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This article discusses the connection between Natural Language Acquisition and gestalt language development. Data and analysis was taken and described throughout this research article to educate the similarities, differences, and give more knowledge to what we know as 'Echolalia'.

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This module covered a lot of information on autism in girls and how it can be misleading or presented differently in females rather than males. One of the big reasons autism can be misdiagnosed in females is because of masking. Masking is a term used to describe the ways females can “hide” or “cover up” some of their symptoms of autism that may lead outsiders to believe they don’t have autism as a diagnosis. Some of their tendencies can be easily masked. For one, repetitive behaviors may be highly noticeable in males to the extent that people would take note of that obsessive behavior. However, when it comes to females, obsessive behavior may seem more typical because what girls aren’t obsessed with their Barbie dolls when they are younger?!

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Module 4- Sensory Integration, regulation, joint attention, etc. 

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Module 4- Sensory Integration, regulation, joint attention, etc. 

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Introception Approach

Goal: The client will be able to identify 10 sensed at 80% accuracy by 3/15/2024 with limited verbal cueing.

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Abstract

For more than 50 years, "Sensory Integration" has been a theoretical framework for diagnosing and treating disabilities in children under the umbrella of "sensory integration dysfunction" (SID). More recently, the approach has been reframed as "the dimensions of sensory processing" or SPD in place of SID, so the review herein describes this collective framework as sensory integration/sensory processing treatment (SI/SP-T) for ASD. This review is not focused on diagnosis of SI/SPD. Broadly, the SI/SPD intervention approach views a plethora of disabilities such as ADHD, ASD, and disruptive behavior as being exacerbated by difficulties in modulating and integrating sensory input with a primary focus on contributions from tactile, proprioceptive, and vestibular systems which are hypothesized to contribute to core symptoms of the conditions (e.g., ASD). SI/SP intervention procedures include sensory protocols designed to enhance tactile, proprioceptive, and vestibular experiences. SI/SP-T procedures utilize equipment (e.g., lycra swings, balance beams, climbing walls, and trampolines), specific devices (e.g., weighted vests, sensory brushes) and activities (e.g., placing hands in messy substances such as shaving cream, sequenced movements) hypothesized to enhance sensory integration and sensory processing. The approach is reviewed herein to provide a framework for testing SI/SP-T using widely accepted clinical trials and event coding methods used in applied behavior analysis (ABA) and other behavioral interventions. Also, a related but distinct neuroscientific paradigm, multisensory integration, is presented as an independent test of whether SI/SP-T differentially impacts sensory integration and/or multisensory integration. Finally, because SI/SP-T activities include many incidental behavioral events that are known as developmental facilitators (e.g., contingent verbal models/recasts during verbal interactions), there is a compelling need to control for confounds to study the unique impact of sensory-based interventions. Note that SI/SP-T includes very specific and identifiable procedures and materials, so it is reasonable to expect high treatment fidelity when testing the approach. A patient case is presented that illustrates this confound with a known facilitator (recast intervention) and a method for controlling potential confounds in order to conduct unbiased studies of the effects of SI/SP-T approaches that accurately represent SI/SP-T theories of change.

Keywords: sensory integration, sensory processing disorder (SPD) intervention, behavioral intervention, treatment effect analysis, naturalistic behavioral intervention

Overview: Sensory Integration/Sensory Processing Treatment (SI/SP-T) for ASD Is A Widely-Implemented Intervention Approach but with An Emerging but Limited Evidence Base

The goal of this article is to provide a review of sensory integration/sensory processing treatment (SI/SP-T) in Autism Spectrum Disorder (ASD), an intervention used widely in schools and clinics, to generate a framework and pedagogy for systematically testing behavioral interventions for children with disabilities. That is, we view SI/SP-T as one of several potential interventions for children with developmental disabilities which can be evaluated using widely accepted evidence-based standards and which can be objectively tested using clinical trial approaches to optimize an intervention for children with disabilities. Because there is considerable variation in nomenclature, and many researchers and clinicians have shifted from using "sensory integration" to "sensory processing," (see Miller et al., 2009) we will be including both of these terms designated as "SI/SP-T" in our review. This combination is utilized because the term "sensory integration" continues to be included in the literature and in clinical practice along with the term "sensory processing." Large scale intervention studies are needed because, despite widespread implementation, particularly for children with Autism Spectrum Disorder (ASD), Down Syndrome, attention deficit hyperactivity disorder (ADHD), and other developmental disabilities, SI/SP-T has an emerging but limited evidence base in the literature (see, for example, Pfeiffer et al., 2018), necessitating additional large-scale studies. Therefore, the review herein will include a description of the origins of SI/SP-T, current evidence, considerations for conducting fair clinical trials, a review of how to control for potential cofounds, a description of how to test for generalized changes in SI/SP using multisensory integration approaches, a case example of how confounds can impact clinical intervention studies of SI/SP-T, suggestions for future research directions, and clinical implications.

Evidence-Based Practice: Levels of Evidence

There have long been universal protocols for evaluating treatment efficacy and effectiveness in medicine and in behavioral interventions (Reynolds, 2008). These procedures arose, in part, from the long-standing persistence of treatments in clinical settings that, when tested fairly, proved to be ineffective or even harmful. For example, chelation, an established biomedical treatment for acute exposure to lead and other toxic metals, was hypothesized to be an effective "detox" for children with ASD (see James et al., 2015). This treatment was based on an unproven presumption that because ASD was caused, at least in part, by exposure to mercury, chelation would improve autism symptoms (see Davis et al., 2013). Moreover, there have been many testimonials and qualitative case studies suggesting that the approach was effective. But, when tested using clinical trials, chelation not only failed to improve symptoms of ASD, but also caused adverse reactions, including death, in some cases (Baxter and Krenzelok, 2008). Of course, the overwhelming majority of treatments for autism do not include death as a potential side effect, but there are certainly many treatments that despite having limited data that conform to evidence-based practice guidelines (Weiss et al., 2008; Guldberg, 2017), are nonetheless widely implemented.

It must be stated explicitly that a limited evidence base does not mean that a treatment is ineffective; when tested, an emerging treatment may subsequently be validated when large scale studies are conducted. However, ethical practice guidelines include preferentially delivering treatments that currently have credible evidence over those that do not. There is an extensive evidence base showing moderate to large effect sizes for improving a wide range of ASD symptoms using behavioral intervention procedures that do not directly target SI/SP (e.g., Naturalistic Developmental Behavioral Interventions, NDBI; see Sandbank et al., 2020). That is, SI/SP-T can be conceptualized and tested as a naturalistic behavioral intervention and conditions such as ASD can yield fair tests of the approach. Because of this, within the framework of widely used treatment efficacy and effectiveness evaluation procedures that include group and single case (single subject) designs, emerging approaches require systematic evaluation and levels of evidence that meet or exceed those of existing interventions (e.g., NDBI) to be included in validated treatment options.

Broadly, evidence-based rubrics classify "evidence" along a weak to strong continuum (see Brighton et al., 2003). The lowest level of evidence includes case presentations and case series studies. These are descriptive and often include qualitative indices such as goal attainment scaling with limited or no experimental control of bias. It should be noted, however, that these studies are indeed evidence and that there have been important discoveries that originated with case reports and case series studies. On the other hand, a lack of control and potential for bias impacting results, are considered weak evidence (Brighton et al., 2003) and there have been many treatments that showed initial promise in case reports that did not prove beneficial when more controlled studies were completed. Case-control studies are similar to case reports and case series studies but include a control/comparison patient (or patients). Although most are retrospective (a group of similar patients wherein some improved and some did not), this approach can yield even stronger evidence when implemented as prospective single subject/single case design control procedures (see Kennedy, 2005; Maggin et al., 2019). The next highest level of evidence includes prospective cohort studies, which essentially can be used to determine whether there are differential pre-post- gains in qualitative and/or quantitative benchmarks such as goal attainment scaling and standardized assessments. These also include limited or no experimental control of bias but are quite useful. The next level, randomized control trial ( RCT), is considered the highest level of evidence when randomization and blinding are implemented. Unblinded and/or subjective qualitative RCTs (e.g., Goal Attainment Scaling) are viewed as credible evidence, but weaker than blinded RCTs. The "ultimate" level of evidence includes a meta-analysis of aggregated strong RCTs showing consistently meaningful effect sizes across studies. Our analysis of SI/SP-T in ASD is predicated on this widely used evidence rubric. Bear in mind that patient and clinician testimonials are not considered evidence.

Origins of SI/SP-T: A Brief Overview of Sensory Integration/Sensory Processing Treatment Approaches

Ayres ( 1972, p. 4) described sensory integration dysfunction as a problem in the ability to "organize sensory information for use" and along with motor performance, as a key element of intervention (see also Ayres, 1963; Ayres and Robbins, 2005). In addition to her clinical work, Ayres published many studies focused on the assessment and treatment of SI, and she developed assessments for SI (e.g., Ayres, 1989, 1996). Ayres' definition encompasses a broad range of behaviors and includes disruptions in social interaction and behavioral regulation (Miller et al., 2007a). While acknowledging that many sensory-based approaches incorporate motor performance in accord with Ayres' framework (Ayres, 1979), we will be focusing the review on sensory parameters. A recent definition of SI derived from a nosology of sensory integration disorder includes "difficulty detecting, modulating, interpreting and/or responding to sensory experiences, which is severe enough to disrupt participation in daily life activities and routines and learning" (Miller et al., 2007a). Several subtypes are proposed in one or more sensory systems, including auditory, visual, gustatory (taste), olfactory (smell), somatosensory (proprioception and touch), vestibular, and interoceptive (the sense involved in the detection of internal regulation, such as heart rate, respiration, hunger, and digestion) domains. In 2009, Miller et al. ( 2009) suggested a change in nomenclature from "sensory integration" to "sensory processing" disorder while maintaining the foundational sensory elements. Thus, these eight sensations are the central targets of many SI/SP-T sessions. Moreover, SI/SP-T is posited to directly improve attentional, emotional, motoric, communication, and/or social difficulties (see Miller et al., 2014). Difficulty in sensory integration/sensory processing is hypothesized to result in challenges related to initiating or sustaining peer interactions, developing engaged relationships, participating in activities of daily living, and regulating arousal behaviors. Specific developmental domains, such as language development (e.g., Ayres and Mailloux, 1981; Mauer, 1999), are also hypothesized to be impacted and to thus incidentally benefit from SI/SP-T. The impact of these sensory parameters on quantitative indices of domains such as language development is directly testable using well-established experimental approaches.

