Communicating With Autistic Children

Journal of Pediairic Psychology1977, Vol. 2, No. 4. 181-186.

Communicating With Autistic ChildrenCatherine Lord and Ann F. Baker

University of North Carolina School of MedicineDepartment of Psychiatry

Chapel Hill. North Carolina

The delayed and disordered language of autistic children is discussed as it affects the deliveryof health care and other services in interdisciplinary settings. Current research is reviewed interms of four major areas of communication-related deficits associated with early childhoodautism: language delay, need for sameness, and impairments in social and informationprocessing skills. Within this framework, methods for communicating with autistic children inhealth-care settings are presented.

Delayed and disordered communication skills are among themost significant of the cognitive deficits and behavioral abnor-malities which characterize early infantile autism (Creak, 1961;Lovaas, 1977; Rutter, 1977). A first step in working with anautistic child is to utilize his or her skills, however limited, to es-tablish an effective method of communication. In this paper wediscuss the communication difficulties of autistic children, ad-dressing ourselves primarily to pediatric psychologists in inter-disciplinary settings. Our observations and suggestions are in-tended to provide both techniques for direct clinical work and atheoretical framework for teaching and consultation,specifically in inpatient pediatric units and interdisciplinary out-patient clinics.

Providing services to autistic children in hospitals and otherinterdisciplinary settings may present particular difficulties. Thedelivery of health care frequently entails physical contact orrestriction of the child's movement. This experience issometimes stressful even for normal children. It may be par-ticularly avcrsive to a non-comprehending autistic child whoresists even what one would think to be pleasant forms of im-pingement. In addition, health care providers usually see thechild less frequently than parents or teachers. They are lessfamiliar with the child's cognitive and social skills. They cannotrely on established routines of interaction that are used byparents and teachers to create the sense of predictability so im-portant to many autistic children.

Establishing an effective communication system can reduce oreliminate many of the typical behavior problems that can hinderthe delivery of health care services. Various educational and

This paper was written while the first author was a postdoc-toral fellow at Division TEACCH, Department of Psychiatry,University of North Carolina School of Medicine, Chapel Hill,North Carolina. Many of the suggestions for methods of com-munication presented here are techniques used regularly at theTEACCH program (see Schoplcr and Reichler, 1971, for adescription of the program's goals and orientation). Wegratefully acknowledge the contributions of the TEACCH staffto the ideas presented in this paper. Requests for reprints shouldbe sent to Catherine Lord, Institute of Child Development, 51East River Road, University of Minnesota, Minneapolis,MN 55455.

therapeutic programs have shown that problems including self-destructive and self-stimulatory behaviors can be reduced byproviding appropriate methods of communication (Creedon,Note 1). Children who can express their needs and who can un-derstand, even in a very limited way, what is going to happen tothem, what they are expected to do, and the consequences oftheir actions will be less frightened and more cooperative in anyinteraction.

Below we briefly review current research on the nature oflanguage and communication-related skills of autistic children.The disordered and delayed abilities these children display arcdiscussed in terms of four major areas of deficit. Within thisframework we then present specific techniques forcommunication.

GENERAL BACKGROUND

In the 1940s Kanncr delineated five behaviors essential for adiagnosis of early infantile autism (Kanner, 1943, 1949). Assummarized by Wing (1976), these behaviors were:

1. a profound lack of affective contact with other people2. an anxiously obsessive desire for the preservation of

sameness3. a fascination for objects, which are handled with skill in

fine motor movements4. mutism or a kind of language that does not seem to be in-

tended to serve interpersonal communication5. the retention of an intelligent and pensive physiognomy

and good cognitive potential, manifested by feats ofmemory and performance tests (Wing, 1976, pp. 15-16).

Kanner originally attempted to explain most autistic behaviorsas manifestations of a principal deficit in affective contact and acentral need for sameness (Kanner & Eisenberg, 1956). Recentlyother investigators have begun to propose that language andsensory-motor deficits, stemming from as yet unidentifiedorganic dysfunction, arc the primary impairments in autism(Churchill, 1972; Ornitz & Ritvo, 1968; Rutter, 1968). Socialand emotional problems are assumed to be secondary to thesecognitive deficits (Wing, 1976).

