PreverbalGuest author: Jo Ristow, MS, CF-SLP is a speech language pathologist at the University of Washington Autism Center. Jo is also a visiting SLP at Seattle Children’s Autism Center.

Part 1

In honor of Better Speech and Hearing Month, some of the speech-language pathologists (SLPs) at the Seattle Children’s Autism Center and the University of Washington Autism Center are presenting a 4-part series on communication skills in autism. We will begin the series with a focus on children who are in the pre-intentional/pre-verbal stage of development.

When we think about children who are at any stage of language development, from pre-intentional/pre-verbal to highly verbal, one of the most important things to keep in mind is the distinction between communication and language. Communication is the exchange of a message between two people. Everyone learns to communicate before they learn language. Pointing, facial expressions and eye gaze are all examples of communication without words. Language, on the other hand, is a learned, symbolic system. Every language that is spoken (or signed, in the case of American Sign Language) has its own set of distinct symbols and rules. Language is symbolic because the meaning is not based on the context or situation, but instead because of knowledge shared between the communication partners. For example, the sounds we put together to say “cat” have no true connection to a furry feline, but we all know what it means because we learned the connection at an early age.

A pre-intentional child is one who has not yet learned that communication is between two partners and often, caregivers need to interpret their behavior to determine their needs and wishes. They may throw a toy or cry because they are hungry when the caregiver is looking, but they would do this same behavior even if they were alone. They may be very “independent” and stack chairs or climb on objects to gain access to objects or food that they want, without communicating their wishes to others. We say that they do not yet have communicative intent.

A pre-verbal child may communicate intentionally, but does not yet use words (or symbols) to communicate. We are usually referring to children who have learned that the key to communication is getting a message across to someone else. These children may be consistently pointing, looking at objects that they like when given a choice, directing vocalizations toward others, or pulling caregivers over toward a desired object and looking up at them for help. These are intentional acts of communication because they are consistent, persistent and acknowledge the partner in some way. However, they are not yet symbolic because they are still dependent on context, not learned and shared language.

Strategies that can help encourage communication and early language development:

  1. Know what your child likes and use it to teach! What does your child spend time doing? We don’t have to rely on traditional items like toys – does your child like to listen to music? Clap? Tear paper or collect objects? While we don’t want to get the child stuck on perseverative interests, we can use highly motivating objects and activities to teach about the power of communication and reinforce communicative intent. We often use whatever we can to engage with a child to set up opportunities to teach communication.
  2. Children learn to communicate by NEEDING to communicate. If we anticipate their needs and provide, children do not NEED to communicate and have difficulty learning the power of communication. Set up or manufacture opportunities or “communication temptations” that require communication for your child to get something he/she wants. This requires a little creativity. You could offer snacks or toys in hard-to-open containers. Only give pieces of a cookie instead of handing over a whole Oreo. Hold up two objects for your child to choose between. Pause momentarily during an ongoing game (e.g. pushing on a swing, tickle game, etc.) and wait for the child to communicate.
  3. The most critical and most difficult step comes after the temptation is in place. This is WAITING SILENTLY for the child to communicate. Don’t expect a word – remember, we’re at the level of communication, not language. A child may reach, pause what they are doing, vocalize or just look in your direction. That is communicative intent!  Require some sort of positive communicative intent before giving your child the desired object. Work with your SLP to decide what signal – eye gaze, pointing, vocalizing, or picture exchange – may be appropriate.
  4. Simplify your language. We use the “one-up” rule: add one more word to your own speech than your child typically uses. That means if your child is not yet using words, use primarily single words to label items they are interested in. Use your language to describe what your child is paying attention to.

For SLPs, the biggest goal is to continue to increase the clarity, frequency and sophistication of the communication the child is using. For pre-intentional children, one of the most critical skills we can teach is joint attention, or the ability to respond to and/or direct another’s attentional focus. Pointing is an excellent place to start. The child should learn to look where an adult is pointing (responding to attentional focus), then how to use a point to request an object, then to use a point to share or show an object (e.g. in a book), which both involve directing attention. Shared joint attention occurs when a caregiver and child are sitting and looking at a book together. Each time the caregiver points to a picture and labels it, they are modeling the symbol (or word) for that object. Joint attention is a foundational skill to language development and in many ways, a primary manner of learning.

For pre-intentional/pre-verbal children, keep in mind that it is never too early to start augmentative and alternative communication (AAC) support, especially for children with autism who are predominantly visual learners. For instance, a great way to teach communicative intent is through picture exchange. Gaining the partner’s attention is built into the skill, as the person has to be attending in order to hand over the picture. A “Big Mack” switch or a single button programmed with a spoken message is another good way to teach intent with AAC. The voice is great because it can gain the attention of a person across the room! Teaching a shoulder tap is another way to do this, but this may be misinterpreted as aggressive – there is a fine line between a tap and a hit! It should be noted that developing a system using alternative or augmentative communication does not inhibit a child’s ability to eventually learn to communicate verbally. In fact, use of alternative communication (e.g. PECS, sign language) can actually serve as a sort of “bridge” between nonverbal and verbal communication.

If the child already has communicative intent through gestures, AAC or eye gaze, you can start building the clarity and specificity of their communicative intents. Teach them to consistently vocalize /b/ for bubbles, or produce a consistent sign or exchange a picture symbol for a desired item. This is the first step towards symbolic communication. Again, AAC is relevant here as there are many different reasons for a child to be preverbal. They may truly be having difficulty learning symbolic language. However, some children may be more affected by motor problem that is not inhibiting language learning (which is a cognitively-based skill), just preventing them from showing what they know using speech or verbal means (which is a muscle-based skill). In addition, work to broaden the child’s variety of communicative intents – help them develop appropriate ways to reject items, request objects and activities and share/show objects in their environment!

Specific therapeutic approaches that support children at this skill level include: Applied Behavioral Analysis (ABA), Picture Exchange Communication System (PECS), Prelinguistic Milieu Training, Pivotal Response Training (PRT), the Early Start Denver Model, the SCERTS model, and others.

Part 2 of Series: Emerging Verbal

Part 3 in Series: Verbal

Part 4 in Series: Highly Verbal


For parents:

An Early Start for Your Child with Autism: Using Everyday Activities to Help Kids Connect, Communicate and Learn by Sally Rogers, Geraldine Dawson and Laurie Vismara

More Than Words Guidebook, 2nd Edition: A Parent’s Guide to Building Interaction and Language Skills for Children with Autism Spectrum Disorder or Social Communication Difficulties by Fern Sussman

A Picture’s Worth: PECS and Other Visual Communication Strategies in Autism By Andy Bondy and Lori Frost

The Affect-Based Language Curriculum: (ABLC): An Intensive Program for Families, Therapists and Teachers by Stanley Greenspan and Diane Lewis

A Work in Progress: Behavior Management Strategies and a Curriculum for Intensive Behavioral Treatment of Autism by Ron Leaf and John McEachin, eds.

Tips from The Hanen Centre

10 Ways to Practice Waiting from Little Stories: Early Speech and Language Development

For professionals:

Autism Spectrum Disorders and AAC by Pat Mirenda and Teresa Iacono eds.

Fey, M.E., Warren, S.F., Brady, N. et al. (2006). Early effects of responsivity education/prelinguistic milieu teaching for children with developmental delays and their parents. Journal of Speech, Language and Hearing Research, 49, 526-547.