Within this theoretical framework, common manifestations of sensory integration/sensory processing deficits in children with developmental disabilities, such as ASD and ADHD when sensory symptoms are displayed including responses to stimulation more quickly, more intensely, and for a longer duration than do typically developing individuals. It should be noted that SI/SPD is not exclusive to ASD, ADHD or any other developmental condition and not every child with ASD, ADHD or any other developmental condition should be diagnosed with SI/SPD. Examples in everyday life include extreme responses to stimuli such as noise in a classroom, odors in a restaurant, the touch of clothing, the clipping of finger and toenails, the movement of playground equipment, and/or the sight of cluttered environments. Behavioral responses are proposed to include a range of "fight, flight or freeze" reactions such as aggression, withdrawal, or preoccupation with the expectation of sensory input. Secondary social effects seen in preschoolers with SI/SPD include severe difficulty forming and maintaining peer relationships and/or extreme efforts to control events in the environment by over-reliance on routines. Hypothesized correlates include profound behavior regulation problems, including temper tantrums, outbursts, hitting, kicking, biting, spitting, and other maladaptive behaviors, and profound withdrawal from groups.

Additionally, preschool children with SI/SPD are also reported as being slow to respond to sensation, showing reduced or absent responses, and/or requiring more intense stimuli to respond to the demands of the situation. Examples include not responding to one's name being called and failing to notice when hurt, thirsty, or hungry (see the examples in Miller et al., 2014). Some children with SI/SPD are also reported to have an insatiable need for sensation, well beyond that which is typical, often to the extent that safety is a concern. These children derive great pleasure from "crashing and falling" and have great difficulty sitting still. Parents and peers may describe such children as being "in my face and in my space," "constantly touching people or objects," and demanding significant time and attention (Miller et al., 2007a; Ben-Sasson et al., 2019). These impulsive and hyperactive behaviors may adversely impact student outcomes. Lastly, preschool children with SI/SPD present with motor delays sometimes categorized as "associated symptoms" (Ming et al., 2007) that are purportedly due to an underlying impairment in the ability to interpret sensations (Roley et al., 2015). Examples include difficulty initiating, planning, sequencing, and building repertoires of action plans, all of which are essential to motor planning to accomplish multi-step daily routines. This SI/SPD framework is often applied to symptoms of conditions such as ASD when delivering SI/SP-T. But it is important to note that the aforementioned features of ASD have also been addressed without utilizing sensory activities so that there are alternative perspectives as to the nature and extent of SI/SP features in ASD interventions (see the review and meta-analysis in Sandbank et al., 2020).

Thus, despite widespread implementation of SI/SP-T based services, there is an extensive portion of the assessment and intervention literature for children with disabilities that does not interpret these behaviors through the lens of sensory integration or sensory processing, relying instead upon another operant/applied behavioral analysis and/or physiological foundations (as examples, see Sappok, 2019; Sandbank et al., 2020). Theoretically motivated, hypothesis-driven studies within the context of fair clinical trials of SI/SP-T are needed to resolve this disparity in the theoretical ontogeny of sequelae of developmental disabilities such as ASD. This will shed light on best practices for intervention in conditions such as ASD. Moreover, there continues to be considerable heterogeneity in the field regarding treatment and the underlying theories driving these interventions (see for example, Sandbank et al., 2020). Importantly, the "fair evaluation" of an intervention must be faithful to the implied or explicit theory of change for that intervention. Because of this, it is important to briefly review a representative theory of change for SI/SP-T.

Theory of Change for Sensory Integration/Sensory Processing Treatment

Hundreds of publications have described SI/SP-T since 1964, though the literature continues to contain relatively few large-scale randomized trials directly testing the intervention (Ayres, 1972; Kimball, 1993; Kinnealey and Miller, 1993; Parham, 1998; Miller et al., 2001, 2007b; Bundy et al., 2002; Pfeiffer et al., 2011, 2018; Schaaf et al., 2014, 2018). Most of the literature on this topic includes inconsistent terminology between studies as well as limited high-quality evidence, and design limitations (see Miller et al., 2007c; Schaaf et al., 2018). Additionally, because authors often utilize terminology, theoretical constructs, and observational frameworks that are inconsistent (see Schaaf and Davies, 2010), it can be difficult to aggregate studies and to specify consistent outcome measures. Thus, although some studies provide credible evidence of treatment effects, SI/SP-T does not yet have a strong evidence-base. For example, Schoen et al. ( 2019) conducted a systematic review of Ayres Sensory Integration (ASI) treatment and found only two studies that met a majority of quality indicators and one additional study that met a "plurality" of quality metrics. In contrast, reviews of NBDIs include dozens or even hundreds of studies (e.g., Sandbank et al., 2020). For purposes of this review, we are using the SI/SP-T nosology by Miller et al. ( 2007a), and we have adapted the conceptual theory of change from Miller et al. ( 2001) as an example of a testable SI/SP-T framework (see Table 1 ). To be sure Ayres Sensory Integration (e.g., the review of ASI in Watling and Hauer, 2015; Schoen et al., 2019) or any other well-defined approach within the broad rubric of SI/SP-T could also be tested, we utilize the framework of Miller et al. ( 2001) herein as an example of how this can be accomplished.

Table 1

Dimensions

Behaviors observed

Sensory symptoms Results in

Difficulty regulating sensory input: over or under responsivity (Tactile, Movement, Taste, Smell, Auditory, or Visual stimuli); difficulty interpreting internal sensations (body awareness, interoception), and difficulty discriminating external sensations (from the environment).

Motor symptoms Results in

Poor coordination, Clumsiness, Awkwardness, Poor posture, Limited planning and sequencing of motor skills; Inability to perform multistep tasks.

Behavioral symptoms
Results in

Aggression, Anger, Dysregulation, Tearfulness, Withdrawal. Anxiety, Poor attention, Hyperactivity, Poor impulse control.

Social symptoms
Social isolation, Withdrawal, Poor social relationships with peers and adults, Discomfort in social situations.

The model in Figure 1 suggests that sensory function is foundational to motor ability, social skill, and a broad range of behavior. Thus, when a disruption occurs in sensory abilities (including disruption in modulation, discrimination, and integration of sensory input), testable cascading effects are posited for several "higher-level" domains, such as social skills. These disruptions are believed to translate to problems with participation at home, at school, and in the community (see Table 1 ). A Model of Change using SI/SP-T as articulated above relates to proposed changes in motor, social, and behavioral challenges. It is noteworthy that SI/SP-T can be implemented in a manner that is consistent with the model within the context of a blinded RCT with primary and tertiary measures of hypothesized effects. Thus, the SI/SP-T theory of change can be measured using a fidelity of treatment scale following evidenced-based standards for all behavioral interventions. The structure and delivery of SI/SP-T are founded on the incorporation of tactile (touch), proprioceptive (pressure, position, and muscle exertion), and vestibular (movement and balance) activities in a naturalistic, play-based intervention session. These sensory events can all be operationally defined and reliably measured using observational coding.

For an intervention to be evaluated fairly, these enhanced sensory integration experiences must be selected specifically to fulfill the needs and behaviors of the individual child and measured systematically. For example, if a child displays an unusual sensory profile marked by tactile over-responsivity, then SI/SP-T activities should provide systematic exposure to different tactile sensations (Miller et al., 2014). Systematic exposure to tactile activities is hypothesized to not only decrease tactile over-responsivity but also to improve the behaviors and skills disrupted by tactile over-responsivity, which can all be measured objectively using event coding and/or rating scales. Again, each of these links changes be tested directly.

Additionally, SI/SP-T is hypothesized to benefit children with reduced tactile discrimination. A child who does not interpret (discriminate) tactile sensations delivered to her fingers, hands, and feet, may have trouble participating in activities requiring accurate tactile interpretation (e.g., difficulty buttoning, writing, and manipulating small objects). Again, this functional relationship is testable.

Testing Behavioral Treatments

For this review, behavioral treatment is defined broadly as interventions that employ clinician-child or parent-child interaction excluding pharmacological agents (e.g., as in Hampton and Kaiser, 2016). This includes naturalistic play-based interventions and highly structured operant conditioning treatment methods (Sandbank et al., 2020). Although some have argued that only operant "discrete trials" should be identified as "behavioral" or exclusively falling within the scope of "applied behavioral analysis," behavioral interventions have long been extended to include play-based "naturalistic" treatments (McLean and Snyder-McLean, 1978). As an example, Sid Bijou, one of the founders of the applied behavioral analysis field, adapted Kantor ( 1977) linguistic theory for study within a behavioral rubric, including conversational elements (see Bijou et al., 1986; Ghezzi, 2010). This framework has been widely applied to study conversational based interventions (see as examples, Koegel et al., 1987; Camarata, 1993; Camarata et al., 1994; Gillum and Camarata, 2004). Table 2 provides a theory of change for a naturalistic behavioral intervention (Pivotal Response Training, Koegel et al., 2016) within a behavioral framework. The key point herein is that SI/SP-T can be examined-and tested-within a behavioral framework similar to those applied for naturalistic interventions (e.g., NDBIs).

Table 2

CUE

Child attention

Gain child's attention before providing cue

Clear and appropriate

Provide related, clear and developmentally appropriate cues

Child choice

Allow child a choice of activity or materials

Take turns

Take turns by modeling appropriate behavior

Maintenance tasks

Intersperse tasks the child has already mastered

Multiple cues

Provide cues that require responding to multiple elements

Child behavior (correct, incorrect, and attempt)

RESPONSE

Contingent

Provide appropriate consequences based on child's behavior

Direct reinforcement

Provide reinforcement directly related to the child's behavior

Good trying

Reinforce child's goal directed attempts

Current Evidence Base for SI/SP Treatment

Given the widespread delivery of SI/SP based assessment and treatment, one would expect an extensive strong evidence base in the literature. Before delving into the current evidence on SI/SP-T, it is important to mention that practices are often widely provided to students with disabilities even in the absence of extensive supporting data-driven evidence. As an example, music therapy is a very common approach provided to children with ASD despite its currently limited evidence base (see Lense and Camarata, 2020). Although problematic, an absence of evidence, unto itself, cannot be construed as invalidating.

Our review indicated that to date, there have been small scale studies of several isolated sensory-based procedures, such as weighted vests or "brushing" programs, which usually suggest the procedures are not effective (e.g., Lang et al., 2012; Taylor et al., 2012). And there are a limited number of studies showing positive effects on goal attainment scaling (see the reviews in Schaaf et al., 2018; Schoen et al., 2019). But there are also several systematic reviews indicating inconsistent, weak, and/or inconclusive evidence. For example, Lang et al. ( 2012) reported, "Overall, three of the reviewed studies suggested that SI/SP-T was effective, eight studies found mixed results, and 14 studies reported no benefits related to SI/SP-T" (p. 1004). The majority of the studies reviewed by Lang et al. ( 2012), however, tested only one sensory-based procedure (e.g., a weighted vest or sensory brushing) but not a comprehensive form of SI/SP-T, in which a multi-component approach is implemented. Thus, a fair test of SI/SP-T necessitates the delivery of multiple elements rather than piecemeal testing of isolated sensory-based procedures and tools (e.g., wearing a weighted vest).

