Prelinguistic Communication Development: Betsy - Crais@med - Unc.edu

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Chapter 2

Prelinguistic Communication Development

Elizabeth Crais and Billy T. Ogletree

Abstract The prelinguistic stage is viewed as the time period between birth and
when a child or adult begins to use words/signs meaningfully. It is a time when
children typically increase their ability to communicate with others, first using eye
gaze, attending, and social-emotional affect and later adding gestures and other
nonverbal means to communicate. This stage builds the foundation for later devel-
oping skills such as using words (or signs) and combining them into sentences to
communicate, as well as understanding and gaining appreciation of the nuances of
successful communication. For children, youth, and adults with autism spectrum
disorder (ASD), the skills typically learned during this stage can be critical to
helping these individuals be effective and successful communicators throughout
their lives. Individuals with significant developmental disabilities including ASD
can have substantially protracted prelinguistic periods of communication and
language development. For some, a singular reliance on prelinguisitic communi-
cation may continue into adolescence or adulthood. Others may fail to develop
productive communication altogether. Knowledge of prelinguistic skills, their
developmental hierarchy, and their impact on children’s and adults’ current and
future ability to communicate are key factors to be considered in assessing and
intervening with children, youth, and adults with ASD. In this chapter, current
research related to prelinguistic communication skills will be highlighted, along
with challenges faced when examining prelinguistic skills, and the research and
practice implications of looking at and intervening in the area of prelinguistic
communication.

E. Crais (*)
Department of Allied Health Sciences, University of North Carolina – Chapel Hill, Chapel
Hill, NC, USA
e-mail: betsy_crais@med.unc.edu
B.T. Ogletree
Communication Sciences and Disorders, Western Carolina University, Cullowhee, NC, USA
e-mail: ogletree@email.wcu.edu

© Springer Science+Business Media Singapore 2016 9


D. Keen et al. (eds.), Prelinguistic and Minimally Verbal Communicators on the
Autism Spectrum, DOI 10.1007/978-981-10-0713-2_2
10 E. Crais and B.T. Ogletree

2.1 Current Research on the Topic

Prelinguistic skills are often viewed as the underpinning on which many other
communication and social skills are built. Indeed, the early use of communicative
means (e.g., gaze, gestures, vocalizations, words) shows a strong relationship with
later language skills in children with developmental delays (McCathren, Yoder, &
Warren, 2000) and those with ASD (Zwaigenbaum, Bryson, & Rogers, 2005).
Children in the first year of life typically interact with their caregivers by intently
gazing at the adult, and using sounds and oral motor imitations (e.g., wide mouth
opening, protruding tongue) that help maintain engagement. In addition, they
exhibit fussing and crying behaviors. These behaviors provide the infant with a
means to express an emotional response to events or situations and to keep the
attention of the adult. Initially, these behaviors are not intentional, but are more
reflexive and responsive. Infants at this point are characterized as being in the
preintentional stage, as they have not yet learned consistent ways to communicate
their needs and wants to their caregivers. For example, infants first cry because they
are hungry, wet, or uncomfortable and not because they realize if they do, their
caregivers will react. Gradually, as infants begin to recognize that caregivers react
when they exhibit particular behaviors, they learn how to communicate for specific
purposes.
By the end of the first 6 months, infants consistently use a combination of
behaviors across modalities such as vocalizations, facial expressions and visual
orienting (Yale, Messinger, Cobo-Lewis, & Delgado, 2003) and they use them
reciprocally with their caregivers (Feldman, 2003). Up to this time point, infants
have been actively engaged in dyadic interactions with their caregivers where their
focus is the caregiver. These face-to-face opportunities encourage sharing affect
and attention. Infants begin to respond and participate with their caregivers in social
routines such as “peek-a-boo” or “this little piggy” where the child is initially
passive, moving toward a more active role, and eventually initiating the social
routine. These exchanges are viewed as joint engagement rather than joint atten-
tion, an important distinction particularly for children with ASD. Whereas joint
engagement involves the adult and child interacting together, it does not necessarily
include the child or adult actively drawing the partner’s attention to an object or
action, although an object may be part of the play. For example, during a game of
peek-a-boo, when a mother holds a small blanket in front of her face, the focus is on
getting the child to pull down the blanket to find her, not on the blanket itself. In
contrast, joint attention includes triadic interaction where one person is purpose-
fully trying to get another person to look at an object or event. For example, when a
father points to an airplane in the sky, he wants his child to look at it and enjoy the
experience with him. The critical nature of joint engagement to the language
learning process is evident as children increase their ability to join in shared
communicative interactions with people and objects (Adamson, Bakeman, &
Deckner, 2004). In addition, as the child continues to develop, both vocal (e.g.,
sounds, sound combinations) and nonverbal acts (e.g., facial expressions, and later
2 Prelinguistic Communication Development 11

gestures) become more consistent and the child gains control over when to produce
them. For example, infants may initially produce a “raspberry” sound (blowing out
while sticking out the tongue) when spitting out food. As caregivers attend to and
perhaps laugh at or imitate the action, the infant eventually with practice produces
the act in imitation and later spontaneously, as a means of gaining or keeping the
adult’s attention. In parallel, as the child is gaining more oral motor control, there is
a fairly predictable development of sounds in the child’s inventory.
As reported by Smith, Goffman, and Stark (1995), typically developing infants
produce reflexive sounds for the first few months, move on to comfort or cooing
sounds between 2 and 4 months, begin to produce longer series of syllables and
prolonged vowels and consonants with much vocal play between 4 and 6 months,
produce reduplicated babbling (e.g., bababa) between 7 and 9 months, and use more
varied and complex babbling (e.g., badaba) and their first words somewhere
between 10 and 12 months. As children gain additional oral motor control, they
are more capable of producing particular sounds and eventually are able to use word
approximations (“baba” for bottle) and consistent words.

