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Communication in Autism

National Institute on Deafness and Other Communication Disorders

What Is Autism?
The brain disorder autism begins in early childhood and persists throughout adulthood affecting three crucial areas of development: verbal and nonverbal communication, social interaction, and creative or imaginative play.

Autism is the most common of a group of conditions called pervasive developmental disorders (PDDs). PDDs involve delays in many areas of childhood development. The first signs of autism are usually noticed by the age of three. Many individuals who are autistic also develop epilepsy, a brain disorder that causes convulsive seizures, as they approach adulthood. Other characteristics may include repetitive and ritualistic behaviors, hand flapping, spinning or running in circles, excessive fears, self-injury such as head banging or biting, aggression, insensitivity to pain, temper tantrums, and sleeping and eating disturbances. Autistic individuals live a normal life span, but most require lifelong care and supervision.

Leo Kanner first identified autism in 1943 when he described 11 self-absorbed children who had "autistic disturbances of affect contact." At first, autism was thought to be an attachment disorder resulting from poor parenting. This has been proved to be a myth. While the cause remains a mystery, most specialists now view autism as a brain disorder that makes it difficult for the person to process and respond to the world. Autism has been observed in several members of the same families. Therefore, many scientists believe that, at least in some individuals, autism may be genetic. Scientists have identified some genes as playing a possible role in the development of autism.

Who Is Affected by Autism?
Autism is one of the most common developmental disabilities. Individuals are of all races and ethnic and socioeconomic backgrounds. Current estimates suggest that approximately 400,000 individuals in the United States have autism. Autism is three to four times more likely to affect boys than girls. Autism occurs in individuals of all levels of intelligence. Approximately 75 percent are of low intelligence while 10 percent may demonstrate high intelligence in specific areas such as math.

How Do Speech and Language Normally Develop?
The most intensive period of speech and language development is during the first three years of life, a period when the brain is developing and maturing. These skills appear to develop best in a world that is rich with sounds, sights, and consistent exposure to the speech and language of others. At the root of this development is the desire to communicate or interact with the world.

The beginning signs of communication occur in the first few days of life when an infant learns that a cry will bring food, comfort, and companionship. Newborns also begin to recognize important sounds such as the sound of their mother's voice. They begin to sort out the speech sounds (phonemes) or building blocks that compose the words of their language. Research has shown that by 6 months of age, most children recognize the basic sounds of their native language.

As the speech mechanism (jaw, lips, tongue, and throat) and voice mature, an infant is able to make controlled sound. This begins in the first few months of life with "cooing," a quiet, pleasant, repetitive vocalization. Usually by 6 months of age an infant babbles or produces repetitive syllables such as "ba, ba, ba" or "da, da, da." Babbling soon turns into a type of nonsense speech called jargon that often has the tone and cadence of human speech but does not contain real words. By the end of their first year, most children have mastered the ability to say a few simple words. Children are most likely unaware of the meaning of their first words, but soon learn the power of those words as others respond to them.

By 18 months of age most children can say 8 to 10 words and, by age 2, are putting words together in crude sentences such as "more milk." During this period children rapidly learn that words symbolize or represent objects, actions, and thoughts. At this age they also engage in representational or pretend play. At ages three, four, and five a child's vocabulary rapidly increases, and he or she begins to master the rules of language. These rules include the rules of phonology (speech sounds), morphology (word formation), syntax (sentence formation), semantics (word and sentence meaning), prosody (intonation and rhythm of speech), and pragmatics (effective use of language). Being fully prepared for the obstacles that come with teaching an autistic child takes not only patience, but a proper understanding of the issue.

What Causes Speech and Language Problems in Autism?
Although the cause of speech and language problems in autism is unknown, many experts believe that the difficulties are caused by a variety of conditions that occur either before, during, or after birth affecting brain development. This interferes with an individual's ability to interpret and interact with the world. Some scientists tie the communication problems to a "theory of mind" or impaired ability to think about thoughts or imagine another individual's state of mind. Along with this is an impaired ability to symbolize, both when trying to communicate and in play.

