Journal o f Autism and Developmental Disorders, Vol. 13, No. 3, 1983

A Pragmatic Approach to Increase Expressive Language Skills in Young Autistic Children I

Jean Madsen Beisler 2 and Luke Y. Tsai

University o f Iowa College o f Medicine

This paper is a description o f a pilot communication program for autistic children designed to increase communication skills in the context o f establishing reciprocal communication exchanges. The methods involved intensive modeling o f verbal responses within joint activity routines and using a reinforcement system based on fulfilling the intent o f the child's communication. Five male subjects ranging in age from 36 to 68 months participated in the communication program for 6 weeks during an inpatient stay at the Iowa Autism Program, Child Psychiatry Service. Com- munication exchanges involving requests for actions and objects, descriptions o f actions and objects, comments on existence and nonexistence, and requests for recurrence were targeted. Individual gains for each subject are outlined. Posttreatment results indicated a significant increase in the mean length o f response, in the mean receptive language level, and in the mean number o f semantic-grammatical rules expressed. Suggestions regarding future research are discussed.

The failure to develop normal communicative speech is one of the principal diagnostic features of autism (Kanner, 1946; Wing, 1969; Rutter, 1978). Operant approaches have been used to develop communication skills in autistic patients (Wolf, Risley, & Mees, 1964; Risley & Wolf, 1968; Lovaas, 1977). These techniques, however, have many shortcomings. For example, reinforcement systems using edibles, tokens, or verbal praise may ignore the functional use of the utterance and therefore would appear to be in- efficient in increasing the autistic child's ability to use communication in

1The authors wisk to thank Dr. Mark A. Stewart and Dr. Bruce Tomblin for their review of the manuscript, and Helen Malloy for final preparation of the manuscript.

~Address all correspondence to Jean Madsen Beisler, Child Psychiatry Service, 500 Newton Road, Iowa City, Iowa 52242.

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0162-3257/83/0900-0287503.00/0 @ 1983 Plenum Publishing Corporation

288 Beisler and Tmi

natural exchanges. Programs that require the child to sit and attend or to maintain eye-to-eye contact for a required number of seconds are time- consuming and do not address the goal of communication as an interaction. Programs that focus on the trainer asking direct questions for the autistic child to answer may give many opportunities to respond but few opportunities to initiate communication. These techniques have not helped the autistic person to learn how to use language for various purposes such as requesting, informing, seeking information, greeting, and commenting on the environment.

When developing a program to facilitate useful language in the autistic population, it is helpful to examine how normal children develop their communication skills. According to Brunet (1975), normal children develop a notion of reciprocal action before they learn to speak. Bruner postulates that this action takes place through early interactive routines. The normal infant learns how to engage someone's attention, how to establish a common focus, and how to participate in the "communication game" by engaging in turn-taking activities. The child learns to expect that his/her initiations will be answered, verbally or nonverbally. A pragmatic perspective would thus focus on facilitating effective interactions to teach these early skills. After these basics are mastered, efforts can be directed toward expanding syntax skills, but always in the context of conversational rules.

Normal infants learn to understand the predictable outcome of their actions, whether they are verbal or nonverbal. If an autistic child is to make a connection between action and consequences, the reinforcement that is used in the communication program needs to be immediately relevant. If we want to teach an autistic child what to way, and how the word or phrase can be used, it would seem that the most relevant consequence would be fulfilling the intent of whatever it is the child has communicated. Fay and Schuler (1980) have suggested that for children who are non- communicative, the teaching of requests seems to be in line with what is known about normal development. Schuler also suggests that this spontaneous use may be more easily promoted when the communication provides an unambiguous payoff.