A critical review published in Pediatrics provides a comprehensive view that more accurately represents the treatment (Johnson and Myers, 2007): "The goal of [SI/SP-T] is not to teach specific skills or behaviors but to remediate deficits in neurologic processing and integration of sensory information to allow the child to interact with the environment more adaptively." This perspective is highlighted in a recent review by Case-Smith et al. ( 2015) who concluded:

Studies of sensory-based interventions suggest that they may not be effective. However, these studies did not follow recommended protocols or target specific sensory processing problems. Although small randomized controlled trials resulted in positive effects for [SI/SP-T], additional rigorous trials using manualized protocols for [SI/SP-T] are needed to evaluate effects for children with [ASD] and sensory processing problems (p. 133).

As these reviews demonstrate, there is currently, at best, an emerging, but limited evidence base on SI/SP-T, with few positive outcomes and some null or negative outcomes.

Moreover, the current state of the evidence for SI/SP-T is accurately characterized in a review by the American Academy of Pediatrics ( 2012): "... the amount of research regarding the effectiveness of [SI/SP-T] is limited and inconclusive" (p. 1186). More recently, Weitlauf et al. ( 2017) reported in a follow-up review:

Some interventions may yield modest short-term (<6 months) improvements in sensory and ASD symptom severity-related outcomes; the evidence base is small, and the durability of the effects is unclear. Although some therapies may hold promise, substantial needs exist for continuing improvements in methodologic rigor (p. 347).

Moreover, recent meta-analyses and systematic reviews have consistently highlighted: (a) the paucity of intervention studies in SI/SP-T; and (b) a crucial need for credible intervention studies of SI/SP-T (see Sandbank et al., 2020). As an example, Pfeiffer et al. ( 2018) conducted a systematic review of SI/SP-T that yielded five articles meeting inclusion criteria and concluded "Because the number of studies that measured sensory processing or SI challenges were limited, researchers are encouraged to include these measures in future research to understand the impact of a broader range of cognitive and occupation-based interventions" (Pfeiffer et al., 2018, p. 1). Similarly, Pingale et al. ( 2020) reported "occupational therapists (OTs) use sensory diets to manage sensory processing disorder in children. The current evidence is limited. Also, the findings of the studies on the effects of sensory diets are mixed" (Pingale et al., 2020, p. 1). Schaaf et al. ( 2018) reviewed five studies and reported that "The evidence is strong that ASI [Ayres Sensory Integration] demonstrates positive outcomes for improving individually generated goals of functioning and participation as measured using Goal Attainment Scaling for children with autism," but also reported that "Child outcomes in play, sensory-motor, and language skills and reduced caregiver assistance with social skills had emerging but insufficient evidence" (Schaaf et al., 2018, p. 1). In sum, large scale clinical trials are needed because there is evidence that SI/SP-T can improve "near point" proximal measures using qualitative Goal Attainment Scaling, but definitive outcomes for broader objective measures are less clear.

Despite a consensus in the literature on the need for additional evidence, SI/SP-T is currently widely implemented in schools by occupational therapists, speech-language pathologists, and other related services personnel (see McIntyre and Zemantic, 2017). For example, Devlin et al. ( 2011) recently reported that SI/SP-T using Ayres Sensory Integration Approach was one of the most prevalent intervention models in schools, which substantiates previous research findings (Spitzer et al., 1996; Case-Smith and Miller, 1999; Watling et al., 1999; Roley et al., 2001). A survey of occupational therapists revealed that 82% of respondents reported that they "always" use sensory-based treatment when working with children with ASD (Watling et al., 1999). Fifty-six percent of parents of children who received applied behavior analysis (ABA) treatment noted that their children with ASD had been exposed to sensory treatment as well (Smith and Antolovich, 2000, p. 1304; see also McIntyre and Zemantic, 2017). There is no doubt that sensory integration procedures have gained widespread popularity despite the ongoing need for a stronger evidence base. Given that SI/SP-T is "testable" within an evidence-based framework, further research is warranted to determine the efficacy of the approach (see Baker et al., 2008). The following sections describe approaches that could potentially strengthen the evidence base for SI/SP-T if the results of clinical-translational studies reveal unique effects for SI/SP-T.

(Multi)Sensory Perception as A Window into SI/Sp-T: Multisensory Integration as A Distal Measure of The Impact of Sensory-Based Treatment

Multisensory integration is defined as the study of how the brain integrates and interprets input from multiple unisensory systems (Alais et al., 2010). The overlap in nomenclature with sensory integration/sensory processing may be confusing to clinicians and researchers. Multisensory integration differs from sensory integration/sensory processing in that it does not include intervention recommendations or downstream sequelae of disability while specifically focusing on tightly designed neural and cognitive studies of how specific primary sensory streams are integrated in real-time (e.g., auditory and visual). Studies of multisensory integration often elicit unisensory responses from two or more primary senses (e.g., audition and vision) and then compare the separate responses to effects observed when the inputs are combined (see Stevenson et al., 2014). If the core tenant of SI/SP-T is accurate, namely that SI/SP-T enhances sensory integration, multisensory integration provides a strong test of generalized effects of treatment explicitly designed to improve sensory integration. The literature on ASD provides an example of how one can expect distal multisensory impacts if SI/SP-T is delivered and the theory of change is accurate. As noted above, Sensory Integration Theory and practice was originated by Ayres ( 1972). Multisensory Integration, a branch of contemporary neuroscience devoted to understanding how the brain synthesizes information from the different sensory systems, establish striking behavioral and perceptual benefits derived from multisensory inputs (see Stein, 2012) and may provide a neurological test of SI/SP-T.

Although the terms "sensory integration" and "multisensory integration" have divergent theoretical and empirical origins, the hypothesized theory of change for the SI/SP-T approach is directly predicated on disruptions in the ability to integrate sensory and multisensory information. Consequently, multisensory integration assessment is hypothesized to be a useful distal, quantitative approach for testing this aspect of the SI/SP-T approach. Recent studies are developing highly effective methods for characterizing multisensory integration in developing children (Neil et al., 2006; Stephen et al., 2007; Hillock et al., 2011; Hillock-Dunn and Wallace, 2012), and some studies are focused on children with ASD. While there is a strong conceptual link between sensory integration and multisensory integration, there has not as yet been a systematic study of whether sensory-based treatment procedures have an incidental effect on multisensory integration. Indeed, sensory-based treatments are specifically designed to increase inputs from multiple sensory sources, which would facilitate learning and improve behavior as a result of improved multisensory integration as a consequence of the sensory-based treatment. Although therapists and teachers across many disciplines often incidentally incorporate information from multiple sensory modalities during treatment in the absence of targeted sensory integration procedures, sensory-based treatments specifically focus on delivering elements across different sensory systems. This approach of providing input from multiple sensory modalities is believed to benefit students by facilitating multisensory integration.

Ayres ( 1972) proposed that multisensory systems play a critical role in establishing a foundation upon which "higher-level" development can occur. Indeed, sensory and multisensory representations are viewed as forming the "building blocks" upon which higher cognitive abilities and learning can occur. However, any social/behavioral intervention, including sensory-based treatment, must ultimately be founded upon a series of empirically tested and validated procedures (Devlin et al., 2011). The strength of these multisensory integration assessments as distal outcome measures lies in the fact that SI/SP-T, if valid, should have a differential significant impact on MSI as compared to nonsensory comparison intervention conditions which do NOT include direct sensory-based treatment. Thus, a comparison of multisensory abilities between SI/SP-T and fair nonsensory behavioral treatment groups may be used to assess the specificity of treatments aimed at improving multisensory function. As an example, the aforementioned NDBI recast communication therapy approach yields strong effects on language, but, hypothetically should NOT improve MSI whereas SI/SP-T is hypothesized to improve language and MSI.

Tests that specifically index multisensory function are becoming increasingly important tools to provide an empirical evaluation of the integrity of sensory processing in individuals with disabilities (see Kwakye et al., 2011). Much of the work to date has focused on testing the ability to detect and discriminate sensory stimuli-both within and across different sensory modalities-in children and adults with disabilities compared to those considered "typically developing." This work has revealed substantial differences in the manner in which individuals with disabilities, specifically ASD and dyslexia, integrate auditory and visual information. Therefore, there is a strong rationale for including multisensory assessments in future evaluations of the differential impact of SI/SP-T on individuals with ASD or who are typically developing as a direct link in the theory of change for sensory-based treatment approaches.

Example From ASD and Multisensory Auditory-Visual Integration

Stevenson et al. ( 2014) reported that the "window" within which the brain integrates and "binds" visual and auditory information-called auditory-visual temporal binding (approximately 100 ms in typically developing school-age children)-is highly variable and often considerably more latent (up to 500 ms or even more) in matched participants with ASD. That is, the auditory and visual sensory streams are not "integrated" within the same time frame in people with ASD. This phenomenon is depicted in Figure 2 , wherein the temporal binding curve for ASD and matched control participants are overlaid on one another. This is also illustrated in Figure 3 , which presents a histogram depicting the relative distribution of the temporal binding window in each group.

We hypothesize that auditory-visual temporal binding should differentially decrease for ASD under SI/SP-T because the theory of change for sensory-based treatment specifically posits that sensory integration will be improved following the delivery of these treatments. We also hypothesize that auditory-visual temporal binding will not be affected in children with ASD who are treated using applied behavioral intervention (e.g., Pivotal Response Training™; Koegel et al., 2016). A plausible theory of change including multisensory integration and use of tactile stimulation as an antecedent treatment ingredient is depicted in Figure 3 .

Controlling for Developmental Confounds

Fair and unbiased evaluation of SI/SP-T requires delivery of SI/SP-T procedures in an appropriate social and communicative developmental context (see Bialer and Miller, 2011; Miller et al., 2014), not decontextualized applications of sensory equipment, activities, and/or personal appliances such as weighted or pressure vests. While acknowledging the validity of this perspective, there exist challenges to testing the unique contributions of SI/SP-T procedures in a context that includes known active ingredients that are causally linked to developmental growth. For example, the aforementioned NDBI recast treatment involves language transactions that are ubiquitous in clinician-child interactions. That is, SI/SP-T conducted in naturalistic play contexts with supportive clinicians contains many known efficacious NDBI recast teaching events in addition to sensory events. As stated directly, social and communication elements themselves without enhanced tactile, proprioceptive, or vestibular enhancements are well established (and powerful) active ingredients in a plethora of naturalistic behavioral interventions (see Koegel et al., 1987; Cleave et al., 2015; Sandbank et al., 2020) that do not include SI/SP activities. Thus, it will be important to test whether unique treatment effects are arising from SI/SP activities and/or whether there are synergistic "value-added" contributions for SI/SP activities when implemented within the context of naturalistic social and communication intervention such as NDBIs.