2.1.1 The Onset of Intentionality

A shift from preintentional to intentional communication is a major milestone for


all children and adults and is critical to the development of higher-level communi-
cation skills (Brady, Marquis, Fleming, & McLean, 2004; Tomasello, Carpenter, &
Liszkowski, 2007). A child’s rate of intentional communication is predictive of
language outcomes and higher rates of nonverbal intentional communication are
related to improved language outcomes (Calandrella & Wilcox, 2000). Typically
developing 12-month-olds communicate intentionally about once per minute,
whereas 18-month-olds do so about two times per minute, and 24-month-olds
communicate intentionally about five times per minute (Wetherby, Cain, Yonclas,
& Walker, 1988). Therefore, a slow rate of intentional communication may be
indicative of current and future communication deficits. For example, when Stone,
Ousley, Yoder, Hogan, and Hepburn (1997) compared the communicative rates of
2½- to 3½-year-old children with ASD or other developmental disabilities (DD),
the children with DD had similar rates of communication as typically developing
12-month-olds; however, the children with ASD had significantly lower rates. Rate
of communication and parent response contingency have also been associated with
higher expressive language in children with disabilities (Brady et al., 2004). Brady
and colleagues (Brady et al., 2004; Brady, McLean, McLean, & Johnston, 1995;
Brady, Steeples, & Fleming, 2005; McLean, Brady, & McLean, 1996) have
suggested that a limited range of communicative functions is related more to an
individual’s level of prelinguistic development rather than a particular disability.
Although typically associated with very early childhood, for some individuals
communicative intent can emerge later in life. Numerous investigations have
documented and profiled nonsymbolic intentional communication in preschool-
12 E. Crais and B.T. Ogletree

aged children, adolescents, and adults with developmental disabilities including


ASD (McLean, McLean, Brady, & Etter, 1991; Ogletree, Wetherby, & Westling,
1992; Wetherby, Yonclas, & Bryan, 1989). Findings have been mixed on commu-
nication rate with some studies reporting rates comparable with normative expec-
tations (Ogletree, Wetherby & Westling, 1992; Wetherby et al., 1989).
The ability to use varied types of communicative functions also plays a role in
predicting children’s later language skills. Bruner (1981) indicated that infants and
toddlers should be using the following major communicative functions by
12 months of age:
• Social interaction: sustaining or initiating a social game or routine, seeking or
providing comfort, teasing, showing off.
• Behavior regulation: regulating the behavior of others to obtain an object,
getting them to carry out an action, or stopping someone from doing something.
• Joint attention: directing others’ attention in order to comment on an object or
event, providing information on an object or event, or acknowledging shared
attention to an object or event.
Children with typical development show an increase in the number of commu-
nicative functions used within these three major areas with increasing age (Crais,
Douglas, & Campbell, 2004; Wetherby et al., 1988). For interpreting the current
literature, terms such as imperative or instrumental act to regulate behavior, and
declarative or referential act to gain joint attention, are also often used. In terms of a
hierarchy of the emergence of functions, social interaction acts and behavior
regulation acts seem interspersed in early development with joint attention acts
following closely (Crais et al., 2004). In a longitudinal study of 12 typically
developing children from 6 to 24 months, Crais and colleagues (2004) reported
that 8 of the infants first produced protests (e.g., physical action like arching the
back to resist something or pushing away objects), whereas the other 4 infants either
requested an action (e.g., reaching to be picked up) or sought attention (e.g.,
flapping arms or banging while smiling and looking at the parent).
As infants develop from the middle to end of their first year they begin to share
attention to objects and other events with their caregivers and move to triadic
engagement (De Schuymera, De Grootea, Strianoc, Stahle, & Roeyersa, 2011;
Mundy, Sullivan, & Mastergeorge, 2009). A major skill that develops through
triadic engagement is following the gaze of others, which opens up opportunities
for the infant to learn from other people about the world around them (Rozga et al.,
2011). Attention monitoring is also learned and includes the child shifting attention
between the referent and the caregiver so the child can determine whether the
caregiver is noticing the referent the child wants and/or the communicative act the
child produced.
Another major skill attained during triadic engagement is the use of joint
attention. In contrast to requesting, where the child wants the object or action
requested, in joint attention the child is communicating to gain social attention
from the caregiver. Joint attention acts demonstrate the child’s abilities to coordi-
nate attention to both people and objects. Two types of joint attention are highly
2 Prelinguistic Communication Development 13

critical: first, the child’s ability to attend to others’ bids for joint attention (response
to joint attention [RJA]) and second, the child’s ability to initiate bids for joint
attention from others (IJA). As observed by McLean and Snyder (1978) and later by
Sameroff and Fiese (2000), children learn to respond to and use gestures and words
within joint attention acts, thus adding to their understanding and ability to use
communication. As suggested by many (e.g., Klin, Jones, Schultz, & Volkmar,
2005; Tomasello, Carpenter, Call, Behne, & Moll, 2005), infants engaging with
objects and others is also critical for their development of the ability to understand
others’ thoughts and goals. Thus, the emergence of RJA and eventually IJA presents
major milestones for children with and without disabilities.
Older children, adolescents, and adults who are prelinguistic communicators
may vary from young, typically developing children with respect to RJA and IJA.
Qualitatively, their responses to the joint attention bids of others may be slow and
require increased effort on the part of the communicative partner, while quantita-
tively IJAs are most often significantly reduced if not absent (McLean, McLean,
Brady, & Etter, 1991; Ogletree et al., 1992).