Recent research has also emphasized the frequent presence ofgeneral mental retardation. Kanner described autisticyoungsters as having "good cognitive potential" as evidenced bymemory and perceptual skills (Kanner, 1943). However, studiesin the last few years have shown that only a minority of autistic

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182 Catherine Lord and Ann F. Baker

children have intellectual abilities in the normal range (DeMyer,Barton, Alpern, Kimbcrlin, Allen, Yang, & Steele, 1974).Although some youngsters have rote memory or visual-motorskills that are at or near age level, other skills are usuallysignificantly delayed (Creak, 1961). Recent surveys indicate thatthe majority of autistic children, about 75 percent, have nonver-bal IQs below 70 (Lotter, 1967; Rutter & Lockyer, 1967). Theselow IQs, like those of non-autistic retarded children, remainstable over time (Lotter, 1967; Rutter & Bartak, 1973). Neitherincreased motivation (Hingtgen & Churchill, 1971) nor reduc-tion of psychotic behaviors (Lockyer & Rutter, 1969) result insignificant increases in IQ scores. Thus the notion of purely"functional" retardation that is therefore only temporary hasbeen rejected as an inaccurate description of most autisticchildren. The child's overall mental age must be taken into ac-count in considering both the content and the method ofcommunication.

COMMUNICATION DEFICITSOF AUTISTIC CHILDREN

The language skills of autistic children vary greatly (Wolff &Chess, 1964). About 50 percent never develop meaningfulspeech. The language of autistic children may include unusualcharacteristics such as TV talk, jargon, literal use of words,"thinking out loud," and immediate or delayed echolalia(Baker, Cantwell, Rutter, & Bartak, 1976; Baltaxe & Simmons,1975; Goldfarb, Goldfarb, Braunstein, & Scholl, 1972).Meaningful speech may range, both receptively and ex-pressively, from single words to complex dialogue (Ricks &Wing, 1976). In addition, other impairments interfere with theautistic child's ability to communicate. Four major areas ofdeficit are discussed below.

Language Delay: Language skills are delayed below both thechild's chronological age and his or her nonverbal cognitiveabilities.

The most significant aspect of most autistic children'slanguage is its overall retardation (Bartak, Rutter, & Cox,1975). Autistic children consistently perform at levels equal toor less than half their chronological age on language tasks.Typically their scores arc also substantially below their mentalage as measured on non-verbal intelligence tests (DeMyer, 1976;Hermelin & O'Connor, 1970).

Normal children have been shown to follow a very predic-table order in the linguistic structures that they learn (e.g.semantic relations, transformations, grammatical morphemes)(Bloom, 1970; Brown, 1973; de Villiers & dc Villiers, 1973). Likeother children with language disorders (Johnston & Schery,1976; Morehead & Ingram, 1976), verbal autistic children alsoseem to follow normal order in their acquisition of these aspectsof language (Lord, unpublished data). However, the ten autisticchildren we have studied acquired fewer of these language struc-tures and at much older ages than do normal children (Brown,1973). For example, an autistic child might begin to form pluralswhen he or she is eight years old, as compared to a norm ofabout four years old (Hedrick & Prathcr, 1972). The autisticchild may also never use the plural form consistently.

Strong predictions can be made across different aspects oflanguage in normal children's speech. For example, one canpredict the grammatical complexity of a normal child's speechon the basis of the average length of the child's sentences(Brown, 1973; de Villiers & de Villiers, 1973). Research inprogress (Lord, unpublished data) suggests that suchrelationships are not nearly as strong for autistic children. Con-sequently, assumptions about language skills made on the basisof one aspect of speech are not valid for autistic children. Anautistic child who speaks in long, complicated sentences may

not understand even single words usually comprehended by nor-mal two-year olds.

Information-Processing Deficits: Deficits of organization, atten-tion, and processing impede initiation of speech and impair thechild's ability to analyze language into the relevant parts and todeduce rules, sometimes resulting in deceptively complex rolelanguage with limited abilities to use that language flexibly.

