1. Created in: Autism Language Program, Children’s Hospital Boston Howard Shane, Ph.D. James Sorce, Ph.D. Meghan O’Brien, M.S., CCC-SLP Marie Duggan Anna Hutt Fredman Sharon Weiss-Kapp, M.S., CCC-SLP ‘Teaching Language Concepts’ (TLC): Language Instruction For Persons on the Autism Spectrum

2. www.aac-rerc.com This work is funded by the National Institute on Disability and Rehabilitation Research of the U.S. Department of Education, under grant number H133E030018. The opinions contained in this presentation are those of the grantee and do not necessarily reflect those of the U.S. Department of Education.

3. Acknowledgement Contributors to this presentation Patients and parents in the Autism Language Program Monarch School students, parents, and staff Model Autism Program, Boston Public Schools Sharon Shaham (Augmentative Communication Program, Children’s Hospital Boston) John Costello (Augmentative Communication Program, Children’s Hospital Boston)

4. Today’s Agenda 1.Overview of Teaching Language Concepts Program (TLC) Why is learning language concepts difficult for some persons with ASD? Why are visuals needed? 2.Three Phases of Instruction Dynamic Scene Cues Static Scene Cues Element Cues 3.Developing Effective and Efficient Implementation Procedures for Teaching Element Cues Using typically developing children Adapting and applying findings to individuals with autism

5. Overview of Teaching Language Concepts Program (TLC)

6. Why Teach Language Concepts? Autism Language Program (ALP): Population: Primarily individuals with moderate to severe autism (from initial diagnosis to adulthood) Core deficit: Difficulties with language comprehension and expression, in addition to pragmatic language skills – Comprehension: Children on the spectrum often experience difficulty comprehending spoken language and/or auditory processing impairment (Novick et al., 1980; Boddaert et al., 2003). Many children are able to follow routine-based, familiar directives, but have not yet demonstrated comprehension of more abstract linguistic concepts (e.g., verbs, prepositions, attributes) – Expression: 50% of individuals with autism spectrum disorders do not use speech functionally (Wetherby and Prizant, 2005; Lord & Paul, 1997; Rutter, 1978) Many children are able to reliably use PECS to request and label, but have not yet developed the ability to describe, comment, or ask questions

7. Model of Language Comprehension (Typical Development) Spoken Language Short-Term Memory Language Processor Comprehension

8. Model of Language Comprehension (Moderate-Severe ASD) Verbal Information Short-Term Memory Language Processor Comprehension = Clinical insight suggests these impairments are due to: Attention to auditory stimuli Not understanding language as meaningful/symbolic Fleeting nature of spoken language Language processor ‘broken’ Combination of these Language comprehension is often compromised Occasional comprehension of noun labels and familiar directives (in context) Impaired comprehension of relational linguistic concepts (e.g., verbs, prepositions, attributes )

9. Current Intervention Practices The importance of visuals: Providing communication via an alternative modality/channel (visual) takes advantage of an area of relative strength -- visual processing -- to extract the intended meaning (supported by research and considerable clinical observation) Sustained presence -- while spoken language is ephemeral, visual symbols remain present, providing an extended period of time for additional rehearsal and processing. However: Many programs targeting individuals with ASD use visuals, yet the focus is typically on –Developing expressive language skills (particularly requesting and labeling) –Scheduling Few communication programs (spoken or visual) focus on developing language comprehension

10. ‘Teaching Language Concepts’ (TLC) Program A visual instruction system for teaching language concepts that tend to be difficult for people with moderate to severe autism (e.g., verbs, prepositions and attributes). TLC is a closed visual language, limited to the essential vocabulary and syntax needed to support the comprehension and expression of practical, everyday communication exchanges. Instruction typically begins in the virtual environment (video clips) and the tabletop environment (photographs, toy figurines and miniature objects), then extends to the natural environment to enable functional communication at home, school and community.