2.1.2 Hierarchy of Gesture Use

Because gestures play a large role in children’s early intentionality and their later
communication skills (and are often limited or absent in some children and adults
with ASD), understanding the developmental emergence of gestures is vital. Ges-
tures are one of the most consistent early indicators of intentionality and, therefore,
are instrumental in helping children express their wants and needs to others (Crais
et al., 2004). Between 6 and 10 months, children begin to use gestures to commu-
nicate with others, such as reaching to be picked up or to gain objects, or pushing
away objects (Carpenter, Nagell, & Tomasello, 1998; Crais et al., 2004; Parladé &
Iverson, 2010).
Gestures are defined as actions used with the intent to communicate and are
commonly expressed using the fingers, hands, and arms, but can also include body
motions such as bouncing for “horsie” or facial features such as lip pouting (Iverson
& Thal, 1998). In contrast, just reaching or grabbing for an object is not considered
communicative unless the child is using the action to signal to someone else their
intention. Therefore, acts are typically not considered a gesture unless they are:
(a) accompanied by eye contact or a vocalization/verbalization aimed toward
another, (b) repeated, (c) used with a body posture oriented toward another, or
(d) used within a social exchange (e.g., dyadic interaction like storybook reading)
where clear reciprocity has already been established between the child and care-
giver (Iverson, Capirici, Volterra, & Goldin-Meadow, 2008).
Iverson and Thal (1998) categorized two primary types of gestures: deictic and
representational. Deictic gestures call attention to or indicate an object or event,
such as pointing to or holding up an object to show someone. As suggested by
Iverson and Thal, these gestures are interpreted by their context and can be used
14 E. Crais and B.T. Ogletree

across a range of objects and events. Deictic gestures are frequently divided into
two types: contact and distal (Brady et al., 2004). Contact gestures include touching
or “contacting” the object or caregiver, such as pulling on an object held by another
or pushing away a caregiver’s hand, and are considered “early” gestures and appear
between 7 and 9 months. Most children as they increase their communicative skills
begin to use additional kinds of gestures and forms of communication (words,
sentences, signs) and therefore become less dependent on contact gestures.
In contrast, distal gestures do not require contact with the caregiver or the object
and include pointing or waving “bye bye” and typically appear later (10–-
12 months). One important distinction that needs mentioning, however, is that a
few distal reaching gestures (e.g., reaching for an object, reaching to be picked up)
actually challenge the typical progression of contact gestures preceding distal
gestures. One reason reported by Crais et al. (2004) may be that although reaching
is typically considered distal, it is also contextually bound to the actions within
which it consistently occurs.
In regard to contact and distal gestures, there are children and adults (e.g., those
with intellectual disability or ASD) who continue to use contact gestures (e.g.,
taking someone’s hand to place it on a door knob to signal “going out”) well past
when other typically developing children stop using them (Paul, Chawarska, Klin,
& Volkmar, 2007). For example, as children with language impairment get older,
they use gestures more than their typically developing peers and are very likely
doing so to compensate for their oral language deficits (Evans, Alibali, & McNeil,
2001). Stone et al. (1997) documented that 3½- to 4½-year-old children with ASD
used significantly more contact gestures than did children with DD who were
matched on chronological and mental age, developmental quotient, and expressive
vocabulary (as well as gender, race, and maternal education). As suggested by
Brady et al. (2005), many children with DD use prelinguistic gestures and vocal-
izations as their main means of communication and do so far into the toddler and
preschool years.
In adults with DD, McLean and colleagues (Brady, McLean, McLean, &
Johnston, 1995; McLean et al., 1991) documented that those who used distal
gestures communicated more often and for a wider range of functions than did
the adults who only used contact gestures. Brady and colleagues (Brady et al., 1995;
Brady et al., 2004; Brady et al., 2005; McLean, Brady, & McLean, 1996) have also
noted that children and adults with disabilities who primarily use contact gestures
and vocalizations seldom communicate for joint attention or to make comments. In
comparison, children and adults who use distal gestures are more likely to produce
comments and requests.
In typically developing children, the first deictic gestures often emerge between
7 and 9 months of age (Carpenter et al., 1998; Crais et al., 2004). They often first
appear as ritualized gestures to indicate refusal (e.g., pushing away), open-handed
reaching, reaching to be picked up, or consistent attention-getting body movements
such as repeated leg and arm flailing (Carpenter et al., 1998; Crais et al., 2004). As
reported by Thal and Tobias (1992), deictic gestures comprise about 88 % of the
gesture repertoire of young infants and toddlers.
2 Prelinguistic Communication Development 15

Representational gestures make up the other major type of gestures, and they
indicate both reference and a particular semantic content. Iverson and Thal (1998)
categorized representational gestures into object-related and conventional gestures.
Object-related gestures denote some feature of the referent (e.g., flapping the arms
to represent a bird flying) that are often called “symbolic” gestures (Acredolo &
Goodwyn, 1988). Conventional gestures are commonly used in a particular culture
and are therefore defined by the culture (e.g., waving “bye”, finger to lips for
“quiet”). They typically represent some action or concept rather than a specific
object. Reflecting cultural specificity, some gestures (e.g., the “okay” sign used in
the US) may be viewed as offensive in some European countries; therefore knowl-
edge of cultural conventionality is important for users (and assessors). Representa-
tional gestures begin to appear around 12 months of age (Acredolo & Goodwyn,
1988) and are typically seen after the emergence of a few deictic gestures (Crais
et al., 2004). This kind of gesture typically emerges within familiar routines and
games that caregivers use to engage and entertain their child (Goodwyn &
Acredolo, 1993; Iverson & Thal, 1998). Games and routines such as “patty-cake”
or pretending to eat and blowing to signal “hot food” contain multiple interactive
opportunities for children to observe and imitate representational gestures.
Individual variability in the emergence and range of representational gestures
between 10 and 24 months has been documented across studies (Crais et al., 2004;
Goodwyn, Acredolo, & Brown, 2000). In a longitudinal study of typically devel-
oping children from 6 to 24 months of age, Crais et al. documented that the
representational gestures used by the children were highly specific to the modeling
of their parents. For example, gestures such as “touch down”, “high five”,
“pretending to sleep” or using a forefinger to the lips and saying “sh” (e.g., asking
for quiet, pretending a baby doll was sleeping) were only seen in those children
whose parents actively demonstrated them. The strong influence of modeling can be
seen in one family who never wanted to give their child the impression that they did
not want him to talk, therefore they never used the “sh” signal, nor did he. Zinober
and Martlew (1985) suggested that compared to deictic gestures, representational
gestures are highly dependent on modeling by caregivers, and their use is more
reflective of parents’ cultural beliefs and practices.