Many autistic children have difficulty in organizing the stepsneeded to solve a problem or analyze language (Henjiclin &O'Connor, 1970). Some children are unable to produce a par-ticular sound on demand (DeHirsch, 1967). The child may notbe able to name something when he or she wants it or to imitatewords. In a moment of extreme excitation or relative calm, anautistic child may say "bubbles" or "I want candy." Fiveminutes later the same child may not be able to produce theidentical phrases even with the most persistent modeling,prompting, or rewards. The child has the motor skills to formthe sounds but does not have the organization to produce thesesounds consistently (DeMyer, 1976). Motor imitation may alsobe impaired. Children watching adults open their mouths for atongue depressor may not be able to use this model to trigger thesteps involved in opening their own mouths (DeMyer, 1971). Insome autistic children, disorganization may appear in the formof poor control of pitch, volume, or intonation (Baker et al.,1976; Hingtgen & Bryson, 1972; Rutter, 1976).

Autistic children often have difficulty focusing and maintain-ing attention. Auditory attention is particularly erratic (Her-melin & O'Connor, 1970). Many parents have thought theirautistic child was deaf (Lowell, 1976; Wing, 1976). Most autisticchildren do not have significant hearing losses. However, recentstudies showed that acuity thresholds of autistic children can beextremely variable across time and situation (Koegel & Schreib-man, 1977; Lowell, 1976). For all practical purposes an autisticchild may "hear" a candy wrapper rustle but not "hear" his orher name being called. Research has also shown that manyautistic children have specific difficulties with speech dis-crimination even when their hearing of pure tones appears nor-mal (Hermelin & O'Connor, 1970). Visual attention may also bepoor (Ornitz & Ritvo, 1968). A child who is distracted by thefiickering of an overhead light may not attend to emphaticgestures or loud verbal directions.

Autistic children have been described as having a particulardeficit in the ability to analyze a situation into components andto form rules on the basis of these components (Frith, 1971;Hermelin, 1976; Ricks & Wing, 1976). Autistic children formrules, but they often deviate from the accepted rules of language.This deficit is often not immediately apparent because they fre-quently have relatively normal rote memories (Ricks & Wing,1976) that enable them to remember locations (Hermelin, 1976),long series of numbers (Hermelin & O'Connor, 1970; Tubbs,1966), entire TV commercials, and frequently-used conversation(Baker et al., 1977). An example of this paradox is a child whocould recite the entire monologue of his favorite quiz show em-cee but could not put two words together to form an originalsentence. His long speeches gave a very misleading impressionof the child's linguistic competence and intelligence.

Autistic children sometimes use the name of a related object,action, or phrase in place of the correct word (Cunningham,1968). For example, a bed might be called "take-a-nap," or arefrigerator called "coke." This tendency can be particularlyconfusing for the listener if the child combines these memorizedunits into "sentences." One child used all-purpose expressionssuch as "This looks like a. . . " or "I want go sec. . ." These rotephrases were combined with other words and phrases toproduce sentences like "This looks like a/water hydrant," or "Iwant go see/Mrs. Jones." Coming from a normal child, thesesentences would be considered quite grammatically complex. In

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fact, this child's sentences were grammatically equivalent to thesimple two-word combinations "Want/Mrs. Jones," and"This/hose." This conclusion was reached after observing thatthis child never said "This" without "looks like a. . ." or "go"without "see." A normal child who produced the two originalsentences would be able to use each word in many differentcombinations.

Echolalia. immediate or delayed rote repetition of anotherperson's speech, is another characteristic of autistic children'slanguage that can be seen as the result of an organizational orattentional deficit. The child may have the memory capacity torepeat a long series of words but not understand or be able touse them in other ways. For example, a child telling a storyabout a thief said "Good grief, chief!" every time he said"thief," preceding on with the story after each rhyme. Whenquestioned about the "chief," the child did not appear to bethinking meaningfully about chiefs and seemed unaware that hehad used the word. This incident can be explained by the child'slack of organization, which prevented him from choosing onlythe relevant words and ignoring irrelevant rhymes when helearned or used the term "thief."

