Severe Communication Impairments Research Articles

A cluster analysis exploration of autism spectrum disorder subgroups in children without intellectual disability

BackgroundThe heterogeneity in autism spectrum disorder (ASD) remains poorly understood, particularly in individuals without intellectual disability (ID), where phenotypic variability can be most pronounced. The presence of phenotypic subgroups continues to be questioned. This study investigated whether children with ASD without ID are differentiable into clinically meaningful subgroups. MethodData from the ‘gold standard’ ASD diagnostic instruments for 61 children (5–14 years) with ASD without ID were subjected to exploratory cluster analysis. Cognition, language, pragmatic communication, and behaviour were used to explore subgroups. ResultsChildren with ASD without ID could be differentiated into Moderate and Severe Social Impairment subgroups when core ASD symptoms were more closely examined. The Moderate Social Impairment subgroup showed less severe social interaction and communication impairments but greater lifetime severity of restricted/repetitive behaviours. In contrast, the Severe Social Impairment subgroup, with poorer social interaction and communication skills, had lower lifetime severity of restricted/repetitive behaviours. This subgroup also had greater cognitive and language difficulties, and poorer adaptive functioning. Importantly, however, these neurocognitive and functional differences showed only small to moderate associations with the differentiated ASD clinical profiles. ConclusionsEvidence of dissociated levels of severity across core ASD dimensions supports the idea that clinically meaningful subgroups within ASD without ID can be identified. The dissociated profiles of ASD features could represent different underlying neurobiological mechanisms for each subgroup. Identifying such subgroups in practice can improve the clinical utility of diagnostic labels in this population. Thus, both categorical and dimensional approaches may be useful in classifying ASD, with neither alone being adequate.

Transforming engagement: a case study of building intrinsic motivation in a child with autism

This longitudinal case study of a 10-year-old girl with autism and severe communication impairment measures the impact of the MORE (Means, Opportunities, Reasons and Expectations) approach to enhancing engagement and communication. Through detailed observation of video data over a period of 28 months, engagement behaviours including interaction with adults and following adult directions increased, while resistant behaviours such as kicking, hitting and pushing adults away decreased. Fluctuation between different ‘states’ demonstrated that the frequency and duration of engagement was influenced by the MORE approach and an emphasis on developing intrinsic motivation. In order to enable further efficacy research, core features of the intervention and the changes in engagement over time are described.

Macroglossia in advanced amyotrophic lateral sclerosis.

An enlarged tongue (macroglossia) has been reported in advanced-stage patients with amyotrophic lateral sclerosis (ALS). In this study we examined the prevalence of macroglossia and analyzed clinical correlations in 65 ALS patients on tracheostomy-invasive ventilation (TIV). Macroglossia was found in 22 patients (33.8%). Compared with those without macroglossia, patients with macroglossia had a younger age of onset, longer duration of disease and TIV use, lower ALS Functional Rating Scale score, higher body mass index, lower energy intake, more severe communication impairment, and lower oral function. Logistic multivariate analysis showed that body mass index (BMI; P = 0.007) and communication impairment (P = 0.029) were significantly correlated with macroglossia. The duration of TIV use was at the cut-off level of significance (P = 0.05). Macroglossia may be the result of overfeeding and replacement by fat during long-term TIV use in patients with advanced ALS. Muscle Nerve, 2016 Muscle Nerve 54: 386-390, 2016.

One's Voice: A Central Component of Personal Factors in Augmentative and Alternative Communication

Augmentative and alternative communication (AAC) devices have opened the gates to interaction for those with severe communication impairments. In the assessment and intervention, all components of the World Health Organization's International Classification of Functioning, Disability, and Health (ICF) should be addressed. However, an important Personal Factor to full integration has been largely ignored—that of one's voice. Each one of us has a unique voice that conveys our age, cultural background and personality—it's how people know and remember you. These affordances of the natural voice are not available to those who express themselves using AAC devices. A personalized digital voice brings the field of AAC to a closer realization of the social model of disability in which individuals are not defined by their disability and it is just one aspect of them. Access to a personalized voice uplifts the AAC user and provides an opportunity for social and emotional engagement that enhances quality of life.