11. Key Ingredients of TLC Visual language for both language comprehension and expression Both mentors and learners use the same visual symbols to communicate with each other Targets language comprehension: viewed as foundation for expression Advanced computer and video technologies attract and maintain children’s attention, provide compelling multimedia language instruction, and enable the use of dynamic visual symbols

12. What TLC Does Not Target TLC is not intended to teach advanced communicative operations: –Abstract concepts: “…with liberty and justice for all.” –Passive voice: “The book was read by the boy.” –Complex syntactic structures: “If he hadn’t checked the weather in the morning, then he would have forgotten to bring his umbrella.” –Figurative language: “She flew to the bookstore.” –Humor : “Why did the chicken cross the road?” TLC provides a solid foundation for launching language- based intervention programs that target the more advanced communicative operations listed above.

13. Three Phases of TLC Instruction

14. TLC Instructional Phases: Learner progresses through all/some of three phases of visual language symbols, from concrete to abstract representations: 1.Dynamic Scene Cues: full-motion video clips of action scenes

15. Bypassing Spoken Language Comprehension Using Dynamic Scene Cues (Moderate-Severe ASD) Verbal Information Short-Term Memory Visual Information (dynamic scene cues) Imitation (as inferred from dynamic scene cues) *Note: No involvement of language processor required for comprehension of dynamic scene cues

16. TLC Instructional Phases: Learner progresses through all/some of three phases of visual language symbols, from concrete to abstract representations: 1.Dynamic Scene Cues: full-motion video clips of action scenes 2.Static Scene Cues: photographs that capture a prototypical moment in the action scene

17. Bypassing Spoken Language Comprehension Using Static Scene Cues (Moderate-Severe ASD) *Note: No involvement of language processor required for comprehension of static scene cues Verbal Information Short-Term Memory Visual Information (static scene cues) Imitation (as inferred from static scene cues)

18. Implications of Static Scene Cue Mastery Use of dynamic and static cues bypasses language processor –Due to load on language processor when using elements, some children may use static scenes as their communication system Mastery of static scene cues is a significant accomplishment –Can be used to promote general understanding and communication related to: Daily Living Skills Play Transitions Requesting Commenting Clarifying Directives

19. TLC Instructional Phases: Learner progresses through all/some of three phases of visual language symbols, from concrete to abstract representations: 1.Dynamic Scene Cues: full-motion video clips of action scenes 2.Static Scene Cues: photographs that capture a prototypical moment in the action scene 3.Language Element Cues: graphic icons representing each of the individual linguistic components that comprise an action scene (e.g., subject, object, verb, preposition, adjective, etc.)

20. TLC Phase 3: Element Cues

21. Model of Visual and Spoken Language Comprehension (Moderate-Severe ASD) Verbal Information Short-Term Memory Language Processor Visual Information (element cues) Comprehension of Visual Representation (element cues) Comprehension of Verbal Representation

22. Symbolate: Language Comprehension? Stringing symbols together does not automatically result in comprehension. Learners must first have a knowledge of language elements and semantic relationships, as provided in VIP. Paradoxically, stringing symbols together may actually interfere with comprehension.

23. Clinical Observations About Element Understanding Some label elements without meaning attached (echolalic-like) Some comprehend agent and object elements -- struggle with relational elements Some comprehend isolated elements -- difficulty interpreting element strings What improves element comprehension? Immersion in symbol-rich environment Mass trials across multiple settings and communication partners Computer-based instruction Persistence over extended period Bottom line: A more effective, efficient way of teaching language elements must be developed.

24. TLC 3 Phases: Clinical Observations Progressing from –Dynamic Scene Cues to Static Scene Cues -- is easy No involvement of language processor required –Static Scene Cues to Element Cues -- is difficult Requires involvement of language processor But The payoff is worth it -- foundation for generative language –Goal: Combine language element cue vocabulary with their understanding of semantic relationships to generate novel sentences for expressing requests, comments, replies, etc. in natural settings.