2.1.3 Importance of Gestures to Facilitating Language Skills

Iverson and Goldin-Meadow (2005) have suggested that gestures allow children to
communicate ideas that they may have difficulty expressing verbally and therefore,
the use of gestures can facilitate language learning. Gestures both precede and are
highly related to language development. Indeed, initial gestural representations
found in children’s early repertoires appear later in the children’s verbal lexicons
(Iverson & Goldin-Meadow). Similarly, in examining sentences, Iverson and
Goldin-Meadow documented that the use of gesture-plus-word combinations
predicted the onset of two-word combinations.
16 E. Crais and B.T. Ogletree

In considering why gestures may facilitate language development, Iverson and


Goldin-Meadow (2005) argue that firstly, the child’s use of gestures may signal to
the caregiver that the child is ready for enhanced input. For example, Goldin-
Meadow and Singer (2003) documented that adults alter their input to children in
response to the gestures produced by the child. Secondly, Iverson and Goldin-
Meadow contend that gestures also lessen the demand on memory in that gestures
are likely easier to produce than words. It has been hypothesized that gestures are
first produced at a time when the child has not yet fully gained control over the oral
mechanism in terms of speech production. The third explanation for why gestures
facilitate language learning is that gestures may be a way for children to try out new
meanings before they are produced in speech, and there is evidence that the act of
using a gesture can impact learning a concept (Wagner & Goldin-Meadow, 2004).
Thus, if the child can use a representation of the word in gestural form, it may help
fill out the meaning of the word while the child acquires the word form.
Gestures can also facilitate labeling by the caregiver and may provide, as
Goldin-Meadow, Goodrich, Sauer, and Iverson (2007) suggest, a “timely word-
learning model” for the child, and thereby children can elicit input that they need to
guide their own learning. Some suggest that commenting by the child (e.g.,
vocalizing and/or pointing to an object to show it, or verbalizing) has a strong
relation to receptive language. When children comment, caregivers usually respond
by labeling the object or providing added input to the child (Brady et al., 2005;
Tomasello, 1999). Thus, children who comment more often will have increased
chances to gain input from caregivers.
In prelinguistic adolescents and adults, gestural forms often occur as part of a
broader communicative profile characterized by vocal immaturity (McLean et al.,
1991; Ogletree et al., 1992). Accordingly, for these individuals, it would appear that
gesture is a less complicated and possibly more effective alternative to intelligible
speech.

2.1.4 Links Between Prelinguistic Skills and Current


and Later Language Skills

Some prelinguistic skills are also concurrently predictive of a range of skills. For
example, early gesture use is strongly related to concurrent comprehension skills in
both children with typical language skills (Bates, Benigni, Bretherton, Camaioni, &
Volterra, 1979) and those with language deficits (Thal & Bates, 1988; Thal, Tobias,
& Morrison, 1991). Similarly, gesture use in children with ASD is also associated
with current language skills. In particular, joint attention skills are highly predictive
of comprehension and production skills in both typically developing children
(Slaughter & McConnell, 2003) and those with ASD (Charman et al., 2003). Social
interaction acts also are predictive of expressive vocabulary in typically developing
2 Prelinguistic Communication Development 17

children (Mundy & Gomes, 1998) and children with ASD (McEvoy, Rogers, &
Pennington, 1993; Mundy, Sigman, Ungerer, & Sherman, 1986).
Gesture use is also predictive of later language skills. For example, early
gestures are strongly related to receptive and expressive production in the second
year of life in both typically developing children (Bates, Benigni, Bretherton,
Camaioni, & Volterra, 1979) and those with disabilities (Thal et al., 1991; Thal
& Bates, 1988). Further, a limited variety of gestures in 9-12-month-old children
has also been associated with a later diagnosis of ASD (Colgan et al., 2006). Rowe
and colleagues (Rowe & Goldin-Meadow, 2009; Rowe, Özçaliskan, & Goldin-
Meadow, 2008) have documented in typically developing children that the number
of gestures used at 18 months of age was significantly related to the size of the
children’s receptive vocabularies at 42 months. In addition, frequency of requesting
and commenting are predictive of later vocabulary size (McDuffie, Yoder, & Stone,
2005; Mundy, 1987; Sigman & Ruskin, 1999; Stone & Yoder, 2001). Vocabulary
comprehension and symbolic play skills are also associated with later language
skills (McCathren, Warren, & Yoder, 1996).
For children with Down syndrome, Mundy, Kasari, Sigman, and Ruskin (1995)
observed that those who frequently requested using gestures and vocalizations had
higher language scores a year later than those who had limited requesting. Mundy
and colleagues (Mundy et al., 1995; Mundy & Thorp, 2006) also reported that both
IJA and RJA acts were significantly related to later language and social skills.
Lower rates of IJA and RJA were also seen in young children with ASD and were
not accounted for by a lower number of communicative acts overall (Stone et al.,
1997). And in at-risk 12-month-olds (younger siblings of children with ASD) who
were themselves later diagnosed with ASD, deficits in RJA, IJA, and requesting
acts were documented (Rozga et al., 2011). Rozga and colleagues suggested these
deficits may hamper the children’s abilities to generate social experiences for
themselves--thus leading to deficits in language skills.
Another factor important for later language and social skills is the combination
of gestures and vocalizations. As children develop, their nonverbal communications
begin to be more varied and more complex, they can communicate for more
reasons, and they learn to coordinate gestures and vocalizations to communicate
(Wetherby et al., 1988). This ability to coordinate aspects of communication can
have important implications for social engagement with caregivers. For example,
coordinating nonverbal cues with vocalizations can heighten the salience of and the
ability of caregivers to interpret the communication, as well as respond appropri-
ately to it (Stone et al., 1997; Yoder & Warren, 1999). In work by Goldin-Meadow
and colleagues (Rowe & Goldin-Meadow, 2009; Rowe, Özçaliskan, & Goldin-
Meadow, 2008), the number of gesture-plus-speech combinations the children used
at 18 months was a strong predictor of their sentence complexity at 42 months.
Further, the first production of a gesture-plus-speech combination has been shown
to be predictive of the age of the first two-word combination (Iverson, Capirici,
Volterra, & Goldin-Meadow, 2008; Rowe & Goldin-Meadow, 2009). When chil-
dren (including those with ASD) combine gestures and vocalizations, they can also
more effectively share joint attention with their caregivers (Parladé, 2012; Winder,
18 E. Crais and B.T. Ogletree