What Are the Communication Problems of Autism?
The communication problems of autism vary, depending upon the intellectual and social development of the individual. Some may be unable to speak, whereas others may have rich vocabularies and are able to talk about topics of interest in great depth. Despite this variation, the majority of autistic individuals have little or no problem with pronunciation. Most have difficulty effectively using language. Many also have problems with word and sentence meaning, intonation, and rhythm.

Those who can speak often say things that have no content or information. For example, an autistic individual may repeatedly count from one to five. Others use echolalia, a repetition of something previously heard. One form, immediate echolalia, may occur when the individual repeats the question, "Do you want something to drink?" instead of replying with a "yes" or "no." In another form called delayed echolalia, an individual may say, "Do you want something to drink?" whenever he or she is asking for a drink.

Others may use stock phrases such as, "My name is Tom," to start a conversation, even when speaking with friends or family. Still others may repeat learned scripts such as those heard during television commercials. Some individuals with higher intelligence may be able to speak in depth about topics they are interested in such as dinosaurs or railroads but are unable to engage in an interactive conversation on those topics.

Most autistic individuals do not make eye contact and have poor attention duration. They are often unable to use gestures either as a primary means of communication, as in sign language, or to assist verbal communication, such as pointing to an object they want. Some autistic individuals speak in a high-pitched voice or use robot-like speech. They are often unresponsive to the speech of others and may not respond to their own names. As a result, some are mistakenly thought to have a hearing problem. The correct use of pronouns is also a problem for autistic individuals. For example, if asked, "Are you wearing a red shirt today?" the individual may respond with, "You are wearing a red shirt today," instead of "Yes, I am wearing a red shirt today."

For many, speech and language develop, to some degree, but not to a normal ability level. This development is usually uneven. For example, vocabulary development in areas of interest may be accelerated. Many have good memories for information just heard or seen. Some may be able to read words well before the age of five but may not be able to demonstrate understanding of what is read. Others have musical talents or advanced ability to count and perform mathematical calculations. Approximately 10 percent show "savant" skills or detailed abilities in specific areas such as calendar calculation, musical ability, or math.

How Are the Speech and Language Problems of Autism Treated?
If autism or some other developmental disability is suspected, the child's physician will usually refer the child to a variety of specialists, including a speech-language pathologist, who performs a comprehensive evaluation of his or her ability to communicate and designs and administers treatment.

No one treatment method has been found to successfully improve communication in all individuals who have autism. The best treatment begins early, during the preschool years, is individually tailored, targets both behavior and communication, and involves parents or primary caregivers. The goal of therapy should be to improve useful communication. For some, verbal communication is a realistic goal. For others, the goal may be gestured communication. Still others may have the goal of communicating by means of a symbol system such as picture boards. Treatment should include periodic in-depth evaluations provided by an individual with special training in the evaluation and treatment of speech and language disorders, such as a speech-language pathologist. Occupational and physical therapists may also work with the individual to reduce unwanted behaviors that may interfere with the development of communication skills.

Some individuals respond well to highly structured behavior modification programs; others respond better to in-home therapy that uses real situations as the basis for training. Other approaches such as music therapy and sensory integration therapy, which strives to improve the child's ability to respond to information from the senses, appear to have helped some autistic children, although research on the efficacy of these approaches is largely lacking.

Medications may improve an individual's attention span or reduce unwanted behaviors such as hand-flapping, but long-term use of these kinds of medications is often difficult or undesirable because of their side effects. No medications have been found to specifically help communication in autistic individuals. Mineral and vitamin supplements, special diets, and psychotherapy have also been used, but research has not documented their effectiveness.

National Institute on Deafness and Other Communication Disorders
National Institutes of Health
31 Center Drive, MSC 2320
Bethesda, MD USA 20892-2320

Excerpted from NIH Pub. No. 99-4315
http://www.nih.gov/nidcd/health/pubs_vsl/

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