In view of the literature on autism and normal development, as well as our own clinical experiences with normal and autistic children, we believe that part of the communication deficit in the autistic childen is that they have not learned to take turns in social exchanges of communication, to anticipate events, or to establish a common focus, or that their efforts would pay off in regulating their environment. There is a need for developing an efficient way to help the autistic children learn the function of language before placing an emphasis on the form of language. The

Increasing Expressive Language Skills 289

intervention model to be reported in this paper was developed on the as- sumptions that (1) the autistic child needs to establish a reciprocal turn-taking relationship with a significant other, (2) verbal language can develop within child-oriented joint activity routines where conversation is defined as an exchange of some message either with or without words, and (3) goals and techniques emphasizing natural conversational exchanges and a reinforcement system consisting of responding to a child's intent of his communication are sufficient to teach new skills and to maintain skills that are already in evidence. We wanted to find out whether autistic children who possess some verbal language could demonstrate a noticeable increase in language skills when exposed to more natural communication exchanges than those activities outlined in previous, structured operant programs.

METHOD

Subjects

Five male subjects participated in this preliminary study while enrolled in the short-term residential program at the Child Psychiatry Service, University of Iowa Hospitals and Clinics. This 6-week residential program includes a multidisciplinary and treatment approach where the children receive 24-hour care. Focus of the general program is medical and behavioral in orientation. The children attend daily educational classes as well as receiving occupational and recreational therapy daily. The nursing staff address such concerns as eating, dressing, toileting, social skills, and behavioral problems. Communication therapy is scheduled on a regular basis. All five children were diagnosed as autistic by two child psychiatrists according to the criteria established by Rutter (1971, 1977).

Audiometric testing indicated that all five subjects' hearing was within normal limits for the development of speech and language. Each child underwent a thorough evaluation during the 1st week of the 6-week in- patient stay. This evaluation included educational assessment; assessment of intellectual functioning using the Merrill-Palmer Scale of Mental Tests (Stutsman, 1948), Leiter International Performance Scale (Leiter, 1969), and other standarized tests; assessment of fine and gross motor skills; neurologic assessment; and assessment of communication skills. Each child's communication skills were assessed by the Sequenced Inventory of Communication Development (Hedrick, Prather, & Tobin, 1975), the Symbolic Play Test (Lowe & Costello, 1976), by analyzing a sample of

290 Beisler and Tnl

conversational speech to assess the mean length of response, as well as by the use of other selected language and articulation tests. During the last week of the inpatient stay, the first three measures were repeated in similar circumstances to the pretreatment assessment. The five subjects were seen individually and in groups for communication therapy following the l-week evaluation. Therapy sessions were 15-30 minutes in length.

Procedure

Because the target of remediation was focused on the use of communication as opposed to the specific form and structure of com- munication, we can only provide the general principles of the interactions established. The exact lexical items used and number of times used were determined by the child's prevailing interests and hence vary for each child and each session. The nature and outcome of each interaction within a specific session take their direction from the child's response at that particular time and thus cannot be outlined in the traditional format where the trainer has preselected the language form to be taught and how many trials for a given item will be presented at any given time. For example, if the target is to facilitate requests for action, any lexical item from the child that exercises this intent would be acceptable and hence can only be analyzed retrospectively after a session. In any given session, a child may engage in a specific request for one action over numerous exchanges, e.g., "push swing," or he may engage in sequentially different requests for different actions, e.g., "open can, take Play-Doh out, give Play-Doh." In subsequent sessions, identical requests may be elicited or new re- quests may be modeled o r elicited depending on the clinical judgment of the clinician as to what the child will be motivated to use. ActiVities are chosen that afford social exchanges either by exchanging duplicate events (e.g., ball throwing), requiring one event before another occurs (e.g., adult pours juice in cup to give to child when requested), requiring a verbal response to get a single action (e.g., tickle), or manipulating favored toys in deferred imitation (e.g., boy doll riding in dump truck). Table I provides an expanded list of examples. In the same regard, the principles outlined below should be viewed as guidelines that can be manipulated flexibly according to the situation at hand and thus require the clinician to be sensitive to the amount and type of input used to elicit output from the child that is as independent as possible from direct prompts for specific forms.