The greatest difficulties with the deceptively complex speechof autistic children stem from its effect on the listener. Most ofus make extremely rapid and unconscious inferences about aperson's intelligence and intentions on the basis of the person'sspeech. Because autistic children's language can sound muchmore complex than it actually is, it is easy to attribute undeser-ved levels of linguistic sophistication to them. We automaticallyspeak differently to a child who produces long sentences than toa child who talks using single words (Snow, 1972). We assumethat a child who produces one long sentence can produceanother similar sentence in another situation. We also assumethat because children produce long sentences they can under-stand even longer utterances. This is not necessarily true forautistic children. They often have difficulty picking the familiarand relevant words out of long sentences. A normal child cananalyze and select the important components of sentences like"I think you should get back in your bed now 'cause it's time forlights out" (i.e. "Go to bed") or "Be a good boy and don't movearound too much or this will hurt" (i.e. "Hold still or hurt").Autistic children may not understand these directions even iftheir own speech contains equally long sentences. Research hasshown that when the complexity of language spoken to autisticchildren is reduced, their echolalia often disappears or decreasesin frequency (Simon, 1977).

Social Deficits: A lack of social awareness and interactionalskills reduces the child's grasp and use of language as part of acomplex interpersonal communication system.

Autistic children have been described as poorly related, in aworld of their own, and unable to participate or respond to nor-mal social interaction (Bcttelheim, 1967; Koupcrnik, 1971).Whether these social handicaps arc due entirely to cognitivedysfunction is not yet clear. However, the similarities betweenthe two patterns of deficit have suggested a central cause or atleast parallel roots to many investigators (Rutter, 1968; Wing,1976). Autistic children often seem unaware of or unconcernedabout social nuances. Social contact (e.g. a smile, a warm voice,a pat on the shoulder) may be neutral or even aversive (Kanner,1943). They may have stercotypic gestures, facial expressions, orintonation patterns (Bartak ct al., 1975; Ricks & Wing, 1976).Recently investigators have begun to approach these behaviorsdirectly as cognitive deficits rather than attributing them Jomotivational or emotional problems. Children who do not un-derstand that a hand extended palm upward means "give me"may stare blankly at a person demanding the toy from them.The children may not realize that they too could ask for the toyby extending their own hands. A child who does not understand

subtle facial expressions or intonation may not respond to afirm command or fleeting smile.

The lack of social responsiveness of autistic children maystem from a failure to understand social rules (e.g. If you bumpsomeone, you are expected to say "Excuse me") (Wing, 1976).The autistic child may not really understand the difference be-tween language as communication (talking to someone) andlanguage as thinking (thinking out loud, talking to oneself), orthe rules that distinguish between these two uses of language.Frequently an autistic child may say something that is quite im-portant to the person with him or her (e.g. "go pee"), but say itin such a way (under the child's breath, facing away from theperson) that there is no way to know if the child intends any realcommunication. Children's inability to understand the rules in-volved in taking another person's.perspective can make state-ments like "How do you think it makes me feel when you won'ttake your medicine?" incomprehensible to them. Even suchstatements as "That hurts!" when a child is pinching may bemeaningless to him or her since the child is not personallyhurting.

Need for Sameness: A strong need for order, routine, and predic-tability may lead to rigid behavioral and language patterns.

Autism is characterized by a strong need for order and aresistance to change (Kanner, 1943, 1949; Rutter, 1977). Thistendency is often manifested in rigid, compulsive behaviors suchas lining up rows of objects, resisting minor changes in furnitureor dress, or becoming upset over a torn paper or missing puzzlepiece (Wing, 1976). In language, the need for sameness mayresult in the child needing to say "good night" to everyone onthe hospital wing before he or she goes to sleep or becoming up-set if someone responds to his or her questions in an unfamiliarway. This tendency can add to the difficulties of working withan autistic child. However, it can also be used to establish con-structive routines.

The cognitive, social, and linguistic deficits of autisticchildren described in this section each have implications forchoosing a method of communication with a given child.

