New screening and diagnostic tools designed for very young children have increased the likelihood that children will be diagnosed with autism spectrum disorders (ASD) during the toddler period, or under the age of three years. Research on the diagnosis of children under age 3 years has included investigations with the Checklist for Autism in Toddlers (CHAT; Baron Cohen, Allen & Gillberg, 1992; Baird et al., 2000), the Autism Diagnostic Observation Schedules (Lord et al., 2000), the Autism Diagnostic Interview-Revised (Rutter, LeCouteur & Lord, 2003), the Modified CHAT (MCHAT; Robins et al., 2001), and the Screening Tool for Autism in Two-Year-Olds (Stone, Coolrod & Ousley, 2000), among others. Earlier diagnoses offer hope for earlier intervention that may lead to significant developmental impacts, but research on appropriate or effective intervention strategies for toddlers with autism spectrum disorders is limited to date. Although we recognize the multifaceted needs of toddlers with ASD, our specific aim in this article is to assist clinicians in enhancing the communication development of these children.
We structure our discussion around four main topics related to toddlers with ASD:
- the developmental phenomena of the toddler years that have been associated with later language and communication outcomes;
- assessment tools and strategies to use in developing an individualized intervention plan;
- intervention strategies to improve communication outcomes; and
- collaboration with families.
Predicting Communication Development Outcomes in Toddlers with ASD
Given the limited amount of direct research on effective interventions to promote the communication development of very young children with ASD, we propose that clinicians use indirect evidence regarding factors that influence developmental outcomes to guide intervention planning for these children. By the time they are 18 to 24 months of age, toddlers with ASD exhibit marked deficits in many aspects of social and communication skills, including imitation of others’ behaviors, orienting to people who speak to them, functional and symbolic play, social engagement with others, using gestures or words for communicative purposes, directing varied facial expressions to others, responding to bids for joint attention to an object or event by such means as following another person’s direction of gaze, pointing, or verbal cues, and initiating bids for joint attention by such means as verbally commenting, pointing, and shifting gaze between a communicative partner and the object or event of interest (Baird et al., 2000; Baranek, 1999; Charman et al., 2001; Maestro et al., 2002; Neitzel et al., 2003; Osterling, Dawson & Munson, 2002; Watson et al., 2000; Wimpory et al., 2000). The early interventionist needs knowledge beyond a listing of the deficits of toddlers with ASD, however, in order to develop guiding principles for intervention goals and strategies.
Chapman (1978), in seminal work, proposed that by 9 months of age, infants are using a variety of nonverbal strategies to meet the challenge of determining what other people mean when they speak. The nonverbal strategies Chapman proposes as important to infants and toddlers between the ages of 9 and 24 months include: looking where other people look (gaze-following); giving evidence of notice (joint attention); imitating other’s actions; and doing what you usually do with an object (functional play). These are the key aspects of nonverbal behavior that typically support the toddler’s progress in mapping of language onto real world objects and events, but they are areas that are problematic for young children with autism.
There is growing evidence that the degree of impairment experienced by young children with ASD in most of these areas is predictive of later developmental outcomes; this is especially true in the area of language development. For example, Sigman and Ruskin (1999) found that among children with autism, the degree to which the children responded to bids for joint attention as preschoolers was positively related to their growth in expressive language skills nine years later. In addition, the number of different functional play acts the children exhibited as preschoolers predicted their expressive language gains at follow-up. In each case, these associations were significant even after controlling for the children’s language level as preschoolers. Together the two preschool measures of nonverbal behavior accounted for 43% of the variance in expressive language gains at follow-up. Interestingly, the extent to which
preschool children with autism initiated joint attention as well as their functional and symbolic play skills were related to their success in engaging socially with their peers at the 9-year follow-up.