Establishment o f Interpersonal Routines and Turn-Taking

During the assessment period, objects and events are identified in which the child demonstrates interest and which are conducive to turn-

Increasing Expressive Language Skills

Table I. Examples of Activities that Encourage Turn-Taking Exchanges and/or Requests

291

Dump trucks that are pushed down a ramp to disappear into a garage (box)

Soap bubble jar with lid and stick where stick is exchanged to proceed to blowing bubbles

Balls to roll or throw back and forth Balloons that can be inflated, deflated in a whoosh of air, and reinflated Tickling Swinging Requesting edibles Dolt play Pushing a top to view spinning motion Pushing a button or lever to activate radio or some motion Completion of puzzles Completion of object assembly (Potato Head, car model, Lego building) Transparent containers with lids difficult to open and containing some

desired object/edible Stringing beads to make a necklace

taking exchanges. F rom this pool, several are chosen that can be used to elicit at least one of the following communicat ion uses: requests for actions/objects, comments on existence and nonexistence, descriptions of objects and actions, and requests for recurrence. For any one activity, the clinician initially models an appropriate verbal response and engages the child in the nonverbal aspects o f the exchange so that the child is repeatedly exposed to the response that results in a predictable outcome. During initial contacts with an activity, the child is not required to verbalize but is expected to participate nonverbally. I f the child does not participate nonverbally, he is postured through the activity. Within one t reatment session, several activities are presented, the number and length of which depend on the child's interest. Initially, only one utterance is modeled for each activity, and any specific activity is used to illustrate only one function.

When the child has had sufficient exposure to the models and the expected outcome, the clinician presents the verbal model and waits with clear expectation for an imitated response f rom the child. Specific guidelines for how many models to give before anticipating a response at this phase cannot he given. Generally speaking, the child will probably need 8-10 repeated exposures to a single activity in a single session for at least three successive sessions before the clinician can program in pauses to see if the child will imitate in order to get the expected outcome. I f the child does not imitate, the initial phase is presented again.

Once the child is offering consistent imitations of the model, the clinician presents the physical context only and waits for the child to offer spontaneously the learned response. The context is arranged to present

292 Beisler and Tsai

some obstacle that must be resolved for the activity to be completed. For example, several blocks are missing to complete the building and their absence cues the child to request the appropriate object. When the child uses the learned response, the expected outcome occurs. If the child does not volunteer a response, the clinidan may use a direction such as "Say

" to elicit a response, and this prompt can be gradually faded using decreasing volume. However, the children in this study quickly learned that it was their turn to do something, and direct commands to imitate were used sparingly.

When the child is offering a specific learned response to an activity, the clinician has several options. A new activity to elicit the same response can be introduced, a new activity to elicit a new reponse illustrating the same function can be introduced, or the same activity can be used to introduce a longer response (moving from one word to a two-word phrase) illustrating the same function.

When several responses of any variety have been learned, discrimination training can be introduced. During the initial phase of this step, the clinician decides what is to be requested and focuses the child's attention on this by pointing to either the object or the action the child is to request or describe, by placing that object or event closer to the child, or by wiggling the object in one hand. If the child does not initiate an exchange in the presence of the physical context, the clinician drops to an earlier phase and models the response, asks a direct question (e.g., "Do you want Jean to open the can?"), introduces an indirect model (e.g., "The can is shut. I'll open the can"), or changes activities so that excessive verbal prompts will not diminish the impact of the environmental cues in self-initiated speech. Because many routines are established for similar activities, the change can be made while maintaining the target goal. Table II illustrates an example of teaching phases for one activity.

General Procedures

The majority of the therapy time is spent on establishing a dear, consistent routine and modeling the child's turn. Activities are set up that use real objects as opposed to pictures, as objects lend themselves more easily to varying combinations. Because a picture is a static array that does not vary, it seems that a high-functioning child could quickly memorize a response that could be based on an unknown attribute in a picture, possibly irrelevant to the target goal. We also wanted the activities to encourage conversational exchanges, and it seemed apparent that what we do in real life the majority of the time is talk about things that we want, need, or see and what we or someone else should do or is doing. Proper names are used

Increasing Expre~ive Language Skills

Table II. Example of Approach for One Specific Responsea

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Target function: Request action

Activity: Blowing bubbles

Initial phase Clinician and child seated on floor. Clinician takes stick, dips into soap, removes stick, says, "Blow," and proceeds to blow bubbles. This single sequence carried out for perhaps 10 repetitions in each of 3-4 sessions. Future extension - clinician will model "all gone" after bubbles are popped.

