If I had a penny for every time a parent or carer said to me I “just want them to talk”, I’d be well off (which I’m not). Trust me; you only have to look at my car to know I’m just an average girl. It’s something all therapists acknowledge. Everyone wants their loved one to talk….be it a child with Autism or a husband/wife/mother/father who has had a stroke. People always want talking! Speech is always the focus! But to us speech and language therapists there is so much more than speech. A whopping 70% of our communication is non-verbal. Talking is just a minute part of communication.
A major part of our job when working with little ones with speech and language delay and/or ASD is explaining to parents that there are other skills which underpin speech and language development which must be acquired first. For example, joint attention is a vital component of communication. Joint attention is when two people are sharing a focus on the same thing or object, and indicate that this is so by eye gazing, pointing or other non-verbal means. It is an understanding between the two people that they are both interested in the same object or event. Joint attention should emerge around 9 months of age and be very well-established by 18 months of age. Most of us are adept at this skill. You’ve probably all done it many times without realising. Imagine your child does something really cute, or repeats a rude comment they’ve overheard you make. You and your partner (or your Mum, friend, teacher etc.) look at each other and lock eyes…..sometimes your eyes may rise upwards. This is a moment of joint attention.
Joint attention provides a critical foundation for social, cognitive, and language development. Another crucial skill underpinning speech and language development is attention and listening skills. A lot of people confuse listening and hearing with each other. Hearing is the physical action of receiving sounds through the ear, while listening is a mental process involving the attachment of meaning to these sounds. Being able to attend to someone and listen to what they are saying is crucial for developing vocabulary, understanding spoken language and speaking.
So, these skills are vital which is why we focus on them when delivering therapy. We’re not just thinking about words, it’s more than words; we’re trying to develop communication skills. With very young children the best way to do this is to use certain strategies that are designed to tune into them. We recommend strategies that involve:
- Putting the family at the heart of the therapy – when parents are involved it helps strengthen a child’s language development. The research shows that children learn to communicate during everyday activities and conversations with the important people in their lives – mainly their parents.
- Making therapy a part of everyday family life – an SLT is only with the child for an hour a week. Parents are with them 24/7 and have a natural, easy relationship with the child. Making use of everyday activities within family life can help them develop better communication.
- Learning to communicate takes place within parent/child interaction. The interaction between parents and child is the catalyst for a child’s language learning. When a parent/adult is responsive to a child’s efforts to be communicative it fosters language learning.
- Being responsive to the child –responding positively, as if they were intentionally communicating something to you (even if they weren’t).
The fundamental principles behind these strategies involve parents changing themselves rather than changing the child. We know from experience that when applied these strategies can be successful. So, you can only imagine our excitement when “The Lancet” recently published the results of a study called “Parent-mediated social communication therapy for young children with autism (PACT): long-term follow-up of a randomised controlled trial”. We were abuzz! There was great excitement within our team! At last we have robust evidence that early intervention can make a big difference to outcomes!!!!! Yay!
The study looked at an intervention which involved improving parent’s interactions with their child in order to improve their skills. It entails working with the parent rather than directly with the child, aiming to optimise developmentally relevant parent interactive behaviours, which will in theory enhance parent–child interaction, consequently improving child communication and more general autism symptoms. The PACT intervention is a 1 year developmentally focused social communication intervention programme for young children that consists of 12 therapy sessions (each 2 hrs long) over 6 months, followed by monthly support and extension sessions for a further 6 months. Parents also agree to do 20–30 min per day of planned practice activities with the child. Parents are recorded interacting with their child and then watch the footage back. As they do so they are guided through easily-missed moments when the autistic child subtly moved to play with their parents. These were opportunities to tune into the other person and truly communicate with them. Communication specialists then worked with the parents to skill them to get the most out of these brief moments and extend their child’s skills.
This makes absolute sense to a speech and language therapist. We do not communicate in isolation. It takes two to communicate…..someone to send a message and someone to decode it, whether the message is verbal or non-verbal. If someone is having difficulty with communication then the communication partner has a greater responsibility to make it work.
The trial which included 152 families, started shortly after the children were diagnosed around the age of three years of age. Families were recruited between September 2006, and February 2008. Seventy Seven of the participants were assigned to the PACT intervention and seventy five were assigned to usual treatment procedures. One hundred and twenty one of the 152 trial participants were traced and consented to be assessed between July, 2013, and September, 2014. This is what makes the study so exciting. It is thought to be the first study to report long-term symptom outcomes to middle childhood (7–11 years) following a randomised controlled trial of early intervention in young children. The participants were measured for Autism symptom severity, parent-child dyadic communication, and language composite scores. They were assessed before the study began, immediately after and then six years later. The outcome was to show that sustained changes in autism symptoms can be possible after early intervention; something that has previously been regarded as difficult to achieve. The results are encouraging and provide evidence that PACT can have the potential for change in the everyday life of the child, in which much social learning takes place, and might continue to have sustained effects after the end of the therapist-delivered intervention to the parent. Interestingly it also showed a loss of the original treatment effect on parental synchrony over time, but maintenance of the effects on child communication and symptom-change. This finding suggests that the improvement in child communication and autism symptoms during treatment could have become self-sustaining during the years following the end of treatment.
The report’s lead author, Prof Jonathan Green from the University of Manchester, said the results were “extraordinary”, but added: “this is not a ‘cure’, in the sense that the children who demonstrated improvements will still show remaining symptoms”.
So, it’s an exciting development and robust empirical evidence that early intervention can make a significant difference, but as a mother to ASD children I want to add a personal message to parents here. Firstly, you are not to blame for your child having ASD. For years I battled with an inner voice that told me that my kids had autism because of something I had done wrong, or was not doing right. Then I battled with trying to “change” them and felt frustrated that my efforts did not bear the fruit I wanted it to. I literally thought that if I worked extremely hard I could alter the situation. With hindsight I think I had unrealistic expectations. It took me a long time to accept them and the situation for what it was. My kids had ASD. I wanted to give them better life chances like any other parent does, but ultimately all of my efforts did not take that away from them. Altering your communication style can help your child…..but that doesn’t mean that you were getting it wrong in the first place, and it won’t take away an ASD diagnosis. It is what it is! They are who they are. It may sound cliché but if life gives you lemons, make lemonade……..and loads of people like lemonade, especially me! Actually I love lemonade.
Written by Alison Mann on behalf of Integrated Treatment Services