Woziniak, Parladé, & Iverson, 2013). This vocal-gesture combination can serve as
a potent stimulus for the caregiver and can help set up an opportunity for joint
attention (Parladé, 2012).
Finally, specific types of gestures can also be predictive. For example, early
pointing is predictive of later advanced language skills in typically developing
children (Harris, Barlow-Brown, & Chasin, 1995; Morissette, Ricard, & Decarie,
1995), those with Down syndrome (Franco & Butterworth, 1996), and children with
ASD (Baron-Cohen, 1989). There also have been links with early pointing and a
greater number of different gestures used and greater comprehension (Butterworth
& Morissette, 1996). Specifically, the onset of pointing has been correlated to
object-name comprehension (Harris et al., 1995). In the work of Stone
et al. (1997), few children with ASD pointed, but if they did, their number of
request and comment points was very similar. A key feature of communicative
pointing is that it not only sets up joint attention with others, but it also impacts what
communication partners look at and possibly what they choose to act on and talk
about.
For individuals who never acquire many of these early skills or language, terms
like “non-linguistic”, “nonsymbolic”, “minimally verbal” or “emergent symbolic”
may best describe their communicative abilities. If these communicators present
with ASD, their manifestation of the condition will likely be more severe, and they
will often exhibit concomitant significant intellectual deficits. Indeed, Ogletree
(2008) has used a categorization of communicative abilities in adults with ASD
describing nonverbal, emergent verbal, and verbal communicators. According to
Ogletree, nonverbal communicators, though nonspeaking, can have expressive
abilities that include nonsymbolic and symbolic means. In contrast, emergent
verbal and verbal communicators express themselves with speech of varying
complexity and may also use other nonsymbolic and symbolic communication
modalities.
Although few research studies have examined the emergent communicative
abilities of adolescents or adults with ASD, some early investigations have included
these groups in their participant pool. Findings from two large studies shed light on
the communicative forms and functions typically observed in these populations.
One additional effort describes both expressive and receptive abilities. Brady
et al. (1995) sampled the communication of 28 adults with severe disabilities
(5 of whom were diagnosed with ASD or a pervasive developmental disorder).
Participants were presented with enticing communicative opportunities designed to
evoke comments and requests. During communication sampling, participant initi-
ations were followed by experimenter responses suggestive of communication
breakdown (e.g., feigning misunderstanding of the participant’s intent). Among
the participants, all were reported to communicate with intentional nonsymbolic
gestures. Participants primarily communicated to request but also commented on
occasion. Participants also repaired communicative breakdowns by repeating,
recasting, and to a lesser degree adding to communicative acts.
Using surveys, McLean et al. (1996) generated descriptive profiles of 211 adults
with severe disabilities. Individuals charged with their care completed
2 Prelinguistic Communication Development 19

questionnaires for 94 adults who presented with ASD or characteristics consistent


with the diagnosis. Responses revealed that only 20 % of the adults were
nonsymbolic (only 6 % unintentional) while 80 % used some form of symbolic
communication. Sixty-one percent of the participants were described as using
combinations of words and symbols.
The studies mentioned above, though not exclusive to adolescents or adults with
ASD, bring into focus some general expectations specific to this population’s range
of expressive abilities. A recent larger study provides more detailed information
about both the expressive and receptive communication of adolescents and adults
with severe disabilities including ASD. Snell et al. (2010) reviewed 116 interven-
tion studies published between 1986 and 2006 that addressed communication in
persons with severe disabilities. Selected research articles included one or more
participants with severe disabilities (defined as an IQ of 44 or below and aligned
language and chronological ages) and featured intervention efforts specific to one
or more areas of communication performance (defined as the ability to understand
or produce communication messages). Findings were reported on efforts with
185 participants with intellectual disabilities, ASD, or multiple disabilities.
Although some studies did not report the ages of participants, at least 85 were
over the age of 12. Of particular interest to this chapter section is Snell et al.’s
presentation of participants’ pretreatment communication levels, expressive mode
use, and receptive communication abilities.
Snell et al. (2010) reported that the majority of participants had pretreatment
expressive communication best described as either prelinguistic or characteristic of
emerging language. In contrast, a very small number of participants (n ¼ 7) used
multiple nonecholalic words and slightly more (n ¼ 11) used echolalia.
Pretreatment expressive modalities included speech, aided and unaided augmenta-
tive and alternative communication, and gestures with or without vocalizations. A
wide range of pretreatment receptive language abilities were described. For exam-
ple, participants from some studies were characterized as nonresponsive with
receptive language ages (RLA) less than 9 months. In other studies, participants
followed simple directions (RLA 9–18 months), understood single words (RLA
18–30 months), and even understood grammar (RLA greater than 30 months).
Snell et al.’s (2010) work is consistent with that reviewed thus far in that it
describes a wide potential range of fairly conventional emergent communicative
abilities. Those who interact regularly with adolescents or adults with severe
disabilities including ASD know that the communicative repertoires of this popu-
lation often extend beyond conventional expectations. Therefore, unconventional
forms are also important to consider.
For decades, persons with ASD (regardless of age) have been recognized for
their use of unconventional communication. Specifically, researchers have studied
challenging behavior and echolalia as potential means of expression. Many studies
have included adolescents and adults with ASD. Challenging behaviors such as
self-stimulation, stereotypy, self-injury, physical aggressiveness, and disruptive-
ness have long been associated with the diagnosis of ASD (Horner, Carr, Strain,
Todd, & Reed, 2002). Increasingly, these behaviors have been viewed within
20 E. Crais and B.T. Ogletree