Second phase Clinician and child seated on floor. Clinician takes stick, dips into soap, removes, says, "Blow," and waits for child to imitate. When child verbally imitates or uses a gesture/ sign, the action proceeds. If the child does not imitate after a 5- to 10-second pause, the child is postured through a gesture or sign to indicate what he wants. Then return to the initial phase for several trials, terminate the activity, and move to a new activity. This phase is continued until child imitates 90% of the time a model is presented.

Third phase Clinician and child seated on floor. Clinician takes stick, dips into soap, removes stick, and waits for a response. When child offers the correct response, the clinician performs the action and expands the model to "blow bubble" or "Jean blow," depending on future targets. This phase is continued until the child spontaneously offers the response 90% of the time. If the child does not offer a response after a 5- to 10-second pause, the response is modeled for the child and a direct question is asked, i.e., "Blow. What should Jean do?"

Fourth phase Option 1

When two different responseshave been learned, "blow" and "push," in separate activities, the clinician arranges the two physical contexts for the activities side by side. The child makes a request, which the clinician then fulfills, If the child repeatedly requests only one of the actions, the climcian may choose to ignore the request and direct the child to the other activity by pointing or giving a verbal prompt such as "How about this?" or "What can I do with this?"

Option 2 The initial request, "Blow," is taught in a new context, i.e., "Blow balloon." When the same request is used consistently for two contexts, the clinician proceeds to contrast the two activities as outlined in Option 1.

Option 3 The initial request, "Blow," is expanded in length, and procedures follow the steps outlined in phases 1-3.

aAny single session may involve any number of activities and responses at different levels of the procedures. Initial sessions will involve fewer activities. As the child adds to his repertoire, more activities can be added and contrasted with a few number of trials on each item.

in p l a c e o f p r o n o u n s as t h e c h i l d r e n w e r e a t the early s t a g e s o f l a n g u a g e

d e v e l o p m e n t . T h e use o f p r o p e r n a m e s c lear ly p o i n t s o u t t h e a c t o r o r receiver a n d s h o u l d h e l p t o f a c i l i t a t e d i s c r i m i n a t o r y r e s p o n s e s in g r o u p ac t i v i t i e s , a s

in t h e c a s e o f J o h n r e q u e s t i n g f r o m e i t h e r o f t w o p e o p l e ( e .g . , " [ N a m e ]

p u s h t r u c k " ) . O n c e a c h i l d h a s s e v e r a l r e s p o n s e s t h a t h e u se s c o n s i s t e n t l y , i t

is q u i t e s i m p l e t o i n t e r j e c t a p p r o p r i a t e q u e s t i o n s , s u c h as " W h a t s h o u l d

294 Beisler and Tsai

Jean do?" or "What do you want to do? However, care was taken to use questions sparingly as the final goal is self-initiated communication. Other appropriate phrases are interjected by the clinician in the hopes of duplicating an actual conversational exchange and of facilitating generalization to other goals and settings.

In the final sessions, we target activities to elicit a sequence of responses that are related to a topic, thus setting the stage for further development of conversational skills. In the presence of the physical con- text, the child can use a series of phrases that request some action, comment on the activity, and describe the action taking place. For example, a closed container was on the table in front of the child. He would request, "Open can." The clinician pointed to the contents and the child said, "There's raisin." At this point, the clinician held the can out of the child's reach, waiting for the child to say, "Take raisin out ," or some close approximation ("Raisin out," "Out"). Before receiving the raisin, the child answered the question "What do you want to do?" After the raisin was consumed, the clinician prompted the child to look in the container, which would elicit the response "Raisin all gone."

Data Analysis

The five autistic subjects' language functioning assessed before the treatmet was compared with the results assessed after the treatment by using Student's t statistic for group means. One-tailed probability was used because the direction of the treatment effect was predicted. Difference was defined as significant when there was one chance in 20 or less that the differ- ences occurred by chance (p < .05).

