SMART Approach to Increasing Communication Outcomes in ASD

Background:  Social-communication impairment is a significant issue for children with autism spectrum disorders (ASD). While most children learn to communicate with spoken language, approximately 25-30% of children with ASD remain minimally verbal, even after years of intervention. Failure to develop spoken language by age 5 years increases the likelihood of a poor long-term prognosis for social and adaptive functioning.  Due to the great heterogeneity in abilities of minimally verbal children with ASD, a sequential adaptive treatment design offers potential for improving outcomes in children who have been slow responders to early language based interventions.

Objectives:  This study blended two evidence based social communication interventions for language impaired children, JASPER and Enhanced Milieu Teaching and tested the effect of beginning treatment with a speech-generating device in the context of an adaptive treatment design for improving spontaneous, communicative utterances in school- aged, minimally verbal children with autism.

Methods:  Sixty-one minimally verbal children with autism, aged 5 to 8 years were randomized to the blended developmental/behavioral intervention (JASP + EMT) with or without the augmentation of a speech-generating device (SGD) for 6 months with a 3- month follow up.  The intervention consisted of two stages.  In Stage 1 all children received two sessions per week for 3 months. Stage 2 intervention was adapted (increased sessions or adding the SGD) based on the child’s early response. The primary outcome was the total number of spontaneous communicative utterances; secondary measures were total number of novel words, total comments from a natural language sample.

Results:  Primary aim results found improvements in spontaneous communicative utterances, novel words, and comments all favored the blended behavioral intervention that began by including an SGD (JASP+EMT+SGD) as opposed to spoken words alone (JASP+EMT).  Secondary aim results suggest that the adaptive intervention beginning with JASP+EMT+SGD and intensifying JASP+EMT+SGD for children who were slow responders led to better post-treatment outcomes. 

Conclusions:  Minimally verbal school aged children can make significant and rapid gains in spoken spontaneous language with a novel blended intervention that focuses on joint engagement and play skills and incorporates an SGD. A new research project, AIM-ASD, is focused on further tailoring of intervention components by also including parent training and other methods of communication interventions.