Theatre and Therapy Project: An Interprofessional Exploratory Pilot Study

The Theatre and Therapy Project was an interprofessional exploratory pilot study designed to examine the efficacy of theatre as a therapeutic intervention context for adolescents and young adults with intellectual disabilities and autism, all of whom had moderate to severe communication impairments. Undergraduate and graduate students from Departments of Communication Sciences and Disorders and Theatre and Dance were recruited, as well as eight client participants ranging in age from late teens to mid-twenties. The study used a pretest–posttest design using specific subtests related to communication, self-direction, and social domains from the ABAS-3 Adaptive Behavior Assessment System, Third Edition were administered, as well as a survey measuring the self-confidence of client participants. Activity-based intervention and video modeling were used to teach targeted speech, language, and social goals. This article describes implementation of this innovative program aimed at improving the communication and self-confidence of client participants. The perspectives of those who were involved in the Project are shared: a parent of a young adult with a developmental disability; students who were involved with providing intervention and collecting data; faculty members and practitioners from the Department of Communication Sciences and Disorders who supervised the speech-language pathology students; and a faculty member and practitioner from the Department of Theatre and Dance who supervised and worked with the theatre students. And finally, the challenges encountered and perceived benefits of this innovative therapeutic program are discussed.

Introduction to the Special Issue: Teaching AAC Use to Individuals with Developmental and Physical Disabilities

Individuals with developmental and physical disabilities also often have severe communication impairment or complex communication needs (Beukelman and Mirenda 2013). The term severe communication impairment refers to situations where the person’s speech is so limited or unintelligible that it is unable to meet his or her everyday communication needs. Lack of sufficient, intelligible speech is prevalent among individuals with developmental and physical disabilities. McQueen et al. (1987), for example, found that approximately 65 % of children with significant intellectual disability had limited or no intelligible speech. Among children with autism spectrum disorder, Tager-Flusberg and Kasari (2013) noted that about 30 % are likely to Bremain with little expressive spoken language ability by the time they reach school age.^ (p. 468). The high prevalence of severe communication impairment among individuals with developmental and physical disabilities makes communication intervention a major habilitation priority for this population. AAC intervention requires identifying suitable non-speech communication modalities, as well as teaching the person to use non-speech modes for effective communication. To this end, AAC research is often focused on developing new and more effective intervention approaches. This special issue of the Journal of Developmental and Physical Disabilities was commissioned to attract papers that focused on developing new and more effective intervention approaches for individuals with developmental and physical disabilities and severe communication impairment. The goal of this special issue is to provide a forum for researchers using a broad range of AAC systems and intervention approaches to share the results of their recent efforts, be they empirical or conceptual. A secondary J Dev Phys Disabil (2016) 28:1–4 DOI 10.1007/s10882-015-9469-6

The Personally Controlled Electronic Health Record (PCEHR) for Adults with Severe Communication Impairments: Findings of Pilot Research.

To date, there is little information in the literature to guide the provision of supports for using the Personally Controlled Electronic Health Record (PCEHR) in populations with severe communication impairments associated with a range of disabilities. In this paper we will (a) outline the rationale for use of PCEHR in these populations by providing an overview of relevant research to date, and (b) present results of three integrated pilot studies aiming to investigate the barriers to and facilitators for PCEHR use by people with severe communication impairments and their service providers. Finally, we will present directions for future research on use of PCEHR by people with severe communication impairments.

Predictors of impaired communication in amyotrophic lateral sclerosis patients with tracheostomy-invasive ventilation

Predictors of communication impairment in patients with amyotrophic lateral sclerosis (ALS) using tracheostomy-invasive ventilation (TIV) were investigated. Seventy-six ALS patients using TIV were enrolled and classified into three subgroups of communication ability: patients who could communicate with communication devices (Stage I), patients who had difficulty with communication (Stage II, III, or IV), and patients who could not communicate by any means (Stage V). Predictors of communication impairment were analysed by the Cox proportional hazard model.Results demonstrated that there were no significant differences in disease duration between subgroups. Within 24 months after disease onset, patients who needed TIV and tube feeding, developed oculomotor impairment or became totally quadriplegic and progressed from Stage I to II and V significantly earlier. Multivariate analyses revealed that within 24 months from onset, the need for TIV and progression to total quadriplegia were significant events in patients who progressed to Stage II, whereas the development of oculomotor limitation was significant in patients who progressed to Stage V. In conclusion, TIV, impaired oculomotor movement and total quadriplegia are predictors of severe communication impairment. Rapid disease progression might indicate future communication impairment after the use of TIV. We highly recommend early detection of impaired communication and identification of the best methods of communication.

