One size does not fit all when it comes to therapy for Autism Spectrum Disorders. But I have
found a few therapies which appear useful to a large percent of individuals, to greater and
lesser degrees, depending on their place on the spectrum. At Brehm, we are talking about ASD
Level 1, primarily, but within that group, there still exists a range of inherent strengths between
those with nonverbal learning disability and those with more language impairment. We also
consider the impact of comorbid conditions, such as ADHD and dyslexia. Each student is so
unique!
The Speech Language Pathologist (SLP) working collaboratively in schools considers student
ability to participate in class and interact with academic material, including both social
interactions and language. If their associative thinking is so intense that they blurt out unrelated
statements or can’t stay on the topic when writing, goals for language comprehension
(including reading) and expression (including written) are in order.
Folks on the spectrum are often given services for pragmatics – while language skills may also
be a significant need, especially for college-bound students. SLPs must look beyond discrete,
separated skills, like single word vocabulary; sentence formulation and repetition; or
comprehension assessments which require “fill in the blank,” single word responses. We have
seen many high school students who fall in the average range on discrete skill subtests, but fall
in the primary grade equivalent when tested at the paragraph level for comprehension. ASD
impairment in language is often related to language meaning, called semantics, while language
form may be strong; decoding may be very accurate, while understanding is poor. Certainly this
is not good for those kids and families with dreams of college! Students need to understand
what they read and hear, what they are being asked to write; and stay on topic when they speak
and write.
In longer amounts of language, such as paragraph reading and expository writing, autistic
students we support often lose the main idea and go off topic quickly, unable to comprehend the
gestalt.This difficulty with “gestalt processing” is difficult to assess, but I would suggest it’s one
of the most important targets for the language development of those with ASD.
Perceiving the main idea versus details is a key cognitive skill when creating outlines, which
underlies both writing organization and note taking. It’s also pretty important socially;
conversation often starts with a main idea and branches out; peers want to know they are
understood in order to build friendships.
I had to search deeply for good language remediation at the adolescent level for ASD. The ratio
of researched interventions for social versus language processing is, unfortunately, about 1000
to 1. What I recommend and use to target gestalt processing I found in research using both
visualizing and something called “congruency.”
Visualizing is very important, in my opinion, to helping establish the gestalt through picturing the
background, which lends context and cohesiveness to a given paragraph. Many SLPs are
trained in the Lindamood-Bell Visualizing and Verbalizing for Language Comprehension and
Thinking (VV) program. Cognitive processes such as inference and theory of mind can be
reinforced through VV. The approach is very appropriate to leverage the strong visual skills
present in those with the “old school” conception of ASD, where language skills measure far
below visual spatial. For those with a Nonverbal Learning Disability (NVLD) profile, where
language is higher than visual spatial, VV may be useful as diagnostic therapy to see if
visualization is present at all and an intensive intervention if it may be stimulated and taught as
an active learning strategy. Research needs to catch up with this theory, however, for those with
NVLD.
Much written expression at the high school level is not easily pictured, and this is where
“congruence” can come in as a therapeutic target and approach. In this remediation, adapted
from a research study* using it as an assessment of comprehension, students are challenged to
determine if the last sentence in a sequence “fits” with the first sentences. Here is an example of
a congruency stimulus at the four-sentence level:
Writing skills take practice. Writing every day can help, even if it is just emails.
Organizing your writing is important for good communication. Saying good morning when
you see someone for the first time is very nice.
This is a fairly obvious incongruence; the topic is clearlyl writing skills. Giving students clear
examples in early therapy, allowing a high rate of success, sets them up for “closer” and more
difficult incongruncies.
Here’s an example of a paragraph which has a less obvious incongruent final sentence.
However it is easier to picture, so if students have been trained in visualizing, they can be
prompted to use it:
The Lights Fantastic Parade is a tradition in Carbondale for the winter holidays. Different
schools and organizations make a float. Everyone is expected to use lots of lights on
their costumes and their floats. Carbondale is in southern Illinois, southeast of St. Louis.
The last sentence is related somewhat to the first three, but it is not truly on the topic posed in
the first sentence, which is the winter parade.
Through this practice, students learn how a topic sentence functions and sets up the “main idea”
of a paragraph, useful in both comprehension and written expression. Most students will start at
the three-sentence level and progress to longer amounts as they improve. SLPs can backup
and give practice with fewer sentences, or focus on identifying the main idea in the topic
sentence. Visual scaffolding may be used with highlighting the key words in the topic sentence.
Therapy moves from reading the stimulus paragraphs to hearing them.
This approach has the dual benefit of presenting useful information for upcoming events, the
thinking of others, and any other concepts which need reinforcing for successful school and
social integration. Granted, it requires the SLP create custom paragraphs for the student, but at
Brehm, we have the time and inspiration to do so! In my opinion – it’s worth every syllable!
*Reference:
Murdaugh, D. L., Maximo, J. O., Cordes, C. E., O’Kelley, S. E., and Kana, R. K.
From word reading to multisentence comprehension: Improvements in brain activity in children
with autism after reading intervention, NeuroImage: Clinical, 16, 303-312.
https://www.sciencedirect.com/science/article/pii/S2213158217302048