RESULTS

Table III shows the age and intelligence of the five autistic subjects. Table IV indicates that there was a significant increase in the mean

length of response over the 6-week treatment period. There was also a sig- nificant increase in the mean receptive language level measured by the Sequenced Inventory of Communication Development. There were some gains on the expressive language portion of this test, though the difference was not significant. Table IV also outlines the changes for each subject. All subjects showed an increase in the mean length of response. Four subjects increased their expressive scores on the SICD.

Increasing Expressive Language Skills

Table III. Ages and Intelligence of Five Autistic Boys

295

MerriU-Palmer Leiter Chronological

Subject age Mental age Mental age number (months) (months) IQ (months) IQ

1 68 60 91 72 108 2 56 59 107 75 136 3 36 37 116 39 110 4 50 44 92 45 93 5 6 2 38 63 39 65

The spontaneous samples were elicited, recorded, and analyzed by the methods outlined in MacDonald (1978). Fifty utterances were used in the analysis. Imitated responses were omitted. Table V indicates that there was a significant increase in the total mean number of semantic-grammatic rules occurring in the spontaneous sample. Further analysis of performance on each rule revealed a significant increase of the mean occurrence for the rules: agent + action, action + object, agent + object, negation + X, and X + location (action). The differences in mean performance on the rules modifier + head, X + location (agent or object), and introducer + X were not significant. Table V also summarizes the changes for each child on the various semantic-grammatical rules.

Specific items on the SICD test protocol were examined to detect patterns of changes. Although all five subjects would imitate words on request at the pretreatment evaluation, only one child would imitate sentences of four words or more. At the posttreatment evaluation, three children would imitate sentences on demand. At the pretreatment evaluation, only two children spontaneously requested a wanted object, but all five did so at posttreatment. None of the children answered yes/no questions pretreatment, and two could do so posttreatment. Two of the children were able to perform two-step commands that were previously failed. It was also interesting to note that all five children improved their performance on the Goldman-Fristoe Test of Articulation to varying degrees.

Posttreatment comments from the parents were favorable. These comments included: "He talks more," "He uses longer phrases," "He pays attention better," "His behavior is better." Follow-up phone calls at 4 weeks and 6 months to home and school indicated that favorable improvements in the child's communication abilities were maintained and expanded.

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DISCUSSION

The results of this preliminary study indicate that these five autistic children made notable gains on their language skills as measured by the particular assessment methods chosen. Each child used longer utterances that contained a higher number of various semantic rules upon discharge when compared to their initial, pretreatment samples. As well, gains were seen in receptive language levels for four of the subjects. These results suggest that modeling responses within turn-taking activities involving real objects and live actions may be a viable alternative to strict operant programs to enhance the communication skills of autistic children, and that a reinforcement system consisting of fulfilling the intent of the communication may be sufficient to increase communication skills for certain autistic persons.

In addition to the measured gains, we found increased abilities to spontaneously expand phrases, as evidenced by the children's posttreatment use of target phrases within a novel expansion. We also noted the apparent ability to insert new vocabulary items in target notions. For example, once a child had learned a response such as "Raisin all gone," he was able to insert other vocabulary for "raisin" with limited practice. We saw this occur spontaneously in several instances where a new vocabulary item was inserted in a target notion. Whether this was due to delayed repetition of modeled responses during previous sessions or was a result of the child learning the process of generative language due to the methods used is unknown. The remedial effects of modeling have been documented by Courtright and Courtright (1979) in teaching language-disordered children, and our results suggest that this is the case in autistic children as well. Table VI illustrates an excerpt of the posttreatment status of one subject.

The methods described were also applicable to group settings. Indeed, an average of 2�88 hours was spent in remedial group work. Because target goals dealt with requests for action, instructions on how to proceed, requests for objects, and descriptions of ongoing activities, these targets were easily translated into group activities to facilitate social exchanges.