contexts to determine their potential communicative value (Carr & Durand, 1985;
Rogers, 2001). While not always used communicatively, challenging behaviors are
now recognized as possible means of expressing messages such as the need to
escape, protest an action, refuse an object, request an action or object, or draw
attention to self or others (Carr & Durand, 1985; Mirenda, 1997).
Another unconventional behavior, echolalia, is also important to take into
account. Echolalia has been described as the repetition (including intonation pat-
terns) of others’ language (Tager-Flusberg, Paul, & Lord, 2005). Echolalia can be
offered immediately after an individual hears the language of others, or it can occur
after a period of delay. It has been suggested that echoing in individuals with ASD
is evidence of a holistic or gestalt language processing style that may represent
initial movement to the development of more generative language (Prizant, 1983).
In fact, a number of verbal adolescents and adults with ASD have used echoic
speech over their course of language acquisition (Le Couteur, Bailey, Rutter, &
Gottesman, 1989). For the purposes of this brief review, it is sufficient to note that
echolalia occurs and may serve communicative functions (e.g., requesting, atten-
tion getting, and escape) in persons with ASD with minimal generative verbal
abilities (Prizant & Duchan, 1981; Prizant & Rydell, 1984). Current research has
both explored techniques to quantify echoic speech behaviors (van Santen, Sproat,
& Presmanes Hill, 2013) and suggested that some types of echolalia may be related
to limited inhibitory control (Grossi, Marcone, Cinquegrana, & Gallucci, 2013).
Research has continued to explore the potential meaning of echolalia, but has done
so within a broader interactional framework, noting echolalia’s role in the accom-
plishment of limited conversational goals, for example, eluding a conversational
partner’s injunction, re-directing a partner’s attention, or maintaining playful con-
versational attunement (Sterponi & Shankey, 2014). Thus with this population,
analyzing and interpreting their communicative repertories, including unconven-
tional behaviors, may help in both assessment and intervention planning.

2.1.5 Impact of Caregivers on Communication

For both children and adults who are in the prelinguistic stage, caregivers play a
large role in facilitating communication skills. Both the characteristics of the child/
adult with a disability (e.g., age, output, readability, disability) and those of the
caregiver (e.g., education level, income level, parenting style) impact caregiver-
child/adult interactions through a transactional process. For example, when a child
produces limited vocalizations, caregivers are less responsive in producing vocal-
izations to the child (Yoder & Warren, 2001) and similar findings are seen with
adults (Olney, 2001). As documented by many, as children communicate more,
their caregivers have more opportunities to provide input (Calandrella & Wilcox,
2000; Yoder, 2006; Yoder & Warren, 2002). In addition, as children become more
competent in their communicative skills with age, caregivers’ input typically
increases both in frequency and complexity. For example, as infants begin to
2 Prelinguistic Communication Development 21

babble, caregivers see this as a sign that their child is ready for higher-level
language and they increase the complexity of their language (Warlaumont,
Richards, Gilkerson, & Oller, 2014). Mothers have been shown to increase both
the amount that they talk and the diversity of the words they use as their children
age (Rowe, Pan, & Ayoub, 2005). For example, in a study of parent-child interac-
tions at 15 months of age, mothers whose children were most communicative (e.g.,
sounds, gestures, words) produced more words and diversity of words in response
to their children (Abraham et al., 2013). In addition, from a transactional perspec-
tive it was assumed the mother’s early input had influenced the child’s output, and
subsequently the reverse was happening. Level of intentionality is also important,
as mothers of toddlers with developmental disabilities respond more consistently to
their children’s intentional communications than they do their preintentional behav-
iors (Yoder & Munson, 1995). Specifically, when children use gestures such as
reaching and pointing, their caregivers respond with additional input that can
facilitate their child’s language development (Calandrella & Wilcox, 2000; Yoder
& Warren, 2002).
Unfortunately, older individuals who are prelinguistic can live in nonresponsive
communicative environments where partners are not sensitive to the potential value
of less obvious communicative behaviors. Olney (2001) notes the importance of
evaluating and responding to even the most nuanced movements within the con-
texts they are offered to build supportive communicative settings.
Caregiver characteristics such as level of education, income level, and parenting
style also impact the child’s communication skills (Duncan & Brooks-Gunn, 2000;
Hart & Risley, 1995; Rowe et al., 2005). Rowe and colleagues (Rowe et al., 2005)
documented that mothers with higher income and educational levels used more
diverse and complex language (than did mothers whose education and income were
lower) and also had children who exhibited superior language skills. In a study of
rural children and their mothers with low incomes, additional factors that impacted
the mothers’ input were the mothers’ knowledge of child development, maternal
responsivity, as well as the child’s temperament (Vernon-Feagans et al., 2008). In
terms of maternal style, mothers who had a more facilitative style (e.g., less
directive, more responsive to the child’s focus) typically had children who later
had larger vocabularies and higher reading skills (Fewell & Deutscher, 2004;
Masur, Flynn, & Eichorst, 2005). As noted by Sameroff (2010), parenting styles
are a result of multiple factors including the parents’ psychological functioning,
personality, religion, culture, their knowledge of child development, and the way
they were raised by their own caregiver/s.
Caregivers’ use of prelinguistic acts can also be influential. For example,
maternal gesture input can impact the child’s gesture use (Capone, 2007; Iverson
et al., 2008) and later language use (Hahn, Zimmer, Brady, Swinburne Romine, &
Fleming, 2014). Goodwyn et al. (2000) documented this type of influence by
training parents to produce either gestures and words together, or focus on spoken
labeling, compared with parents who did not receive any training. At the study’s
end, parents who used gestures and words together had children whose gesture
repertoires were larger than the other two groups of children. Thus, caregivers can
22 E. Crais and B.T. Ogletree

provide their children with input that helps them move from preintentional to
intentional communication. As infants (and adults) move out of the preintentional
and into the intentional stage, they gain much more control over their environment.
For individuals with ASD, prelinguistic behaviors are critical and recognizing
their characteristics and hierarchy of development can be beneficial for researchers
and clinicians in assessment and intervention planning. The range of predictors of
concurrent and later skills can also be challenging to researchers and clinicians.