METHODS OF COMMUNICATION

Communicating with an autistic child requires an innovativeand flexible approach. In addition to the communicationdeficits discussed above, behavioral impulsivity, insensitivity topain, or other deficits may further interfere with the child'sability to respond to requests and express needs (DeMyer, 1971;Schopler & Rcichler, 1971). However, communication at somelevel is possible for every autistic child. Labeling a child as"resistant," "untestable," or "oppositional" does not changethe fact that he or she needs to understand and to be un-derstood. For each child there are words, gestures, or behaviors,however subtle or dramatic, that convey a message. Followingare specific suggestions for establishing communication withautistic children in health care settings.

Language Delay: Language skills are delayed below both thechild's chronological age and level of nonverbal cognitive abilities.

1. Find out as much as possible about the child's skillsbefore seeing him or her either in an office visit or before an in-patient admission. Ask parents or teachers about the child'slanguage. Language assessment summaries may also be goodsources. Helpful information includes language level (Can thechild follow simple directions? Can the child answer "yes" or"no?"), nonverbal communication abijity (understanding ofgestures or pictures; signing; reading) and individual idiosyn-cracies (using "code" words or phrases such as "bye-bye" for"no" or "look, look" for a favorite toy).

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2. Watch how people who know the child talk to him or her.Parents or teachers may assure you that the child understandseverything they say. However, they may actually use frequentdramatic gestures or physically guide the child through tasks.When working with the child, experiment or encourage otherswho deal with the child most frequently (e.g. nurses, playtherapists) to experiment with directions or questions of varyingcomplexity. When in doubt, assume a very low level ofcompetence.

3. Talk slowly and simply. Use short sentences, omitting un-necessary words and complex grammatical forms (e.g. "First awheelchair ride, then go to sleep" rather than "All right now,it's time for you to have a little X-ray and then we'll put youdown for a nap".) Talk to the child as you would to a child lessthan half his or her age. Be concrete and specific. For example,say "Do you want a hot dog?" rather than "What do you thinkyou'd like for lunch today?"; "Show me where it hurts" ratherthan "What happened to you?". If the child does not respond,repeat your question or direction in the same or a simpler way.Switching to equally complex alternative sentences may be moreconfusing (e.g. "What happened to you?" "What's all over yourarm?" "Tell me what's the matter."). Always be ready to backdown to a simpler level (e.g. one-step instead of two-step direc-tions; a gesture instead of a verbal command).

Information-Processing Deficits: Deficits of organization, at-tention, and processing impede initiation of speech and impair thechild's ability to analyze language into the relevant parts and todeduce rules, sometimes resulting in deceptively complex rotelanguage with limited abilities to use that language flexibly.

1. It is generally not useful to respond to the loose associa-tions, echolalia, and confused constructions present in thelanguage of many autistic children. The children may have nounderstanding of their own speech or may not be able to clarifytheir statements. Responding to their irrelevant language addsto the confusion. Listen for the level of the child's meaningfuloriginal language, as opposed to rote phrases. Match the level oflanguage you use with the child to these utterances. A child whomechanically repeats "Time to open the door" whenever he orshe wants to leave may not understand what a "door" is or beable to "go to the door" when told to do so.

2. Use words and phrases consistently, since the child maybe paying attention to the whole configuration, not the in-dividual words. If the cue for allergy shots has always been "It'sshot time" on every visit, the child may fail to understand andtherefore be upset if the cue is changed to "Ready for a shot?"

3. Verbal prompting helps some children express them-selves. If you begin a sentence (e.g. "I want. . .") or say the firstsound of a word, the child may be able to finish it.

4. Demonstrating actions the child must learn to perform(e.g. taking oral medications, using crutches) may be clearerthan a verbal explanation. The children themselves may need tobe physically guided through the movements, since their imita-tion skills may be poor.

5. Make sure you have the child's visual attention when youtalk. Watching the speaker's face may help the child attend toand process speech.