Communication Intervention to Teach Requesting Through Aided AAC for Two Learners With Rett Syndrome.

Evidence on effective communication interventions for persons with Rett syndrome is needed to drive the standard of care with this population. This study examined the effectiveness of an intervention package to teach multiple, aided communication requests for two persons with Rett syndrome (ages 27 and 7) through within participant, adapted multiple baseline designs across items/activities. Participants were taught graphic mode requests on speech generating devices, with access methods based on motor ability; one participant responded by pressing a touch screen, and one participant responded by fixed eye-gaze. Results are discussed in relation to the effectiveness of the intervention packages on increasing the accuracy of independent request selection responses emitted and the number of sessions required to reach an a priori performance criterion for both participants. Difficulties during initial prompting and during prompt fading with the eye-gaze response are considered. The findings suggest implications related to emerging evidence on the intervention methods to teach requesting skills to this population, and future research directions for communication intervention options for persons with severe communication impairment and limited motor repertoires.

Supporting Nick to Make Decisions: An Exploration of Ways to Promote Choice and Control

This article focuses on both the importance and challenges of decision-making for people with intellectual disabilities, using the example of one young man, Nick, as the context for discussion of these issues. Nick is a young man with significant physical and intellectual disability. He has a severe communication impairment and uses a range of Alternative and Augmentative Communication (AAC) strategies to express himself. The article is written by Nick's mother and uses examples from family life to explore the daily tensions in, and opportunities for, choice making.Communication is at the core of decision-making, and examples of enablers and barriers to successful communication are given. Nick's cognitive abilities impact on the complexity of decisions he can make, the circumstances in which he can make those decisions, and which decisions are relevant and appropriate for him. Supporting Nick in decision making therefore requires an intimate understanding of his personality, his strengths and weaknesses, and what is important to him in his life.Strategies to support Nick to optimise his success in communication and decision-making are given. Emphasis is placed on the importance of providing opportunities for learning through practice to continue to build capacity for decision-making throughout life.

An iPad-Based Intervention for Teaching Picture and Word Matching to a Student with ASD and Severe Communication Impairment

iPads® have been successfully used as speech-generating devices (SGD) for children with ASD and limited speech, but little research has investigated the use of iPads to enhance academic skills, such as picture/word matching. In the present study, a student with ASD received intervention to teach picture and word matching using an iPad-based SGD as the response mode. A multiple baseline across matching tasks design was used to evaluate the effects of a graduated guidance prompting procedure and differential reinforcement on correct matching across four matching tasks (i.e., picture to picture, word to picture, picture to word, and word to word). With intervention, the student showed increased correct matching across all four combinations, suggesting that picture and word matching with an iPad-based SGD can be successfully taught using graduated guidance and differential reinforcement. This approach might have relevance for teaching a range of academic/literacy skills to students with ASD who present with limited or no speech.

An evaluation of speech production in two boys with neurodevelopmental disorders who received communication intervention with a speech-generating device

BackgroundChildren with neurodevelopmental disorders often present with little or no speech. Augmentative and alternative communication (AAC) aims to promote functional communication using non-speech modes, but it might also influence natural speech production. MethodTo investigate this possibility, we provided AAC intervention to two boys with neurodevelopmental disorders and severe communication impairment. Intervention focused on teaching the boys to use a tablet computer-based speech-generating device (SGD) to request preferred stimuli. During SGD intervention, both boys began to utter relevant single words. In an effort to induce more speech, and investigate the relation between SGD availability and natural speech production, the SGD was removed during some requesting opportunities. ResultsWith intervention, both participants learned to use the SGD to request preferred stimuli. After learning to use the SGD, both participants began to respond more frequently with natural speech when the SGD was removed. ConclusionThe results suggest that a rehabilitation program involving initial SGD intervention, followed by subsequent withdrawal of the SGD, might increase the frequency of natural speech production in some children with neurodevelopmental disorders. This effect could be an example of response generalization.