25. The Empirical Challenge Can we better understand the process? Can we expedite the process?

26. Developing Effective and Efficient Implementation Procedures for Teaching Element Cues

27. The TLC Approach Strategy: First study typical children, then apply findings to children with autism Rationale: –Not yet literate –Able to verbalize thought process –Compliance Subjects: Ages 3 yrs, 11 mos to 6 yrs, 4 mos Procedure: General task - sequence three linguistic elements: left-to- right reading order – agent + action + object – agent + preposition + object – Experimenter provides no spoken language to label elements – Learner demonstrates comprehension of element string by acting out directives Multiple design-prototype-test cycles to refine TLC instructional approach

28. Iteration 1: Top-Down Approach - Sequentially Through Three Instructional Phases Iteration 1 Procedure Learner presented with –Dynamic scene cues; imitate action –Static scene cues; imitate action –Element cues; demonstrate comprehension by acting out directives For each instructional phase, learner viewed the visual cues and was provided with spoken prompt, “Now you do it!”

29. Outcome: –Able to accurately imitate dynamic and static cues –Difficulty understanding task when presented with element cues (often attempted to match objects to elements rather than carry out directive) –Difficulty comprehending left-to-right sequence of ‘reading’ elements –Difficulty understanding meaning of verb/preposition (abstract) symbols –Difficulty comprehending de-contextualized element strings. –Tendency to act on objects in a familiar manner (e.g., ‘man climbs ladder’ rather than ‘ladder on man’) Iteration 1: Top-Down Approach Sequentially Through Three Instructional Phases

30. Iteration 2: Modified Top-Down Approach Modifications to Iteration 1 Procedure: –Introduced visual template to focus attention on left- to-right order of elements, and presented elements in left-to-right sequence –Introduced Mixed Display (Static scene cue along with Element cues) and demonstrated association between scene cue and its elements –To enhance understanding of task expectation: Presented task as ‘game’ to discover meaning of the relational (verb or preposition) symbol Experimenter modeled the task

31. Iteration 2: Visual Template

32. Outcome: –Initially learners did not appear to attend to the relational element -- verb or preposition (e.g., “You don’t need that one”) –Still initially attempted to match the agent and object elements to their physical objects –Given repeated trials, demonstrated comprehension of the individual elements, but continued to experience difficulty with the left-to- right ‘reading’ order for elements Iteration 2: Modified Top-Down Approach

33. Iteration 3: Bottom-Up Approach Modifications to Iteration 2 Procedure Instruction started at element rather than dynamic phase Presented elements on computer monitor –Experimenter modeled the task –Guided discovery to select combination of element strings to play corresponding video clip Then moved to tabletop –Presented non-electronic task with identical element cues and physical objects; –Experimenter modeled the task –Learner encouraged to create element strings to direct the actions of communication partners

34. Iteration 3: Bottom-Up Approach Outcome: –Older learners were able to execute each directive presented and label each element –Younger learners had difficulty attending to screen and task; more likely to engage in their own independent play with the materials

35. Iteration 4: Modified Bottom-Up Approach with Compelling Scenes Modifications to Iteration 3 Procedure: –Created ‘fun’ scenes depicting engaging, motivating activities using human models and life-sized objects –Clicked on message window to activate video clip of corresponding element string (in hopes of enhancing attention to relational element) –Presented learner with an ‘agent’ element cue representing him/herself –Encouraged learner to use elements to direct his/her own play and actions of communication partners

36. Iteration 4: Modified Bottom-Up Approach with Compelling Scenes Outcome: –Actively engaged –Successfully combined elements - although still initial tendency not to attend to relational element (verb or preposition) –Prepositions more difficult than verbs

37. Iteration 5 Modifications to Iteration 4 Procedure: –Focus attention to relational element (verb or preposition): Animated relational element Click on relational element to play video

38. Key Ingredients to Teaching Element Cues Present elements electronically Guided discovery with element combinations (to play video) Provide children with symbols representing themselves and familiar communication partners to allow them to direct the activity Begin instruction with fun, motivating tasks. Gradually expand to language-arts activities. Animate center elements to direct attention to element and enhance likelihood of comprehension

39. Directions for future TLC research Improve symbols –Animated symbols (verbs, preposition, attributes) Generalization of language skills targeted in TLC to natural setting Facilitating generative language