2.2 Challenges When Examining Prelinguistic Skills

There are a host of challenges facing researchers and clinicians when examining
prelinguistic skills, ranging from assessment context issues to selecting intervention
targets. As suggested by Parladé (2012) and Wetherby (2006), measuring social
communication behaviors is difficult as there is so much variability in the interac-
tion context, the social partner, the individual child, the information source, and the
properties of the assessment tool. One of the challenges that impacts both assess-
ment and intervention decisions is the context of data gathering. Contexts for
examining prelinguistic skills have ranged from standardized to non-standardized,
examiner administered to parent report, and designs may be longitudinal or cross-
sectional. Many studies have included examiner-administered standardized assess-
ments such as the Autism Diagnostic Observation Schedule-2 (Lord, Rutter,
DiLavore, Risi, Gotham, & Bishop, 2012), and for young children, the Communi-
cation and Symbolic Behavior Scales-Developmental Profile (Wetherby & Prizant,
2002) and Early Social-Communication Scales (ESCS) (Seibert, Hogan, & Mundy,
1982). These tools typically include stimuli such as exciting toys or events (e.g.,
wind-up toy, balloon, animated toy suddenly activating) that the examiner uses to
engage the child (Kasari, Sigman, Mundy, & Yirmiya, 1990; Mundy et al., 1986;
Stone et al., 1997; Wetherby et al., 2004). The advantages of using examiner-
administered standardized tools are the structured protocol, the similarities across
administrations in terms of the type and number of opportunities/prompts for
communication, and the standardization sample of children. Standardized measures
can also diminish clinician or parent variability that may be more of a factor in
observational or parent report measures, respectively. However, the limitations
include the unfamiliarity of the examiner and the setting, which can have an impact
on the child’s performance. Indeed, the work of Fuchs, Fuchs, Power, and Dailey
(1985) indicates that although preschool and school-age children without disabil-
ities perform equally with familiar and unfamiliar examiners, children with com-
munication difficulties perform more poorly with unfamiliar examiners.
Other means to examine communication skills may include videotaped
examiner-child or caregiver-child interactions, followed by coding of the observed
behaviors. Other methods have included caregiver report measures such as the
MacArthur-Bates Communicative) Development Inventory (CDI) (Fenson et al.,
2007), naturalistic observation or caregiver guided observations or a combination
2 Prelinguistic Communication Development 23

(Crais et al., 2004). The benefits of using parent report include the potential to
gather a more representative sample, as parents spend more time with the child than
professionals, are familiar to the child, and provide a familiar context. In addition,
the parent has multiple opportunities to see the child across contexts. Naturalistic
observation typically involves videotaping the child and caregiver at home during
some “usual” interactions such as playing with toys and then coding the behaviors
observed (Capirci, Iverson, Pizzuto, & Volterra, 1996; Crais et al., 2004; Iverson &
Goldin-Meadow, 2005; Parladé, 2012). Guided caregiver observations may include
a checklist of typical gestures along with definitions and examples and detailed
instructions about what is and is not a gesture (Crais et al., 2004) and having
caregivers document the targeted behaviors and when they see them over some
timeframe. The benefits of these measures include familiarity of partner and
context, as well as opportunities to see the child in her/his usual surroundings,
which may allow the child’s full repertoire to be observed. Indeed, there is some
evidence that children produce more vocalizations and gestures when at home
versus in a laboratory setting (Iverson, Capirci, & Caselli, 1994; Lewedag, Oller,
& Lynch, 1994). The drawbacks of naturalistic settings are the lack of structure and
ability to control the context, thereby not always having similar numbers of
opportunities for some types of behaviors.
A final method of data gathering is the use of retrospective video analysis
(RVA). RVA entails gathering home video footage of children before diagnosis
or, for some families, even before concerns arise (Baranek, 1999; Colgan et al.,
2006; Osterling & Dawson, 1994, Watson, Crais, Baranek, Dykstra, & Wilson,
2013). Most studies include children who are later diagnosed with ASD or another
DD and a group of children who are typically developing. Through the use of
rigorous guidelines, these videos can be coded by “blind” observers to look for
differences across groups. The drawbacks to RVA are that caregivers may select the
video footage to capture or avoid (e.g., camera turns off when child becomes fussy
or acts in unusual manner); not all behaviors desired may be observed; and sound
quality/camera angle may at times make coding difficult. However, the strengths of
RVA include the natural setting and familiar adults (or siblings) as well as the range
of contexts that can be included (e.g., meal times, outdoor play, floor play).
The challenge in employing only one measurement method may be that children
differ in which prelinguistic means they use (and how frequently) in one setting/
context versus another. For example, in gesture use, few studies have combined
standardized and non-standardized methods, and few have included both parent
report and naturalistic means. However, a few studies have used combined methods
(Crais et al., 2004; Parladé, 2012; Rowe & Goldin-Meadow, 2009). For example, a
recent study by Parladé (2012) included both structured versus naturalistic contexts
in examining social communicative behaviors in 14- and 18-month-olds who were
at high risk for an ASD diagnosis (younger siblings of children with ASD) or low
risk for ASD with a negative family history. As documented by Parladé, there was
very little correspondence between the joint attention behaviors (fewer) seen on the
ESCS and the larger number of joint attention behaviors displayed in the natural-
istic sampling context. As suggested by Parladé, different contexts may afford
24 E. Crais and B.T. Ogletree

differential opportunities for specific functions. For example, more behavior


requests than joint attention behaviors were seen in the context of the ESCS with
its elicitation probes, whereas in the naturalistic setting behavior requests and joint
attention acts were equally represented. As an explanation, Parladé argued that
children with ASD may show more “sticky attention” to the kinds of objects often
used in elicitation tasks in tools like the ESCS (e.g., bubbles, windup toys) and
therefore demonstrate more behavior requests to get the toy activated than joint
attention to share interest. Thus, sampling contexts in standardized settings may
need to provide additional opportunities for joint attention acts.
The issues of differential responses relative to the familiarity of the partner and
context are also important. As discussed by Crais et al. (2004) when considering
Carpenter et al.’s (1998) study of 24 typically developing children seen in a lab
setting, despite monthly observations and elicitations from 9 to 15 months, 9 of the
24 children never gave declaratively, 4 never pointed declaratively, 3 never gave
imperatively, and 9 never pointed imperatively. In contrast, in the Crais et al. (2004)
study where children were observed monthly in their homes interacting with their
caregivers, all 12 children displayed all four of the above gestures. These differ-
ences across studies argue for the use of multiple methods for gaining information
about children’s communicative behaviors, mirroring Tager-Flusberg et al.’s (2005)
and Crais, Watson, and Baranek’s (2009) recommendations to expand the context
of assessment to include more natural communication samples. In addition, as
noted by Parladé (2012), combining the results of standardized assessments and
parent report with observational data from the home setting improved substantially
the diagnostic predictability for the high- and low-risk groups of children studied.
For detailed discussions of various assessment approaches for prelinguistic com-
municators, see Chaps. 5 and 6.