As a specific example, it is well-established in the treatment literature that transactional communication exchanges facilitate language and social skills development (see National Academies of Sciences, Engineering and Medicine, 2016). The theory of change for recast treatment is based upon a naturalistic ABA approach to transactional developmental modeling (see Camarata and Yoder, 2002). Key elements for the theory of change in this naturalistic ABA approach include reinforcing attempts using social attention and natural reinforcers and pairing teaching models within meaningful communication interactions.

Recast treatment and other transactional approaches (e.g., pivotal response treatment, Koegel and Koegel, 2019) incorporate transactional elements such as reinforcing and pairing in treatment sessions (see Figure 4 ). Stahmer et al. ( 2010) describe pivotal response training or pivotal response treatment as a form of naturalistic behavioral intervention based on the principles of ABA, an approach soundly supported by the scientific literature (National Research Council, 2001). Thus, transactional intervention fits within the broad rubric of evidence-based naturalistic ABA interventions that include the design, use, and evaluation of environmental modifications and interventions to produce socially significant improvement in human behavior. ABA uses antecedent stimuli (events that happen before a behavior occurs, such as a teacher asking a child what color a crayon is) and consequences (events that happen after a behavior occurs, such as giving the child the crayon after he or she names the color), to produce changes in behavior. Table 2 (from Stahmer et al., 2010) describes the key elements in the intervention.

Because of this, there is a potential confound within SI/SP-T that must be considered when conducting treatment trials; namely, fair implementation of SI/SP-T includes numerous communication transactions that are known drivers of development in typical children and in diverse populations of children with disabilities, so the unique impact of SI/SP procedures should be tested. The question is whether treatment gains associated with SI/SP-T are differentially associated with the sensory ingredients or, more broadly, to the transactional ingredients.

Therefore, it is important to discriminate the effects of sensory ingredients from those of transactional ingredients. A potential solution could be to deliver SI/SP-T while omitting transactions, but experts in SI/SP-T concur that this type of socially unusual intervention-wherein the clinician does not interact with a child in a normal fashion-may unfairly bias the results against SI/SP-T. Another solution is to conduct an RCT wherein one arm includes delivery of transactional treatment with sensory events, as compared to transactional intervention without sensory ingredients. This alternative approach is both practical and feasible and can be conducted with high fidelity of implementation and to test for synergistic "value-added" effects from SI/SP-T.

As a case, for example, which we acknowledge is a weak form of evidence, but none the less a useful illustration of this point, consider the following patient. A male, age 6; 3, with ASD displayed salient facial rubbing. Within the SI/SP-T theoretical framework, an OT diagnosed "sensory seeking" type sensory processing disorder and prescribed treatment using contingent sensory brushing wherein brushing on the forearm was delivered in response to facial rubbing events. Note that facial rubbing and delivery of sensory brushing are both highly salient events that were coded from video records with 100% concordance between independent coders. In addition to the sensory brushing, the clinician incidentally delivered communication transactions while sensory brushing (i.e., she interacted verbally with the child while brushing him). A counterfactual condition, wherein transactions were delivered in the absence of brushing, was developed and subjected to video coding for the fidelity of treatment. Naturally, coders concurred that there were no sensory events in this condition with 100% accuracy, and the concordance for communication transaction delivery was 92% (which is within the usual range of fidelity for transactional treatment, see Davis et al., 2016 as an example).

Two different treatments-sensory brushing plus incidental communication transaction and communication transaction WITHOUT brushing-were delivered to this case using an alternating treatment design within the rubric of a single-case design (see Kennedy, 2005). Sensory brushing plus transaction was delivered first, followed by a return to baseline (no treatment) phase, then a transactional only phase, then another return to baseline (no treatment) phase, and finally, another sensory brushing phase. The results are depicted in Figure 5 . The blue dots and lines represent the session counts for the "sensory seeking" facial rub events and the red squares depict the number of sensory brushing events in the session. Both conditions included an average of two communication transactions per minute. As seen in the figure, the high baseline count for facial rubbing before initiating treatment decreased during sensory brushing treatment conditions. After each treatment condition was completed, facial rub counts quickly increased during the return to baseline phases.

It is perhaps useful to examine the first baseline and treatment phases, which included sensory brushing. As can be seen, no brushing was delivered during baseline, during which time the participant exhibited a very high level of facial rubbing, ranging from 33 to 52 events per 1-h session. In the first treatment phase, the behavior decreased dramatically, falling to fewer than 20 face rubs in every session and to zero in six of the 22 sessions. A clinician keeping these data could certainly conclude that the sensory brushing was highly effective! The return to baseline phase provides further confirmation of treatment efficacy because the facial rub count immediately increased above the levels observed in treatment. However, it is important to bear in mind that sensory brushing was not the only "ingredient" delivered during this phase; incidentally, an average of two transactional events per minute during the session was provided as well when the clinician verbally interacted with the child while brushing him.

Note that in the second treatment phase, the same clinician delivered NO sensory brushing (see the red squares in phase 2) while continuing to deliver communication transactions at the same rate. As can be seen by the blue circles and line, the number of face rub events mirrored the frequency of behaviors observed in phase 1; these events decreased precipitously to below 20 per session, and on two occasions, between zero and ten events were recorded (the numbers were a little confusing without nouns) there were two at zero and six that were less than ten (but higher than zero). Again, a return to baseline yielded an increase to nearly baseline frequency of behaviors, and reinstatement of the sensory brushing treatment replicated the results from phase 1, except for a spike in face rub events during sessions 7-9. One could argue that these results suggest that communication transactions were driving the decrease in facial rub events rather than the sensory brushing. This case graphically illustrates the need to control for confounds when testing SI/SP-T.

Summary, Conclusions, and Future Directions

SI/SP-T is a widely-used approach for treating individuals with diverse conditions and symptomology. A currently limited but emerging evidence base necessitates fair, unbiased clinical studies comparing SI/SP-T procedures to those of other established treatment approaches. This review included a presentation of one such validated NDBI treatment: Recast Treatment, which is based on a broader transactional intervention framework. Also, multisensory integration, broadly, and auditory-visual integration specifically, were discussed as promising approaches to differentially test the SI/SP-T theory of change. The article also includes a case presentation wherein confounding factors could potentially account for treatment effects that may be inaccurately attributable to an SI/SP procedure, sensory brushing, which more plausibly could be attributed to conversation transactions.

SI/SP-T is testable within the context of rigorous treatment studies, and key ingredients can be measured. Importantly, these trials should be conducted fairly and without bias to empirically evaluate the efficacy of SI/SP-T. Moreover, there has been an ongoing need for fair clinical trials of SI/SI-T. The review herein indicates that such trials can be conducted using the highest quality standards of implementation and employing objective quantitative proximal and distal measures in addition to more qualitative indices such as goal attainment scaling. Finally, these studies must be conducted using procedures that are not only faithful to the authentic implementation of SI/SP-T but also control for confounding factors. These studies should be conducted with all populations posited to benefit from SI/SP-T such as ASD, ADHD, Language Disorders, and Down Syndrome. Calls for fair studies have been appearing in the literature for more than two decades; these must be conducted soon.

Author Contributions

SC and MTW have collaborated on the multi-sensory processing research described in this article. LM and SC have collaborated on behavioral event coding for evaluation of sensory based treatments described herein and on developing a measurable theory of change for testing sensory based intervention approaches. All authors contributed to the article and approved the submitted version.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Footnotes

Funding. This research was supported in part by a grant from the Wallace Research Foundation and by 1R34DC010927-01 from the National Institute on Deafness and Other Communication Disorders (SC and MTW, MPI). The Scottish Rite Foundation of Nashville also provided support.

References

American Academy of Pediatrics (2012). Sensory Integration Therapies for Children With Developmental and Behavioral Disorders. Available online at: https://pediatrics.aappublications.org/content/129/6/1186. Accessed October 10, 2020.

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Articles from Frontiers in Integrative Neuroscience are provided here courtesy of Frontiers Media SA

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Evaluating Sensory Integration/Sensory Processing Treatment: Issues and Analysis

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For more than 50 years, "Sensory Integration" has been a theoretical framework for diagnosing and treating disabilities in children under the umbrella of "sensory integration dysfunction" (SID). More recently, the approach has been reframed as "the dimensions of sensory processing" or SPD in place of SID, so the review herein describes this collective framework as sensory integration/sensory processing treatment (SI/SP-T) for ASD.

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Approach: Play-Based

Goal: Client B is in stage two due to his echoing and recast of phrases, the client uses mitigated options frequently. The goal of therapy would be to support speech that is individualized to the client himself. The best option for this client would be to use play-based therapy techniques with the activity of using interactive play with cooking toys or barn animal toys. As the clinician I would also elicit wait time throughout the session to give the client opportunities to speak individually.

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Echolalia is the precise repetition (echoing out loud) of words and sounds. Echolalia can be a symptom of aphasia, dementia, traumatic brain injury, and schizophrenia, but it is most often associated with autism spectrum disorder (ASD).

Echolalia is not always a self-calming tool for autistic kids, like rocking or hand-flapping tend to be (these repetitive behaviors are called stimming). Echolalia has its own patterns-it might even be how your autistic child first uses speech to try to communicate with you.

While echolalia can be an autism trait, it's also a point of entry for a parent or speech-language therapist to start working with your child.

This article will go over what echolalia is and how it's related to child development and conditions like autism. You'll also learn how to help a child manage echolalia if the behavior is not helpful.

Echolalia in Child Development

Echolalia is actually a part of child development. As neurotypical toddlers learn to speak, they imitate the sounds they hear. Over time, the typically developing child learns language and is able to use it to communicate their needs and ideas by connecting new words together.

By the time they are 3 years old, most children communicate with others by selecting words or crafting phrases using their own unique voices and intonation.

By the time they are 4 or 5, kids are able to ask and answer questions, carry on conversations, and otherwise use language in their own way to communicate with others.

Echolalia in Autism

Echolalia can also be a common feature of autism. Autistic children are not always nonverbal-many use words and may even use very complex "adult" words. With echolalia, these words are, in a sense, not their own.

A child says the words in the same order-and usually in the same tone-as they heard them on a TV show, read in a book, or overheard from a teacher or another adult in their life.

One of the difficulties in understanding echolalia in autistic children is that the repetitive echolalia speech patterns can be used for different reasons. Those purposes might change over time. It's also possible for a person to use echolalia for multiple purposes at the same time.

Reasons autistic children use echolalia in speech patterns include:

Self-stimulation: Often called "stimming," this use of echolalia speech patterns is meant as a calming strategy. The repetition helps an autistic child cope with overwhelming sensory challenges.

Prefabrication: The use of repeated phrases and scripts helps to communicate when it is too hard for the speaker to form their own original words.