6. Use non-verbal communication systems as a supplementor an alternative to spoken language. Visual or tactile stimuliare usually easier for autistic children to attend to and com-prehend than auditory stimuli. Possibilities include: (a) Objectsor pictures can be used to convey information or to give childrena way to communicate their needs. A mute child may be able topick up a spoon or cup to express hunger or thirst. Series of pic-tures (e.g. a doctor, then a lunch tray, and last a seesaw) can bepresented to children to show them the schedule of theirday. (b) Written communication is easier than speech for a

small number of high level children. The good visual skills ofsome autistic youngsters can result in early reading skills,although reading recognition often outstrips comprehension.For children who read with comprehension, written com-munication may be more effective than speech. A smaller num-ber of children may be able to write brief phrases with moredarity than they can speak, (c) Signed speech (usually a sim-plified version of one of the standard sign languages used by thedeaf) is being used with autistic children in various programs.For children with experience in signing, it may be helpful recep-tively or expressively.

Social Deficits: A lack of social awareness and interactionalskills reduces the child's grasp and use of language as part of acomplex interpersonal communication system.

1. Because social rcinforccrs are often not effective with theautistic child, other techniques may be needed to maintain thechild's awareness of and responsiveness to your efforts at com-munication. The child's attention and behavior may stay muchmore organized if the child has tangible materials on which tofocus (e.g. a puzzle placed in the chair where the child is to sit;soap bubbles to distract a child during a physical exam; a bit offavorite food following compliance with directions). An activitywhich makes no language demands or a short period of com-plete freedom from interaction may reduce stress and serve as areward.

2. Exaggerate your body language. If you arc happy withthe child, smile broadly, clap your hands and tell the child so. Ifyou are angry, use a loud voice, shake your head, or slap thetable.

3. Because the child may not be able to take other people'sperspective, it is most effective to set up events that have directconsequences for the child: "If you cat dinner, you can watchTV" rather than "I'll be so proud of you if you eat all your din-ner." A firm "No!" or a few seconds in the corner for hittinganother child may be much more effective than "It makes Mikesad when you hit him. See, he's crying."

Need for Sameness: A strong need for order, routine, and predic-tability make acceptance of change difficult, leading to rigidbehavioral and language patterns.

1. In all interactions with the child, unnecessary stimulishould be avoided. Conversation should be simple and the num-ber of personnel should be kept to a minimum.

2. Events should be paced so that the child can comprehendthem. Give the child a chance to explore and adjust to a newperson or object (e.g., a minute to look at a new medical instru-ment before it is used). If possible, warn the child in advancewhat is going to happen and how long it will take. Series of pic-tures, a schedule of events, or laying out the materials to usedand putting each away afterwards may be helpful.

3. Use the child's need for predictability to establishroutines that will make the child feel comfortable. The samegreeting from a nurse each morning may give the child a sense ofsecurity. Always sitting in the same chair in the examining roommay create a ritual that will reduce the child's anxiety and makecommunication about other matters easier.

SUMMARY AND CONCLUSION

Deficits in communication arc among the most significantand the most complex of the many handicaps of autisticchildren. Special problems exist for pediatric psychologists andothers working with these children in interdisciplinary settings.We have discussed these deficits in terms of four majorareas: language delay, need for sameness, and impairments insocial and information processing skills. Within this framework.

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we have presented methods for communicating with autisticchildren.

Each autistic child has the capability and motivation to com-municate with other people at some level. The clinician mustassess this capability and establish effective communicationmethods. With careful observation, the language and behaviorsof the child can be seen to follow a pattern and to have logicalrules, at least partially understandable to others. This patternmay be different from the norm, but it provides a starting pointfor intervention. The clinician must understand and respect thechild's own communication system. He or she must also usewhatever additional techniques the child can comprehend. Suc-cessful communication will be a compromise between normalmethods and the individual communication patterns of theautistic child.

REFERENCE NOTE

1. Creedon, M.P. Language development in nonverbalautistic children using a simultaneous communicationsystem. Paper presented at the meeting of the Society forResearch in Child Development, Philadelphia, March,1973.

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Society of Pediatric Psychology

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Communicating With Autistic Children