Three children with autism spectrum disorder learn to perform a three-step communication sequence using an iPad®-based speech-generating device

BackgroundMany children with autism spectrum disorder (ASD) have limited or absent speech and might therefore benefit from learning to use a speech-generating device (SGD). The purpose of this study was to evaluate a procedure aimed at teaching three children with ASD to use an iPad®-based SGD to make a general request for access to toys, then make a specific request for one of two toys, and then communicate a thank-you response after receiving the requested toy. MethodA multiple-baseline across participants design was used to determine whether systematic instruction involving least-to-most-prompting, time delay, error correction, and reinforcement was effective in teaching the three children to engage in this requesting and social communication sequence. Generalization and follow-up probes were conducted for two of the three participants. ResultsWith intervention, all three children showed improvement in performing the communication sequence. This improvement was maintained with an unfamiliar communication partner and during the follow-up sessions. ConclusionWith systematic instruction, children with ASD and severe communication impairment can learn to use an iPad-based SGD to complete multi-step communication sequences that involve requesting and social communication functions.

Autistic adolescents show atypical activation of the brain′s mentalizing system even without a prior history of mentalizing problems

Some autistic children pass classic Theory of Mind (ToM) tasks that others fail, but the significance of this finding is at present unclear. We identified two such groups of primary school age (labelled ToM+ and ToM−) and a matched comparison group of typically developing children (TD). Five years later we tested these participants again on a ToM test battery appropriate for adolescents and conducted an fMRI study with a story based ToM task. We also assessed autistic core symptoms at these two time points. At both times the ToM− group showed more severe social communication impairments than the ToM+ group, and while showing an improvement in mentalizing performance, they continued to show a significant impairment compared to the NT group. Two independent ROI analyses of the BOLD signal showed activation of the mentalizing network including medial prefrontal cortex, posterior cingulate and lateral temporal cortices. Strikingly, both ToM+ and ToM− groups showed very similar patterns of heightened activation in comparison with the NT group. No differences in other brain regions were apparent. Thus, autistic adolescents who do not have a history of mentalizing problems according to our ToM battery showed the same atypical neurophysiological response during mentalizing as children who did have such a history. This finding indicates that heterogeneity at the behavioural level may nevertheless map onto a similar phenotype at the neuro-cognitive level.

Classification of silent speech using support vector machine and relevance vector machine

To provide speech prostheses for individuals with severe communication impairments, we investigated a classification method for brain computer interfaces (BCIs) using silent speech. Event-related potentials (ERPs) were recorded using scalp electrodes when five subjects imagined the vocalization of Japanese vowels, /a/, /i/, /u/, /e/, and /o/ in order and in random order, while the subjects remained silent and immobilized.For actualization, we tried to apply relevance vector machine (RVM) and RVM with Gaussian kernel (RVM-G) instead of support vector machine with Gaussian kernel (SVM-G) to reduce the calculation cost in the use of 19 channels, common special patterns (CSPs) filtering, and adaptive collection (AC). Results show that using RVM-G instead of SVM-G reduced the ratio of the number of efficient vectors to the number of training data from 97% to 55%. At this time, the averaged classification accuracies (CAs) using SVM-G and RVM-G were, respectively, 77% and 79%, showing no degradation. However, the calculation cost was more than that using SVM-G because RVM-G necessitates high calculation costs for optimization. Furthermore, results show that CAs using RVM-G were weaker than SVM-G when the training data were few. Additionally, results showed that nonlinear classification was necessary for silent speech classification.This paper serves as a beginning of feasibility study for speech prostheses using an imagined voice. Although classification for silent speech presents great potential, many feasibility problems remain.