Self-talk: Memorized phrases may help a child talk themselves through a difficult process. They can use phrases heard from parents, teachers, or on television.

For many autistic children, echolalia is an important part of developing spoken communication.

For example, if a teacher tells an autistic child to "say thank you," the child might repeat "say thank you" back to them instead of just saying "thank you." It may not be the response the teacher was going for, but it's a step in the right direction.

Types of Echolalia

There are different kinds of echolalia. The terms can be a bit confusing because our understanding of echolalia has changed over time. What was once considered a problem to "fix" is now viewed as a possible pathway for speech development.

The different types of echolalia include:

Functional or interactive echolalia, which is directed toward communication with others

Non-interactive echolalia, whichoccurs for reasons other than communication

Mitigated echolalia, which repeats some words but with changes

Immediate or delayed echolalia, which describe the timing of the repetitive words

Interactive and Non-Interactive Echolalia

Children speaking in an interactive way are trying to communicate with another person and are using memorized phrases for a real purpose-the challenge is figuring out the meaning.

For example, a child may hear a line from a TV commercial such as "got milk?" Later when they are thirsty, they may say "got milk?" in exactly the same tone and accent as the ad on TV instead of directly asking for a drink.

Another example: A child might say "back off, lieutenant!" when angry, because they heard an angry character say that in a movie. The child has connected the words with the emotion of anger and is using the phrase to indicate that they're mad.

As the listener, it can be confusing at first. You'll need to try to understand how the child has "wired" these words to their ideas.

It's much the same way that idioms-descriptive turns of phrase- get lost between languages. No one literally means that "it's raining cats and dogs"-but we know what is meant when it's said.

In non-interactive echolalia, the child isn't trying to speak to anyone else. They might be repeating words or phrases to themselves for their own purposes-for example, to "practice" an idea or as a calming mechanism.

The repetition could be stimming, but it may have no meaning at all. It's not always clear if the child is choosing intentional words or repeating words they don't understand.

Either way, what's important is that an autistic child is borrowing the words of others and still needs help finding their own. Tapping into these echolalia patterns may offer a window for caregivers and speech pathologists to build on a child's unique style and work toward original language use.

That's especially true of mitigated echolalia, in which the child makes small changes to the original phrasing.

For example, if you ask a child which cookie they would like for a treat, they might just echo back "cookie" at first. As they gain more language skills and understanding, they might respond in the future by using a phrase they heard on a cookie commercial-like "Oh, oh, Oreo!"-to respond in a more specific way.

In this example, they might eventually drop the "oh, oh" and just echo the word "Oreo" to make their preference known.

Immediate and Delayed Echolalia

Sometimes echolalia is immediate and the child is echoing the words they hear. For example, a caregiver asks the child, "Do you want a drink?" and the child responds with "You want a drink."

The inability to switch pronouns is common. The child might be responding appropriately and may actually want a drink. However, instead of using an original phrase in the flow of normal conversation (like "yes, please," or "I'd like lemonade"), the child echoes the precise language.

Echolalia can also be delayed. For example, a child watches an episode of "Sesame Street" and later that day they recite the interactions between Bert and Ernie or sing a line from the theme song.

A child may also use Ernie's words intentionally, or the words are just repeated sounds. In delayed echolalia, there's a distance between hearing and using the words.

Related Behaviors and Conditions

There are some other behaviors and conditions that are similar to echolalia that may occur in autism.

Palilalia is a speech disorder that's marked by the involuntary repetition of words and phrases. In that sense, it is like echolalia but there are some key differences.

One difference is that in echolalia, the repetition or echoing is focused on other people's words and is received when the child hears them.

Palilalia often involves increasingly rapid speech with the same repeated sounds.

Echolalia and palilalia are not limited to autism; in fact, palilalia tends to be seen more in Tourette's syndrome, Parkinson's disease, and seizure disorders. Palilalia can even be a side effect of some drugs.

Echopraxia

Echolalia is sometimes confused with a term that sounds similar-echopraxia.

In echopraxia, a person repeats a movement that they see another person doing. However, they are not doing it intentionally-it's more like a reflexive action that they may not even be fully conscious of.

For example, they see a person scratch their head and they automatically move to scratch their head, too.

An autistic child may have echopraxia, but it also occurs in Tourette's syndrome.

Scripting is another tool many autistic people use. It's a little like echolalia since they are saying words or phrases that they heard somewhere.

However, scripting is generally an intentional strategy. For example, an autistic child might repeat a catchphrase from a character on a TV show when they're talking with their classmates because they are not sure what to say.

Echolalia Treatment

Much as you may wish to limit your child's echolalia, especially in public, the reality is that echolalia can serve a valuable function. It can be a very positive behavior in the right circumstances.

Even if your child's echolalia requires more support than others, it's a good starting point for interventions like speech therapy. For example, a child might memorize entire segments of a favorite video and recite them repeatedly as a way to calm themselves down and reduce anxiety.

The recitation may also indicate a real fascination for aspects of the video, just as it does in neurotypical children.

Echolalia that's purposeful gives you a reason to celebrate-it means that your child has developed a tool for verbally communicating their wants and needs.

They can keep building skills with the help of a speech therapist and will benefit from having caring adults around them who are intentional about words when talking with them.

Improving Communication

While it can be difficult to effectively communicate with your child when they're exhibiting echolalia, there are multiple exercises that speech therapists use that can be directly applied to home practice, interaction, and engagement. Some of these techniques include:

Limiting the "WH" Questions

You may routinely ask "who," "what," "when," "where," and "why" questions just as a matter of daily interaction with your child, and this is perfectly normal. Unfortunately, however, they may not understand or internalize the nature of the question and continue to repeat it.

Instead of asking them open questions, such as: "What do you want for a snack?" or "How are you feeling?" give them choice questions, such as "Do you want an orange or cheese?"

Once they are more comfortable with this exercise, you can start gradually working the "WH" questions back in.

This will help your child to learn how to answer your questions and cut down on the potential for repetition.

Communicate Visually

When asking choice questions, try and show them their options (clothes, food, books, etc.) so they can take visual cues and make their choice. You can also animate their choices by shaking your head "yes" or "no" so they can easily understand.

Using visual aids improves vocabulary and comprehension while giving your child a clear and simple choice while building communication skills.

Follow Through Immediately on Their Answers

Once they make their choice, complete the dialogue by accommodating their selection. This fulfillment is a language lesson in and of itself and helps them identify objects by name. Repeat the name of the object as often as possible so they can understand.

You can also use special intonations to let them know which options are good (foods, books, toys, pets) and which are dangerous (fire, knives, needles, medications, etc.).

Conversational Modeling with Relevant Terms

You can use key terms to help your child improve their communication and understanding of certain items. Try removing the actual question from the dialogue and just focus on the key word itself.

For instance, if you want to know if your child is tired, just repeat the word "tired" or "sleepy" instead of asking them if "they are" tired. This will help to reduce repetition of questions while expanding vocabulary.

You can practice these techniques and others for about 10-15 minutes per day, or however long or frequently is recommended by your child's speech therapist. It's important to realize that these techniques take time and repetition. Try not to get overwhelmed or discouraged if they don't work immediately.

Echolalia is the repetition of words or phrases. It's a common behavior in autistic people and can have many functions. For many autistic children, the different types of echolalia are steps toward developing their language skills and learning how to communicate.

If you're not sure how to make sense of your child's use of echolalia (or even if it is useful to them), it can help to work with a speech therapist. They can help you to understand echolalia and support your child as they learn to communicate with you.

Frequently Asked Questions

Echolalia is a feature of several conditions or disorders rather than being one in and of itself. Echolalia is actually a normal stage of language development in early childhood, but kids typically outgrow it around their third birthday.

In older children and adults, echolalia is a common trait of autism. However, it can also occur in people with aphasia, dementia, traumatic brain injury, and schizophrenia.

Echolalia does not necessarily need to be treated, but many children benefit from speech and play therapy. Talk to your child's provider about seeing a speech-language pathologist who treats echolalia.

There are three types of echolalia: immediate, delayed, and mitigated. Here are a few examples of each:

Immediate: You ask your child if they want to go to the park. Instead of answering "yes" or "no," they just repeated "park" back to you.

Delayed: Your child heard a TV character say, "that's super!" They repeat the phrase "that's super" frequently, sometimes in contexts that make sense (like when you tell them you are going to the park) but also at times that may seem random (like when they are in the car with you).

Mitigated: When your child is a little older, you might ask them if they want to go to the park. Instead of repeating "park" or saying "that's super!" they might start putting these ideas together and respond by saying: "The park? Well, that's super!"

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Why Does My Autistic Child Echo Words and Sounds?

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Echolalia is repeating words and sounds. It's normal in young children who are developing language and is also a feature of autism. Learn more.

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Approach: Focused stimulation

Goal: The client will be able to model past-tense verbs 8/10 times during activities such as storytelling by the end of the school year.

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Module 9- AAC and Aided Language Modeling

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Module 9- AAC and Aided Language Modeling

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Approach: Functional/Social Competence

Goal: By the end of the year, the client will utilize the AAC device to discuss interests and desires with communication partners with 80% accuracy.

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Samuel C. Sennott, Janice C. Light, David McNaughton

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AAC Modeling Intervention Research Review - Samuel C. Sennott, Janice C. Light, David McNaughton, 2016

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A systematic review of research on the effects of interventions that include communication partner modeling of aided augmentative and alternative communication…

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Approach: Operational Prompting

Goal: By the end of school semester, the client will be able to adjust volume on their device based on their environment with 90% accuracy.

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What Does PROMPT Speech Therapy Do?

If a child suffers from speech delay, disorder, or another type of impairment, it is often necessary to begin therapy immediately. The PROMPT method is often one of the first options for those who fit the mold because of its effectiveness.

PROMPT is a tactile-kinesthetic approach to speech therapy. What does that mean? In this type of therapy, the pathologist will guide the patient's articulators manually. This includes the lips, jaw, tongue, and vocal folds. To do this, the therapist will target particular words and sentences. To help the child learn, the therapist will use touch cues to help to support the proper movement of each articulator during the speaking process.

By doing this, the patient can produce phonemes. These are the smallest types of sounds that allow for distinguishing one word from the next. During each speech session, the child and therapist work in this way, through touch cues, to create better physical function. This often includes moving through various sounds over time at a steady pace. The patient will move from one sound to the next, at their own pace, as they learn and accomplish the first set of sounds.

The child gains improvement in their skills in multiple ways. This includes the assistance they receive as well as repetition. They also learn to build more complex sounds over time, adding one to the next until they master the sounds fully.

Various techniques are in use that use the muscles, jaw, and face to help create improved sound. This therapy is not just to help individuals learn single speech sounds. Instead, therapists can use this method to help children learn full words, phrases, and sentences.