2.3 Implications for Research and/or Practice

From a research perspective, there are a number of frontiers left to explore relative
to prelinguistic communication. One is to quantify clear “red flag” boundaries for a
range of prelinguistic behaviors in infants and toddlers. For example, although there
are rough guidelines to use to determine when smiling should appear, for behaviors
such as the range of consonants that should be produced, when first gestures are
used, and when joint engagement is consistently used between adult and infant,
most have moderate variation across infants. In these cases it is often easier to use
“expected ranges” rather than red flags because many prelinguistic behaviors do not
have clear guidelines that unequivocally indicate at what point a child is delayed or
disordered. Therefore, to help in diagnosis and intervention planning, additional
research is needed to define the upper boundaries or absolute red flags across a
range of prelinguistic behaviors.
Yet even though we do not know all the boundaries, gathering information about
the use of prelinguistic skills can help differentiate between children with and
2 Prelinguistic Communication Development 25

without disabilities including ASD. Milestones noted previously in terms of social


smiling, sound making, babbling, onset and use of intentionality, onset of gestures,
communicative functions, frequency and type of gesture use, and the ability to
combine means of communication can all be analyzed for signs of delay or
disability. In addition, factors such as non-hierarchical development (e.g., multiple
words in a child’s inventory, but none used functionally; a child learning letter and
number names with limited use of gestures) can help in the diagnostic process as
well as to identify areas to target in intervention.
In addition, because of certain patterns of gesture use, distinctions can also be
made across disability groups. For example, the work of Watson et al. (2013) and
Wetherby, Watt, Morgan, and Shumway (2007) has documented that the lower
inventory of gestures of young children with ASD is one variable that can help
distinguish them from children with other disabilities. As noted, between 9 and
12 months infants later diagnosed with ASD show patterns of similar number (but
less variety) of social interaction gestures when compared to children who are
typically developing (TD) and DD; whereas by 15–18 months they use fewer of
these gestures than children with TD or other DD (Colgan et al., 2006; Watson
et al., 2013). For behavior regulation acts at both 9–12 and 15–18 months, infants
with ASD use similar numbers of acts as children with DD, but less than those with
TD and more contact gestures (Landa, Holman, & Garrett-Mayer, 2007; Watson
et al., 2013; Wetherby et al., 2004). The largest difference across groups appears in
join attention acts where infants and toddlers with ASD at both 9–12 and 15–-
18 months show no or few acts compared with children with DD or TD (Landa
et al., 2007; Watson et al., 2013; Wetherby et al., 2004). Thus, gesture frequency,
variety, and type can help make distinctions between children with ASD versus
another DD.
Object-related or symbolic gestures are also important components of symbolic
play acts and are strongly related to language skills. Looking at gesture and play, for
both TD children (Bates, Bretherton, & Snyder, 1988) and those with DD (Ken-
nedy, Sheridan, Radlinski, & Beeghly, 1991), higher levels of gestural production
and play maturity have been associated with higher levels of comprehension. Thus
examining and profiling a child’s use of gestures, along with other related commu-
nication domains such as comprehension and play, can provide additional infor-
mation about a child that can be used for clinical decision making. For example, in a
study of siblings of children diagnosed with ASD, Mitchell et al. (2006) noted that
neither comprehension nor production of words at 18 months had distinguished the
high-risk siblings (those who went on to be diagnosed with ASD) from those at low
risk (not diagnosed with ASD). However, the use of gestures did differentiate these
groups. Therefore, Mitchell and colleagues argued that gesture use can be more
informative than language measures at this age. They further suggest that examin-
ing gesture use alone cannot be used as a singular screening measure, but can be
combined as part of routine developmental surveillance as the delays in gesture use
may be one of the earliest indicators of ASD in these children. Thus, as suggested
by Sauer, Levine, and Goldin-Meadow (2010), examining early gesture use can
provide clinicians with a mechanism to identify children who may eventually have
26 E. Crais and B.T. Ogletree

persistent language deficits, before the delays are seen in the child’s speech.
Gestures in turn become a target of any intervention strategy developed to address
current and possible future delays in communication skills.
Finally, using prelinguistic behaviors in combination is another means that can
be used to identify children with potential disabilities including ASD. As
documented by Wetherby et al. (2004), the lack of coordination of eye contact,
facial expression, gestures, and vocalizations can be used as a red flag for toddlers
with ASD. In addition, Goldin-Meadow and colleagues (Goldin-Meadow, 2008;
Rowe & Goldin-Meadow, 2009) observed that gesture-plus-speech combinations
predicted the age at which children produced two-word combinations. And Parladé
(2012) has recommended examining the ability to combine vocalizations with eye
gaze or gestures, and specific gestures such as showing and pointing that my help
differentiate young children before the age of 12 months who may be struggling
with communication challenges.
For children or adults in the prelinguistic stage of communication, facilitating
their use of prelinguistic means in terms of frequency, variety, and types of
functions should be a major focus of their educational goals. In addition, as
suggested by Brady et al. (2004), facilitating their partners’ use and modeling of
these means can improve partner interactions thereby enhancing the communica-
tion skills of these prelinguistic individuals.

2.4 Conclusion

This chapter has highlighted a range of prelinguistic skills important for individuals
in the prelinguistic stage of communication development. For individuals in this
stage, acquiring a range of these behaviors is critical to current and later commu-
nication development. In addition, as the acquisition of many of these skills can
enhance the individual’s immediate communication effectiveness and efficiency,
the transactional effect on communication partners can further advance the indi-
vidual’s skills as partners can be more responsive, providing more models and
additional opportunities for the individual to communicate. Thus, clinicians and
researchers can and should target these behaviors within both the assessment and
intervention context.

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