In the present study, we found that elaborate plans for getting the child to imitate in some sequence of fading or prompting were unnecessary. After the activities and responses were frequently modeled, these children began to fill in their turn. As well, we found that extrinsic reinforcement systems were not needed. The natural consequences of the communication exchange were enough to maintain the child's attention as well as increase his language skills. An interesting sidelight was that interfering behaviors such as tantrums, poor eye contact, inattention, and self-stimulation did not need separate treatment. Although all five subjects were observed in

Increasing Expressive Language Skills 299

Table VI. Sample of Posttreatment Status for Subject 5

1. Target use: Target forms:

Lexical items:

Phase of teaching: Combinations child

Request action Agent + action +objeet Recurrence + action Agent - Jean, Mike, boy, girl, baby Action - sleep, open, push, blow, throw, tickle, eat Ob jec t - table, pretzel, raisin, ~ truck, chair, top, box, bubble, ball Recurrence - more Spontaneous requests in contrasted physical contexts

uses: Jean push truck Open box Jean push chair Push top Boy push truck Michael get chair a Girl push top Jean throw abll Mike push top More tickle Blow bubble Tickle tummya

2. Target use: Target forms: Lexical items:

Phase of teaching:

Comment on environment Modifier + X, X + location, agent + action + object Modifier - Possession: Jean, Michael

Nonexistence: No X - Object: nose, hair, pretzel, raisin, shoes, chair, shirt

Preposition: in, off, out Agent, action, object - See list under # 1 Spontaneous requests in single physical context with a point prompt or question

Combinations child uses: Baby sleep table Jean nose Jean head Pretzel (in) truck In hand In chair Boy eat raisin Jean hair Shoes off No raisin Michael hair No pretzela There's no raisina Out truck a In shirta

Target use: Request object Target forms: Agent + action + object

Recurrence + object Lexical items: See above lists Phase of teaching: Spontaneous requests in single physical contexts after two warm-up

trials with a model Combinations child uses: Michael raisin

Michael pretzel Michael eat pretzel Pretzel Jean eat pretzel More pretzel Ball More bubble

aphrases that were not targeted in remediation sessions.

300 Beisler and Tssd

other situations to engage in such behaviors at rather high levels, these behaviors did not occur in the language session to an extent that would interfere. The authors feel that this was due to several factors:0) The use of real objects in child-oriented activities held the child's interest; (2) the use of natural consequences made sense to the child and, when these consequences were of great interest, were sufficient to maintain positive learning behaviors; and (3) the tasks and the language forms used were appropriate to the child's developmental level.

In past reports, the question of sampling methods for spontaneous conversation have been raised. Two studies (Scott & Taylor, 1978; Kramer, James, & Saxman, 1979) concluded that the mean length of utterance was greater at home than in a clinical setting. Despite this, our parents of these autistic children commented that they saw their child saying more, using more words, using longer phrases, and using new phrases in the posttreatment observation sessions. This leads us to believe that our conversational samples were indicative of the child's actual expressive abilities and could be reliably used as expressive measures, even though gathered in the clinical setting.

A frequent criticism of "natural" approaches to language therapy is the assumed difficulty of charting specific behaviors. In this study, statistics were kept on each activity in each session. Percentages of types of responses to types of stimuli were easily computed. An example is given in Table VII. From the child's chart, we were then able to give an accurate account of conditions and the child's response to those conditions so that we could see where further emphasis needed to be placed and when the child was ready to proceed to higher levels.

Although our clinical impressions are that these specific language gains are largely the results of the treatment methods used, we do recognize several limitations in drawing a firm conclusion as to whether this was the only reason for the gains seen. The five subjects were young and high-functioning in the cognitive domain. These types of autistic children tend to respond favorably to treatment in general. Future studies using these approaches with lower functioning children and with nonverbal children would be helpful in clarifying the applicability across the autistic population as a whole. As well, the contributions of the 24-hour care program would presumably have a positive effect on treatment for any one particular domain. Because the care staff in the center are trained to effect changes in the child's behavior and abilities, this kind of general stimulation cannot be separated from the treatment methods outlined unless a control group is used. The option of a controlled group was not possible for the practical reasons of time and availability of well-matched subjects as well as the author's belief that treatment methods felt to be effective should not be

Increasing Expressive Language Skills 301

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withheld from subjects, even in the interest of controlled research. This could be circumvented in the future by more complete baseline data during a longer inpatient admission. However, present concerns for cost containment may make this a practical issue.