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PROMPT Method in Speech Therapy for Children

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Lean about the PROMPT method in speech therapy and how it is used as an effective treatment for childhood apraxia.

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Module 11- Social Skills and Peer Mediated

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Module 11- Social Skills and Peer Mediated

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Approach: Peer-mediated

Goal for child in group: By the end of the semester, the child will initiate a conversation with peers in class by asking "What did you do over the weekend?" with 3 out of 4 opportunities given.

Goal for peers: By the end of the school year, the child will endure a turn taking conversation with peers using phrases such as "what about you" or "your turn" with 80% accuracy.

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Abstract

Background

Peer mediated intervention (PMI) is a promising practice used to increase social skills in children with autism spectrum disorder (ASD). PMIs engage typically developing peers as social models to improve social initiations, responses, and interactions.

Method

The current study is a systematic review examining PMIs for children and adolescents with ASD conducted using group designs. Five studies met the pre-specified review inclusion criteria: four randomized controlled trials and one pre- and post-test design.

Results

Four of the studies were conducted in school settings, whereas one study was conducted in a camp setting. The studies all reported that participants improved in social skills (e.g., social initiations, social responses, social communication) post intervention. Additionally, sustainment, generalization, and fidelity of implementation were examined.

Conclusion

PMI is a promising approach to address social skills in children with ASD, and this approach can be conducted in meaningful real-word contexts, such as schools. Limitations of the studies as well as future directions are discussed.

Keywords: Peer-mediated interventions, Systematic review, Autism spectrum disorder

1. Introduction

Social impairment is a debilitating core deficit that affects children with autism spectrum disorder (ASD; American Psychiatric Association (APA), 2013). Difficulty reading social cues as well as engaging in interpersonal communication may preclude children with ASD from successfully interacting with their peers, particularly in the school setting ( Bauminger, Solomon, & Rogers, 2010). Many studies of school-aged children with ASD have shown a disrupted pattern of social engagement, where children with ASD have fewer reciprocal friendships ( Bauminger & Kasari, 2000; Bauminger, Solomon, Aviezer, Heung, Gazit et al., 2008; Bauminger, Solomon, Aviezer, Heung, Brown et al., 2008; Chamberlain, Kasari, & Rotheram-Fuller, 2007), are unengaged with their peers on the playground ( Frankel, Goropse, Chang, & Sugar, 2011; Kasari, Locke, Gulsrud, & Rotheram-Fuller, 2011; Macintosh & Dissanayake, 2006; Schupp, Simon, & Corbett, 2013), and more peripherally included in smaller social networks ( Chamberlain et al., 2007; Locke, Kasari, Rotheram-Fuller, Kretzmann, & Jacobs, 2013; Rotheram-Fuller, Kasari, Chamberlain, & Locke, 2010). To address these concerns, many interventions have been developed to promote and facilitate social interactions.

Research evaluating social skills interventions in children and adolescents with ASD has highlighted peer-mediated interventions (PMI) as one of two most promising intervention methodologies to improve social skills ( Bass & Mulick, 2007; Chan et al., 2009; McConnell, 2002; Reichow & Volkmar, 2010; Rogers, 2000). PMIs comprise training typically developing peers (e.g., classmates) on behavioral and social strategies to engage children with ASD ( Bellini, Peters, Benner, & Hopf, 2007; Chan et al., 2009; Kasari, Rotheram-Fuller, Locke & Gulsrud, 2012; Rao, Beidel, & Murray, 2008). PMIs can be beneficial for children and adolescents with ASD for several reasons. First, peers can model appropriate social behaviors. Second, peers often are readily accessible in school settings to act as intervention agents, and third, children with ASD can use peers to practice their newly acquired social skills ( Chan et al., 2009). Broadly, PMIs have shown improvements in social network inclusion (i.e., number of social connections, peer acceptance, and classroom connectedness), non-verbal social skills (e.g., eye contact, joint attention), play skills (e.g., turn-taking), reciprocal social-communication skills (e.g., conversations, initiations, responses)as well as greater social interaction and increased friendships for children and adolescents with ASD ( Bass & Mulick, 2007; Carter & Kennedy, 2006; Jung, Sainato, & Davis, 2008; Kamps, Potucek, Lopez, Kravits, & Kemmerer, 1997; Kasari et al., 2012; Laushey & Heflin, 2000; Owen-DeSchryver, Carr, Cale, & Blakeley-Smith, 2008; Roeyers, 1996; Strain & Kohler, 1995).

There have been a number of reviews of social skills interventions (see Bellini et al., 2007; Cappadocia & Weiss, 2011; Chan et al., 2009; Ferraioli & Harris, 2011; Kasari & Patterson, 2012; Rao et al., 2008; Reichow, Steiner, & Volkmar, 2012; Rogers, 2000; Wang, Cui, & Parrila, 2011; Watkins et al., 2015; White, Koenig, & Scahill, 2007; Zhang & Wheeler, 2011). Of those, few have focused on PMIs (see Chan et al., 2009; Ferraioli & Harris, 2011; Wang et al., 2011; Watkins et al., 2015; Zhang & Wheeler, 2011). Single-subject design studies in PMIs have been more extensively studied. Two meta-analyses have been conducted examining the efficacy of PMIs ( Wang et al., 2011; Zhang & Wheeler, 2011). Both of these studies exclusively examined single-subject designs and found PMIs to be highly effective for children with ASD. Chan et al. (2009) were more comprehensive in their review and summarized all PMI studies from inception to 2009. In their review, peer training methodology and specific intervention components used in 42 PMI studies were discussed. The authors highlighted the main methods of peer training used in each study, such as reinforcement, verbal explanation, modeling, group discussion, and on-going feedback. The review suggests that PMIs for children with ASD may be quite different from study to study, particularly in the targeted skill sets (i.e., academic skills, disruptive behaviors, social skills). While improving different skill sets are essential for the overall quality of life for individuals with ASD, it is with utmost importance that PMIs specifically targeting social skills be further examined, as social impairment is a core deficit affecting individuals with ASD ( APA, 2013). More recently, Watkins et al. (2015) extended Chan and colleagues' work and summarized 14 additional PMI studies that were published between 2008 through 2014. In their review, Watkins et al. (2015) also focused on the intervention characteristics and strategies. They examined the different strategies used in PMIs and discussed how PMIs may be more appropriate for children with ASD who exhibit different characteristics and deficits. Watkins et al. (2015) highlighted various PMI strategies that included initiations by peers, proximity, prompting and reinforcing initiations.

All of the reviews suggest that PMIs are effective in improving social skills in children with ASD. However, only a small number of group designs were included in these reviews, and these reviews primarily included single-subject designs and studies that targeted ancillary skills (e.g., academic achievement, maladaptive behaviors) associated with ASD rather than core social skills deficits. Since PMIs are one of the most promising interventions for children with ASD, we need to better understand for whom PMIs are most effective by examining studies that have rigorously tested PMIs using group designs. Single subject design studies have provided promising results in the effectiveness of PMIs. However, one of the disadvantages of single subject designs is the generalizability of the results to groups of individuals, particularly one that is as heterogeneous as children with ASD. The current review will expand the literature on PMIs by focusing on studies that used experimental group designs for all school age children (preschool to high school) with ASD that targeted social skills. The current review will use Reichow, Volkmar, and Cicchetti's (2008) evaluation protocol to rate the quality of the PMIs using group designs in the past 30 years. Specifically, the current PMI review summarizes the observed social outcomes and focuses on generalization, sustainment, implementation fidelity, and discusses the clinical implications of these studies in school settings.

2. Methods

2.1. Search strategy

A comprehensive search was conducted in June 2015 using three electronic databases (PsycInfo, Educational Resources Information Center (ERIC), and PubMed) covering education, psychology, and medicine. Keyword search terms spanned four areas included those related to autism (autis* or pervasive develop* or Asperger*); social skills (social skill* or social interaction* or social initiations* or social engagement*) and peer mediated intervention (peer*) and school based (school*). A total of 1343 articles were found using this keyword search; but only five studies met the inclusion and exclusion criteria described below.

2.1.1. Inclusion and Exclusion Criteria

A set of inclusion and exclusion criteria was applied to the manuscripts that were obtained from the search. Included studies:

1. Involved participants of any age diagnosed with ASD including autism, pervasive developmental disorder, or Asperger syndrome.

2. Examined a PMI for which a social skill (e.g., peer engagement, initiations, responses) was the primary outcome.

3. Described a peer-training component as part of the PMI.

4. Were published in English.

5. Were not restricted by publication year.

2.2. Rating method quality

The methodological quality of the studies was rated using Reichow et al.' (2008) evaluation protocol. The protocol included items specific in rating group trials. The protocol included six primary quality indicators (i.e., participant characteristics, independent variable, comparison condition, dependent variable, data analysis, and use of statistical tests) and eight secondary indicators (i.e., random assignment, inter-observer agreement, blind raters, fidelity, attrition, generation and/or sustainment, effect size, and social validity). Two independent raters assessed and double coded all five studies. Cohen's Kappa was used to calculate interrater reliability (κ = 1.00, p < 0.001).

3. Results

The systematic search of the literature resulted in 1343 articles. Titles and abstracts of the articles were examined. After removal of irrelevant articles, duplicates, and reviews, a total of five articles were included in the current review. Overall, there were four randomized controlled trials and one pre- and post-test design. In addition, four of the studies were conducted in school settings, whereas one study was conducted in a camp setting. Study characteristics and outcomes are summarized in Tables 1 and ​and2 2 .

Table 1

Author

# Participants

Grade/Age

# Peers and Characteristics

Intervention Setting and Procedures

Trainer

Peer Training

Treatment Length and Dose
Kasari et al. (2012)
60

1-5
Age: M=8.14

3 typical peers from target child's classrooms. Peers were nominated by teachers based on appropriateness and peers' social network salience.

Peers were trained to engage children with social challenges on the playground.

Research Staff

Peers identified isolated children and used strategies to engage them; Direct instruction, modeling, role play, and rehearsal strategies were used to teach these skills to engage children with ASD.

6 weeks; 2×/week

Table 2

Author

Social Skills Measures

Social Outcomes

Generalization

Sustainment

Fidelity

Effect Size

Blind Observer

Inter-rater Reliability

Corbett et al. (2014)
Developmental Neuropsychological Assessment measures social perception
Social Responsiveness Scale (SRS) measures social functioning including social awareness, communication, and cognition
Companionship Scale measures verbal and nonverbal behaviors
Peer Interaction Paradigm: 20-min playground interaction with two novel peers to measure social engagement

Significant increase in all social outcomes, except social communication on the SRS and social engagement on the Peer Interaction Paradigm.

