A Multi-Component Communication Intervention for Preverbal Preschoolers with Autism: Outcomes from an RCT

Background: Half of children with autism at age 33-months are preverbal (Eaves & Ho, 2004) and are at high risk for remaining in the 30% of children with autism who are persistently minimally verbal (DeMeyer et al., 1973, Tager-Flusberg & Kasari, 2013). Targeting foundational skills for spoken language in the preverbal ASD population, including imitation, receptive language, and joint attention (Weismer, Lord, & Esler, 2010, Paul, Campbell, Gilbert, & Tsiouri, 2013), may be crucial for reducing the prevalence of children who remain minimally verbal. The purpose of this study was to test a multi-component intervention that combined direct teaching of foundational skills with a naturalistic communication intervention, parent training, and a speech generating device (SGD) for preverbal preschoolers with ASD.

Objectives:

• Do children receiving a multi-component communication intervention show greater improvements in communication skills compared to children in a control group?
• Do caregivers who are trained in the intervention use more language facilitative strategies than parents who are in a control group?

Methods: Preschool-aged children with autism (N= 68; mean age= 43 months) who used fewer than 20 words in a naturalistic language sample (NLS) were randomly assigned to receive a multi-component communication intervention or to the control group. Both of the groups received an SGD programmed specifically based on the child’s communicative abilities for use for the duration of the study.

The intervention group received 36 60-minute sessions comprised of four evidenced-based components: (a) direct teaching of foundational skills, (b) training to use an SGD; (c) a naturalistic communication intervention (J-EMT); (d) parent training in communication-support strategies.

Children and their caregivers were assessed before intervention, immediately after the 4-month intervention, and 4-months following intervention. Language and communication was assessed on: the Preschool Language Scales (PLS, Zimmerman), the Early Social Communication Scales (ESCS; Mundy, 2003), a 20-minute NLS with an assessor blind to group assignment, and a 10-minute caregiver-child interaction (CCX). The number of socially communicative utterances (SCU) was coded from the language sample and CCX. Parent use of strategies was coded from the CCX.

Results: Children in the intervention group made greater gains than children in the control group across all communication outcomes, however the significant differences between groups were observed only for the number of initiations of joint attention at posttest (b=0.644, SE=0.270 p=0.017) and SCU in the CCX at follow-up (b=0.838 SE=.425, p=.049). Object interest and frequency of escape behaviors moderated the effects of intervention on initiating joint attention, such that children in the intervention group with lower frequency play behaviors and higher frequency escape behaviors at pretest demonstrated significantly more joint attention at posttest. Caregivers in the intervention group used significantly more language facilitation strategies following intervention.

Conclusions: A brief multi-component communication intervention improved joint attention skills in preverbal children with ASD immediately following intervention and increased social communicative utterances with their trained caregivers 4 months after intervention. Future research should examine mediators of treatment to better identify how this treatment approach is effective. Longer term follow-up of children’s communication outcomes is needed.