Other methodological concerns that may limit certain conclusions on the effectiveness of this treatment approach relate to the reliability of the assessment procedures. The standard error of measurement for MLU, the SICD, and the frequency of semantic-grammatical rules are not available. As well, spontaneous samples gathered outside of the testing situation may lend more information as to the extent of the child's improvement. While this would be a preferred assessment, our clinical experiences with autistic children have pointed out the extreme difficulty generating any kind of spontaneous sample o f enough quantity to use for comparative purposes across settings when dealing with autistic children at the early stages of language development.

Our purpose in presenting these treatment approaches was to suggest possible alternatives to those language approaches currently used with autistic children. Because of methodological constraints, we cannot conclude that the methods described above are the most effective way to teach autistic children to communicate. We do take the position that these kinds of approaches are more consistent with the recent research in normal communication development, especially as it relates to pragmatics, than those methods used in operant programs. We would caution the excessive a n d / o r premature use of operant programs, especially for autistic children who possess adequate cognitive skills to respond to more natural approaches. Further research addressing the concerns outlined above will be helpful in defining approaches that help the autistic child learn to use language in effective communication exchanges across various settings.

REFERENCES

Brunet, J. The ontogenesis of speech acts. Journal of Child Language, 1975, 2, 2-19. Courtright, J., & Courtright, I. Imitative modeling as a language intervention strategy: The

effects of two mediating variables. Journal of Speech and Hearing Research, 1979, 22, 389-402.

Fay, W., & Sehuler, A. Emerging language in autistic children. Baltimore: University Park Press, 1980.

Hedrick, D., Prather, E., & Tobin, A. Sequenced Inventory o f Communication Development. Seattle: University of Washington Press, 1975.

Kanner, L. Irrelevant and metaphorical language in early infantile autism. American Journal of Psychiatry, 1946, 103, 242-246.

Kramer, C., James, S., & Saxman, J. A comparison of language samples elicited at home and in the clinic. Journal of Speech and Hearing Disorders, 1979, 44, 321-330.

Increasing Expressive Language Skills 303

Leiter, R. G. The Leiter International Performance Scale. Ckicago: Stoelting, 1969. Lovaas, O. I. The autistic child: Language development through behavior modification.

New York: Irvington, 1977. Lowe, M. & Costello, A. J. Symbolic Play Test: Experimental edition. Great Britain: NFER,

1976. MacDonald, J. D. Environmental Language Inventory. Columbus: Charles E. Merrill,

1978. Risley, T. & Wolf, M. Establishing functional speech in echolalic children. In H. N. Sloane

& B. D. MacAule~; (Eds.), Operant procedures in remedial speech and language training. Boston: Houghton Mifflin, 1968.

Rutter, M. The description and classification of infantile autism. In D. W. Churchill, G. D. Alpern, & M. K. DeMcyer (Eds.), Infantile autism. Springfield, Illinois: Charles C Thomas, 1971.

Rutter, M. Infantile autism and other childhood psychoses. In M. Rutter & L. Henson (Eds.)., Child psychiatry: Modern approach. Oxford: Blackwell, 1977.

Rutter, M. Language disorder and infantile autism. In M. Rutter & E. Schopler (Eds.), Autism: A reappraisal o f concepts and treatment. New York: Plenum Press, 1978.

Scott, C., & Taylor, A. A comparison of home and clinic gathered language samples. Journal of Speech and Hearing Disorders. 1978, 43, 482-495.

Stutsman, R. Merrill-Palmer Scale o f Mental Tests. New York: Harcourt, Brace and World, 1948.

Wing, L. The handicaps of autistic children: A comparative study. Journal of Child Psychology and Psychiatry, 1969, 10, 1-40.

Wolf, M., Risley, T., & Mees, H. Application of operant conditioning procedures to the behaviour problems of an autistic child. Behaviour Research and Therapy, 1964, 1, 305-312.