20-minute playground interaction with two novel peers (ns)

NO

Research Staff Training Fidelity: pre and post training (89% and 91%, respectively)
Peer Treatment Implementation Fidelity: Rated on a Likert scale of 1-5. Pre-intervention range: 2.6-3.67. Post intervention range: 3.67-4.2

Range: d=0.23-0.74

NO

NO

Kalyva and Avramidis (2005)
1-h circle time observation to measure social initiations and responses were coded.

Significant increase in social responses, but not social initiations

NO

2 month follow up: significant increase in social responses but not initiations

NO

N/A

NO

93.4%

Kamps et al. (2014)
10-min free play observation to measure total communicative acts

Both groups increased in total communicative acts (No significant difference between groups)

Two 10-min free play generalization probes with trained and untrained peers in Fall, Winter, and Spring. Both groups increased in initiations, responses, and total communication (No significant difference between groups)

Improvements maintained for total communicative acts from beginning of the year to mid-year, but did not increase in the spring

School Staff Implementation Fidelity: 3 h in-service training including, role play, rehearsal, and, model direct instruction; 15-100% (average: 86%)

N/A

NO

Non-treatment social probe: 33-100%; Generalization probe: 40-100%
Intervention session: 84-89%

Kasari et al. (2012)
Playground Observation of Peer Engagement (POPE) measures solitary and joint engagement
Social Network Salience (SNS) measures child's prominence within his/her classroom social network
Teacher Perception of Social Skills (TPSS) measures teacher's perception of children's social skills

Significance increase in SNS and TPSS

Significant increase in TPSS

12-week follow up: significant increase on the POPE and SNS, but not TPSS

Research Staff Implementation Fidelity: 94%

d = 0.69

YES

100%

Roeyers (1996)
10min videotaped sessions to measure duration of social interaction, social initiations and social responses

Significant increase in all social outcomes.

Social Behavior Rating Scale completed by school staff

NO

NO

N/A

YES

96%

3.1. Methodological quality

The five studies had mixed quality ratings between "strong" and "adequate." Three of the studies received a "strong" quality rating ( Kamps et al., 2014; Kasari et al., 2012; Roeyers, 1996). These studies had "high" quality ratings for all primary quality indicators and at least four of the secondary quality indicators. The other two studies were rated as "adequate" and "weak", respectively ( Corbett et al., 2014; Kalyva & Avramidis, 2005). The "adequate" rated study met four of the primary quality indicators and at least two of the secondary quality indicators, and the "weak" rated study met fewer than four of the primary indicators. Overall, these studies used manualized treatment or described their intervention in detail, had strong links between their research questions and data analysis, and demonstrated generalization and/or sustainment (maintenance of skills after intervention has ended) of targeted skills.

3.2. Participants receiving intervention

The five PMI studies examined included children from preschool to high school age (N = 260). The number of participants in the studies varied widely across the fives studies, ranging from a small sample of five participants ( Kalyva & Avramidis, 2005) to a large RCT of 95 participants ( Kamps et al., 2014). Overall, two studies included fewer than 12 children ( Corbett et al., 2014; Kalyva & Avramidis, 2005), and three studies utilized 60 or more participants ( Kamps et al., 2014; Kasari et al., 2012; Roeyers, 1996). Four of the five studies (80%) comprised elementary-aged children with ASD. Only one study examined preschool-age children ( Kalyva & Avramidis, 2005), and none of the studies specifically targeted middle or high school age children. Corbett et al. (2014) recruited children between the ages of 8-17, but their program was not specifically designed for adolescents. Additionally, most of the studies enrolled children who had at least average IQs, except for one study ( Roeyers, 1996). To participate in these interventions, children were expected to communicate using 2-3 word phrases minimum. Although Roeyers (1996) examined children of varying levels of cognitive ability, including children who had low IQ/DQ scores, cognitive ability was not specifically examined as a moderator for treatment outcomes. Autism diagnosis also was examined differently in each of these studies. The Autism Diagnostic Observation Schedule (ADOS) is used as a gold standard for classifying individuals with ASD, but only two of the five studies used the ADOS to confirm autism research eligibility ( Corbett et al., 2014; Kasari et al., 2012). The other three studies used the DSM III ( Roeyers, 1996), and school autism eligibility ( Kalyva & Avramidis, 2005; Kamps et al., 2014) to confirm children's ASD diagnosis.

3.3. Peer training

For all studies, peers were selected via teacher nomination. Three studies documented that teachers nominated peers who had regular attendance, had appropriate social skills, and were high in social status in the classrooms ( Kamps et al., 2014; Kasari et al., 2012; Roeyers, 1996). For one study, peers also had experience interacting with children with ASD ( Corbett et al., 2014). Peer models comprised typically developing students who were in the same general education classroom, a grade belowor above, as children with ASD. Peers were not specifically matched on gender. In all studies, peers were asked to identify children who were isolated or playing alone and engage that childin an activity or game play. Most of the studies also gave a presentation about ASD except for one study (see Kasari et al., 2012).

All studies used a structured peer-training model to teach specific strategies (e.g., respond to target children, model for target children) to typically developing peers, with the exception of Kalyva and Avramidis (2005). In Kalyva and Avramidis (2005), teachers provided general instruction to typically developing peers to help children with ASD play followed by positive reinforcement. The remaining four studies had a didactic component, modeling by trainers ( Corbett et al., 2014; Kamps et al., 2014; Kasari et al., 2012), and role-play or rehearsal with typically developing peers ( Kamps et al., 2014; Kasari et al., 2012; Roeyers, 1996).

All the studies included a peer training component and no separate training for just the children with ASD except for Kasari et al. (2012). Typically, peers were trained first, and then placed to interact and socialize with children with ASD. During these socializations, the trainers' main role was to support and facilitate the interactions between children with ASD and the peers. The settings for their interactions varied depending on the study. For example, most of the studies conducted their play indoors in the classrooms, except for Kasari et al. (2012) who conducted their intervention outdoor on the playground.

3.4. Social outcomes

All studies used a social skills measure, but the type of measure and social outcome widely varied across studies. All studies used direct observations to measure children's social skills, but only two studies used observers who were blinded to children's treatment condition ( Kasari et al., 2012; Roeyers, 1996). All of the observation measures examined children's initiations of and responses to social communication; however, these data were collected in different social contexts and used different operational definitions. For example, Kalyva and Avramidis (2005) examined social initiations and responses separately during a one-hour circle time, while Kamps et al. (2014) combined both social initiations and responses (i.e., communicative acts) and observed children during a 10-min free play. Other studies also measured children's joint engagement, conversation, and duration of social interaction ( Kasari et al., 2012; Roeyers, 1996).

In addition to observations, two of the studies also used multi-rater (i.e., parents, teachers, and researchers) social skills measures ( Corbett et al., 2014; Kasari et al., 2012). Corbett et al. (2014) had parents complete the Social Responsiveness Scale ( Constantino & Gruber, 2005), which measures children's social awareness, social communication, and social cognition. Researchers were asked to rate children's social skills using the Developmental Neuropsychological Assessment (NEPSY; Korkman, Kirk, & Kemp, 2007), that measures social perception, and the Companionship Scale ( Bauminger, 2007) that assesses children's verbal and nonverbal social behaviors using a 5-point Likert scale ( Corbett et al., 2014). Kasari et al. (2012) used the Teacher Perceptions of Social Skills, which measures children's social skills and classroom behaviors (e.g., quality interactions with peers) on a 3-point Likert scale. Data also were collected directly from children. Children were asked to complete a peer nomination measure that examined their social acceptance and social network inclusion before and after treatment as well as during a 3-month follow-up ( Kasari et al., 2012). Lastly, two of the studies also reported effect sizes for the social outcomes ( Corbett et al., 2014; Kasari et al., 2012). The effect sizes varied depending on the social outcome and ranged from small to large effect size (d= 0.23-0.74). Of the different social outcomes from the two studies, social awareness had the smallest effect size and total social skills had the largest effect size.

3.5. Implementation fidelity

Various types of implementation fidelity (e.g., adherence, competence, use) were reported in three of the five studies ( Corbett et al., 2014; Kamps et al., 2014; Kasari et al., 2012). Of the three studies, implementation fidelity was collected on research staff members that were trained to deliver the intervention within the school or camp setting in two studies ( Corbett et al., 2014; Kasari et al., 2012), and only one study measured implementation fidelity on trained school personnel ( Kamps et al., 2014). Implementation fidelity was measured using a variety of techniques including coding therapist treatment notes ( Kasari et al., 2012), a checklist monitoring tool ( Kamps et al., 2014), and pre-and post- training exams, rating scales, and treatment logs ( Corbett et al., 2014). Overall, implementation fidelity was high ranging from 86% to 94% fidelity across studies. Lastly, only Corbett et al. (2015) examined peer implementation fidelity.

3.6. Generalization and sustainment

Four studies examined generalization of acquired social skills ( Corbett et al., 2014; Kamps et al., 2014; Kasari et al., 2012; Roeyers, 1996), and three of the studies examined sustainment ( Kalyva & Avramidis, 2005; Kamps et al., 2014; Kasari et al., 2012). Generalization was examined differently in each of the studies. Two studies used generalization probes during free play with both trained and untrained peers and examined the frequency of children's social interaction and communicative acts ( Corbett et al., 2014; Kamps et al., 2014). The other two studies used teacher reports of social skills to measure generalization of skills to different contexts ( Kasari et al., 2012; Roeyers, 1996).

Three of the studies examined sustainment although the sustainment period was relatively short. Kalyva and Avramidis (2005) had a 2-month follow up of their participants. Both initiations and responses were examined in the study, but only children's responses to social communication were maintained at follow up. Kasari et al. (2012) had a 3-month follow up where the primary social skills outcomes (i.e., playground engagement and social network inclusion) were sustained; however, teacher-reported social skills were not significant at the follow-up period. Kamps et al. (2014) had a longer sustainment period (Fall to Spring); however, improvement of communicative acts only maintained from Fall to Winter, but not to Spring.

3.7. Evidence-based practice

Using Reichow et al.'s (2008) framework and definition, the evidence demonstrated by the reviewed studies indicates that PMIs have "established evidence based practice." By definition, Reichow et al. (2008) state that treatments have "established evidence-based practice" if they have "at least two group experimental design studies of strong research report strength conducted in separate laboratories by separate research team." (p. 135). There were three studies in this review ( Kamps et al., 2014; Kasari et al., 2012; Roeyers, 1996) that were evaluated as being "strong" using Reichow et al. (2008) criteria ( Table 3 ).