Parent-reported Pain in Rett Syndrome

Clinical reports suggest that patients with Rett syndrome (RTT) live with significant chronic health issues as well as severe motor and communication impairments. Consequently, patients with RTT may be at risk for living with pain but not having it recognized. The purpose of this preliminary study was to document parent reported estimates of pain frequency, pain communication, and pain source. Caregivers of 44 patients with clinically diagnosed RTT (mean RTT age = 21.5, SD = 13.5) completed a health survey about their daughter that contained a number of items specific to pain from the Non-Communicating Children's Pain Checklist - Revised Among survey responders, 24% reported that their child had experienced pain on 8 or more days (> 1 week) in the previous 30 days. The most frequent form of pain communication was facial expression (85%) and vocalization (82%, eg, moan, cry). The most commonly reported pain source was gastro-intestinal (66%). Pain frequency was significantly (P<0.05) correlated with age (0.41), number of pain sources (0.72), and number of health problems (0.45); and the number pain sources was significantly (P<0.05) correlated with number of health problems (0.67). These preliminary results suggest that pain is a problem for a significant subgroup of patients with RTT. Almost one quarter of respondents indicated their daughters experience over a week of pain per month. The frequent health and communication issues associated with RTT suggest an increased risk that pain may be overlooked or discounted in this vulnerable population.

Assistive technology for promoting choice behaviors in three children with cerebral palsy and severe communication impairments

A technology-based program to promote independent choice behaviors by three children with cerebral palsy and multiple disabilities was assessed. The program was based on learning principles and assistive technology (i.e., customized input devices/sensors, personal computers, screening of preferred stimuli according to a binomial criterion). The first purpose of the present study was to provide the participants with a new set-up of assistive technology and to allow them to choose among three categories (i.e., food, beverage and leisure), and to request a specific item out of four in each category, adopting a procedure that minimized (according to a conditional probability criterion) unintentional choices. The second aim of the study was to carry out the effects of the program on detectable mood signs (i.e., happiness index). The study was conducted according to an ABAB sequence with a subsequent post intervention check for each participant. The results showed an increase of engagement and of the happiness index during intervention phases. Psychological as well as educational implications were discussed.

Accommodating to motor difficulties and communication impairments in people with autism: the MORE intervention model.

Motor impairment in individuals with autism potentially impacts on their development in all spheres. This paper is particularly concerned with people with severe communication impairments suggesting that recognition of the impact of motor impairments on their lives could lead to more effective interventions being developed. One such intervention is the MORE (Means, Opportunities, Reasons, and Expectations) model, founded on the “least dangerous assumption,” that is assuming competence until otherwise established through long-term observation and assessment. Components of the model include recognizing the importance of having high expectations and linking this to the way people are spoken to; timing within an intervention and over long periods; the importance of eye-hand coordination and teaching independent pointing skills. It is suggested that literacy should be offered as an early step which could significantly enhance communication.

How facial expressions in a Rett syndrome population are recognised and interpreted by those around them as conveying emotions

Rett syndrome (RTT) is a neurodevelopmental disorder, including autonomic nervous system dysfunctions and severe communication impairment with an extremely limited ability to use verbal language. These individuals are therefore dependent on the capacity of caregivers to observe and interpret communicative signals, including emotional expressions. People in general, including therapists tend to focus on changes in facial expressions to interpret a person's emotional state or choices, but with this population it is difficult to know if the interpretations are correct. The aims of this study were to investigate if the Facial Action Coding System (FACS) could be used to identify facial expressions, and differentiate between those that expressed emotions and those that were elicited by abnormal brainstem activation in RTT. The sample comprised 29 participants with RTT and 11 children with a normal developmental pattern, exposed to six different musical stimuli during non-invasive registration of autonomic brainstem functions. The results indicate that FACS makes it possible both to identify facial expressions and to differentiate between those that stem from emotions and those caused by abnormal brainstem activation. This knowledge may be a great help to an uninitiated observer, who otherwise might incorrectly interpret the latter as an expression of emotion.

Coaching Communication Partners

Rett syndrome (RTT) occurs primarily in females and is characterized by deficits in cognition, communication, hand use and ambulation. This quasi-experimental study explored the use of a coaching program to increase communicative interactions between girls with RTT and their communication partners. Communication coaching strategies were provided to adults who worked with four girls with RTT during mealtime in their classrooms. Data analysis revealed that the number of bids for communication increased over time for all girls with RTT. Feeders waited longer for girls to respond, used fewer conversational fillers and responded to the girls’ behaviors as if they were intentional. These observations suggest communication coaching may be a valuable tool clinicians can use to enrich communicative interactions in the classroom for these individuals with severe communication impairments. Limitations and suggestions for further research are discussed.