repair indicated marginally significant effects of mean length of utterance and number of different words, and significant effects of global social skills and autism symptomology. Effect sizes were small to moderate. CONCLUSIONS: Ability to repair was measured in a naturalistic setting, which allowed children with FXS to utilize repairs in their daily interactions. Although children with FXS may have delayed development of repair relative to typically developing expectations, in general they nonetheless catch up and demonstrate a robust ability to repair by three-and-a-half years of age. However, this study provides evidence that individual differences in language and social skills may influence ability to repair in children with FXS. Finally, the relationship between autism symptoms and repair remains unclear, necessitating further exploration. IMPLICATIONS: Given the noted delay in repair in young children with FXS, clinicians working with this population should target development of this skill as early as possible to maximize successful social interactions. This may be particularly necessary for children with FXS and co-morbid autism.

Preverbal Communication Complexity in Infants.

The development of prelinguistic communication in typically developing infants is marked by changes in complexity as well as frequency, yet most measures focus on frequency. In the current study we used the Communication Complexity Scale (CCS) to measure prelinguistic complexity of typically developing infants in a cross-sectional sample of 6-, 8-, 10- and 12-month-olds (N = 204) during semi-structured play interaction. For each toy/interactive episode, infants' highest level of communication complexity (ranging from 0 for no response to 12 for multi-word verbalization), for both joint attention (i.e., social) and behavior regulation (e.g., requesting) functions, was scored. In addition, the same interaction was coded for frequency of all prelinguistic communication acts. Results of multivariate models indicated age-related differences in prelinguistic complexity. Measures of prelinguistic complexity and frequency evidenced moderate to strong correlations, with age-related differences by function (joint attention and behavior regulation). Significant associations with parent-report communication questionnaires were observed for both complexity and frequency measures. Results indicate that evaluating complexity of infant preverbal communication skill with the CCS is a valuable approach that can meaningfully index developmental differences in prelinguistic and early linguistic communication.

Child Challenging Behavior Influences Maternal Mental Health and Relationship Quality Over Time in Fragile X Syndrome.

Parenting children with neurodevelopmental disabilities is often challenging. Biological mothers of children with Fragile X Syndrome (FXS) may be susceptible to increased risk of mental health problems. This study examined the longitudinal relationships between maternal mental health, child challenging behaviors, and mother-child relationship quality in children and adolescents with FXS. Fifty-five mother-child dyads were followed from childhood into adolescence. The findings suggest that child challenging behaviors, maternal mental health, and mother-child relationship quality were stable during that period. Additionally, elevated levels of child challenging behaviors negatively impacted maternal mental health. Finally, child challenging behaviors, in combination with maternal mental health, influenced mother-child relationship quality. Clinical implications are discussed.

Task and Participant Variables Predict Communication Complexity Scale (CCS) Scores: Closer Examination of the CCS.

Communication Complexity Scale (CCS) scores for 269 minimally verbal participants were examined to determine if communicator behavior and task and communicator characteristics were related to scores in a manner consistent with theoretical and research evidence expectations. Each participant completed an interactive assessment with 6 joint attention tasks and 6 behavior regulation tasks. Caregivers completed the Vineland Adaptive Behavior Scales II. Results indicated (a) joint attention tasks yielded lower scores than behavior regulation tasks, (b) older participants had lower scores, (c) individuals with autism spectrum disorder scored more similarly than those without, (d) the difference between joint attention and behavior regulation scores was greater for the autism spectrum disorder group, and (e) adaptive behavior was significantly positively related to complexity scores.

Communicative Use of Triadic Eye Gaze in Children With Down Syndrome, Autism Spectrum Disorder, and Other Intellectual and Developmental Disabilities.

Purpose This study examines differences in the communicative use of triadic eye gaze (TEG) during a communicative interaction in 2 neurodevelopmental disorders: Down syndrome (DS) and autism spectrum disorders (ASD), and a 3rd group of varying disabilities associated with intellectual and developmental disabilities (IDDs). Also, the relationship between TEG use and language abilities was explored. Method Participants were 45 children, 15 in each group. The frequency of TEG was coded during a scripted communication assessment when children were between 3 and 6 years of age (37-73 months). Receptive and expressive language was measured using raw scores from the Mullen Scales of Early Learning concurrently between 3 and 6 years and again 2 years later when children were between 5 and 8 years (59-92 months). Results Descriptively, children with DS had a higher frequency of TEG than children with ASD and IDD, but significant differences were only observed between children with DS and ASD. More TEG at Time 1 in children with DS was associated with higher receptive language at Time 1 and higher expressive language at Time 2. For children with ASD, a trend for a positive association between TEG at Time 1 and language abilities at Time 2 was observed. No significant associations were observed for children with IDD. Conclusion Children with DS used TEG significantly more than children with ASD in this sample. Identifying strengths and weaknesses in TEG use is important because providing caregiver training to facilitate TEG can result in increased opportunities to respond with language models and promote language development.

Similarities in Functional Play and Differences in Symbolic Play of Children With Autism Spectrum Disorder.

Contradictory reports of play strengths and weaknesses for children with autism spectrum disorders (ASD) persist in the literature. We compared the play of 19 children with ASD to 19 typically developing (TD) children matched on language and cognitive skills. All children were verbal. Results revealed no differences in indiscriminate actions, functional play, and object interest. The children with ASD showed less symbolic play and a significantly fewer number of children met criteria for emerging or mastered symbolic play. A specific deficit was observed for "doll as agent" symbolic play. Outcomes suggest that compared to children without disabilities, children with ASD may have comparable functional play skills and struggle with the transition to some, but not all types of symbolic play.