Table 3

Author

Primary Quality Indicators

Participant Characteristic

Independent Variable

Comparison Condition

Dependent Variable

Link between research question and data analysis

Use of statistical tests

Author

Secondary Indicators

Random Assignment

Interobserver Agreement

Blind raters

Fidelity

Attrition

Generalization/Maintenance

Effect Size

Social Validity

4. Discussion

In the past few decades, there has been an increase in PMI studies for children with ASD. Despite this increase, many studies utilized single-subject designs, and relatively few have used large randomized controlled field trials. This review points to a current shift in the field in that more studies have started to use group designs in real world community settings. Only one of the group design studies ( Roeyers, 1996) in the current review was included in the last published systematic reviews of PMIs (see Chan et al., 2009; Watkins et al., 2015). Notably, three of the five studies in the current review were published in the last five years. Furthermore, most of these studies also demonstrated quality ratings of "high" or "adequate", and that it is possible for children with ASD to make significant changes in their social skills in both school and camp contexts as reported by parents, teachers, researchers, and children and adolescents themselves.

This review highlights the growing need for future research in five critical areas. While the number of PMI studies that use a group design was limited, all of the studies focused on a select sample of children with ASD - namely, children with average to above average cognitive functioning. It is possible that PMIs could be the most effective for high functioning children with ASD; however, without comparable data on the majority of children with ASD who are not represented in research - particularly children who are minimally verbal and lower functioning - as well as ethnically and culturally diverse samples, it is not possible to profile for whom PMIs are most effective ( Kasari & Patterson, 2012). Future research is needed to understand the effectiveness of PMIs particularly for underserved, under resourced, and underrepresented populations.

Second, in our review of the literature, there were no randomized controlled group designs that specifically focused on middle and high school students with ASD. Because the social landscape dramatically changes between elementary and secondary school, there may be fewer established guidelines for selecting peers models for adolescents with ASD. Logistical factors such as changing classroom periods and fewer opportunities for unstructured social interaction in middle and high school settings may influence how peer models are selected to participate and how PMIs are implemented. Nonetheless, middle and high school students with ASD may be most in need of PMIs given the fragility and critical importance of social relationships during adolescence. Future research is needed in this area to determine whether PMIs are appropriate for middle and high school students with ASD and/or whether adaptations (e.g., delivery, selection of peer models) to existing PMIs are needed for successful implementation.

Third, this review provided insight into the components of peer training models that future PMI studies may want to consider. Most of the PMI studies in this review had a didactic component, modeling sessions, and rehearsal practices as part of the peer training. Interestingly, the only study that did not have these components also did not have significant increases in social initiations (but had social responses) from children with ASD. This suggests that peer models may need more structured training to help them intentionally think about, plan, and create opportunities for social interactions to promote social initiations when they interact with children with ASD. This is particularly important for future studies as researchers design their interventions and decide on targeted social outcomes for children with ASD.

Fourth, the discussion of implementation fidelity is notably absent from many PMI studies, particularly those conducted in real world settings (e.g., training school personnel) where implementation fidelity is arguably more important. The type of implementation fidelity measured (e.g., use, adherence, dose, quality of delivery, etc.) and the processes in which implementation fidelity data are collected (e.g., observer rated, self-report) has not been systematically measured across studies. This review highlights the critical need for systematic ways to measure implementation fidelity. Although only one study reported achieving above 80% implementation fidelity when school personnel implemented the intervention, the expectation of achieving 80% implementation fidelity, the level to which we train experts in clinic or university-based studies, in school or other community settings may not be realistic given the barriers and constraints (e.g., inexperienced and untrained school personnel, time, resources, etc.) to implementation observed in the school context ( Locke et al., 2015). Perhaps engaging in the core components of the intervention or using certain evidence-based strategies as opposed to none is a sufficient catalyst for improvement in various social outcomes in schools and other community contexts. There is also very limited fidelity data specifically measuring peer implementation. Measurement of how well peers implemented these strategies will be important considering that peers are the main social partners for children with ASD, particularly on the playground where adults may not be present. Additional research should examine potential mediators and moderators (e.g., child characteristics, teacher fidelity) that may contribute to the effectiveness of peer-mediated interventions. Future research is needed to understand these critical questions related to successful implementation in real-world settings.

Lastly, the assessment of generalization and sustainment of social skills were under examined in these studies. The targeted social skills (i.e., initiations, responses, social interaction) in these PMIs were intended to help children with ASD develop and maintain meaningful relationships with others. Thus, to make PMIs more relevant and meaningful in school settings, children with ASD should be able to use and sustain these newly acquired social skills in different social contexts and not just within the context where the intervention was conducted. Future research should consider the context in which social outcomes are gathered to fully explore generalization and sustainment of learned skills. In addition, the follow-up periods were relatively short in the three studies that examined sustainment. Despite the limited time frame of conducting research in school settings ( Owens et al., 2014), it may be of critical importance to explore long-term sustainment of intervention effects into the next school year and beyond.

5. Conclusion

Although this review only included five articles, there is much to be gleaned from reviews with small sample sizes ( Reichow et al., 2012; Spain & Blainey, 2015). This review is consistent with previous review studies in terms of treatment effects ( Chan et al., 2009; Watkins et al., 2015), and provides further support of the effectiveness of PMIs for children with ASD by examining group design studies. Though there are populations of children with ASD (e.g., minimally verbal) that PMIs have not targeted, the group designs demonstrated that PMIs are effective for many children with ASD. The range of abilities of these children was more diverse in these group designs than what has been demonstrated in previous single subject design studies. It also provides support that PMIs may be conducted in schools, within the context where the most meaningful gains can be made.

Even though PMIs have an "established evidence base" using Reichow's protocol, more work still needs to be done in this field. According to Chambless and Hollon (1998), empirically supported interventions should have: 1) a comparison control group; 2) a treatment manual (i.e., fidelity); 3) clearly defined population(s); and 4) reliable and valid assessment outcomes. This review revealed that group and comparison designs are relatively scarce, and very few of the PMI studies measured implementation fidelity (n = 3). In addition, studies should use more standardized assessments to capture diagnosis and social skills from multiple informants. The limitations highlighted in this review suggest that PMI approaches are promising to address social skills in children with ASD, but there are many unaddressed and understudied areas (e.g., moderate to severe individuals with ASD, middle and high school students with ASD, implementation fidelity, and the generalization and maintenance of meaningful social outcomes) that warrant additional research. Future research on PMIs should focus on: 1) addressing more diverse populations of children with ASD, specifically children who are minimally verbal and adolescents with ASD; 2) measuring implementation fidelity; 3) collecting generalization and maintenance data, and 4) examining potential mediators and moderators.

Acknowledgments

This study was partially funded by NIMH K01MH100199, the Autism Science Foundation (Grant # 13-ECA-01L) and FAR Fund Early Career Award awarded to the last author.

References

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A systematic review of peer-mediated interventions for children with autism spectrum disorder

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Peer mediated intervention (PMI) is a promising practice used to increase social skills in children with autism spectrum disorder (ASD). PMIs engage typically developing peers as social models to improve social initiations, responses, and interactions.The ...

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Module 12- Video and Computer Aided Instruction

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Module 12- Video and Computer Aided Instruction

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Approach: Video Modeling

Goal: By the end of the school semester, the client will be able to watch a basic video model teaching them how to tie their shoe and will be able to tie their shoe 80% of the time with video model support and 65% of the time without video model support.

Approach: Visual Support

Goal: By May 9th, the client will successfully transition from one task to another with no dysregulation 80% of the time using a visual support in the classroom setting.

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Pragmatic Language: Enhancing Social Skills for Meaningful Interactions Pragmatic Language: Enhancing Social Skills for Meaningful Interactions Introduction: Social skills play a crucial role in our daily interactions. They enable us to navigate social situations,...

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Incorporating Video Modeling into Speech Therapy Sessions: A Guide | Everyday Speech

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Incorporating Video Modeling into Speech Therapy Sessions: A Guide Incorporating Video Modeling into Speech Therapy Sessions: A Guide Welcome to my blog! Today, we will be exploring the powerful tool of video modeling and how it can enhance social emotional learning (SEL) in speech therapy sessions.

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Module 13- Visuals and Special Interests 

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Module 13- Visuals and Special Interests 

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Approach: Visual Support

Goal: By the end of the semester, the student will be able to understand and complete a step-based task with 80% accuracy using a visual support when necessary.

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Using visuals and visual schedules in speech and language therapy is far from a new idea. Visuals are one of an SLPs favorite tools for scaffolding and teaching new skills! This is because they're practical, can be used to teach a wide variety of skills, and can even be useful in carryover of target skills into new environments.

Some examples of visuals SLPs might use in therapy are:

Visual Schedules (including first/then boards)

Visual schedules are so important for many of our students with autism, anxiety, or lower receptive language skills. They help our students understand what is coming next and because of this, can reduce anxiety and frustration.

If you're looking to increase your use of visual schedules, I'd highly recommend the app ChoiceWorks. It's a fantastic, versatile app that I've used for years!

Panda Speech also offers a completely FREE visual schedule on this blog post of hers.

Visual Strategies (e.g., graphic organizers, mind maps, anchor charts)

Graphic organizers and anchor charts have become a staple in my therapy sessions. I love using the large Post-It note posters to make these so I can write and draw them live during sessions.

Sentence Strips

I love using sentence strips for my students of all ages! I use them to expand utterances and to model functional carrier phrases that my students can use to comment, label, request, ask questions, and more!

Because I was using them so often, I created a resource filled with functional carrier phrases that I could use in a wide variety of activities including games and picture books. It contains 70 different sentence strips with a variety of carrier phrases on them. Click here to check it out.

Skill Specific Visuals

These types of visuals usually provide direct teaching about a specific speech, language, or social skill. The ones I provide for my students typically provide a short, student-friendly explanation of the skill and a visual representation of that skill or strategy.

If you're looking to increase visual supports in your speech and language therapy to teach specific skills, I have several resources that will help you do just that!

First, if you want to teach specific language skills including vocabulary strategies, reading comprehension strategies, types of text, and more, click here to check out my Visuals for Language Skills and Strategies resource.

If you're looking for skill specific visuals to target social skills, click here to check out my Social Skills Focus Sheets. They're great for getting students to focus on one targeted skill each session and for self-reflecting on their use of that skill.

And because of my love for visuals, most of the resources in my store contain helpful visuals for both students and SLPs alike!

Hope that's helpful! Thanks so much for reading!

And in case you're interested, I send out a few emails a month with helpful tips, my favorite speech therapy finds, freebies, sale information, new product releases and more. You can sign up using the box below:

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Using visuals and visual schedules in speech and language therapy is far from a new idea. Visuals are one of an SLPs favorite tools for scaffolding and teaching new skills! This is because they're practical, can be used to teach a wide variety of skills, and can even be useful in carryover of target skills ...

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Approach: FCT with vocal client

Goal: by the end of the semester, the student will use a picture card to show that he is dysregulated rather than throwing objects at 80% accuracy with no verbal prompting

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Approach: music-mediated

Goal: By May 24th, the student will be able to self regulate their emotions by using visual prompting from a social story song 8/10 times.