Improving communication - Confirming understanding

Written by Dr. Glenis Benson, a lifelong autism professional.

 *Identity first language (IFL) will be used throughout, not person-first language (PFL) in deference to the wishes of adult advocates. Furthermore, autism spectrum conditions (ASC) will be used in place of autism spectrum disorders (ASD).

“The single biggest problem with communication is the illusion that it has taken place.” George Bernard Shaw

Introduction:

Although communication impairments are a core defining component of ASC, to date, there has been insufficient focus on the comprehension of spoken language. Typically, expressive abilities are targeted for intervention; thankfully, there has been a recognition that autistics must have a means by which they can express their needs, be it verbal or with the aid of some augmentative alternative communication (AAC) method.

Their ability to understand what is said to them has not been so closely investigated. Sure, there is a recognition that many are very literal, and it is well understood that idioms and metaphors may be challenging, but all too little thought has been given to the general, day-to- day ability to comprehend spoken language, especially verbal directives like “please brush your teeth” for instance.

Understanding matters!

Intended Audience:

This toolkit is designed to sensitize parents of children of all ages, teachers, and self-advocates to this element of the broader domain of communication impairment in autism, and to provide strategies to support accurately understanding spoken language.

Rationale for this toolkit:

If there is truly an issue with language comprehension, why is there not greater recognition of this problem? The answer is that it is complicated.

A.Often autistics are able to complete a verbal directive giving rise to the conclusion that they have understood the spoken words, but frequently there are alternative explanations; there are means by which they can complete the task without understanding the words. When we give directives we often tap and/or point to augment our verbal message; autistics may be attending to these visual prompts to assist with the completion of the directive.

A developmental pediatrician, known for diagnosing masses of children in her day, required trainee resident physicians to keep their hands in their pockets so as to NOT inadvertently provide visual cues that would aid in the individual’s understanding of the questions being asked of them. She wanted the residents to understand that they could be giving ‘clues’ if their hands were not otherwise in the pockets of their lab coat thereby allowing the individual to follow a directive even though they had not understood the spoken word

Consider Hunter, an autistic kindergarten student. I had observed Hunter in his kindergarten classroom on a couple of occasions and hypothesized that his understanding of the teacher’s spoken words was highly suspect. His father, however, explained that Hunter understands everything, and then he provided me with this example. He explained that in the morning when they see the school bus coming down the lane, he can say, “Clean up your dishes and get ready for the bus” and Hunter follows through, faithfully every morning.

Is this evidence that Hunter understood his dad’s language? Not necessarily.

There are multiple explanations for Hunter’s ability to follow this directive:

B.Many directives are repetitive; we say the same thing every day especially when it comes to personal care and household routines. Perhaps the autistic individual has learned the routine as a function of the context, independent of the verbal directive (e.g., I see the bus, so I engage in my ‘leaving for school’ routine). They can also appear to have understood the spoken words especially in the classroom, when in fact they are imitating their 25 classmates. Then again, sometimes autistics can infer the intent of the speaker by comprehending only the nouns in the directive; nouns are concrete and can be visualized unlike words that are abstract for which a picture cannot be made in one’s head (more about thinking in pictures-TiP below). Visualizing the nouns alone may assist them with understanding the directive.

 C.Formal speech-language assessments may not reveal the receptive language challenges. Speech language pathologists (SLP) are charged with assessing both expressive as well as receptive language and if they rely on formal assessment instruments, they can often erroneously conclude that receptive language is not that compromised. To be clear, a formal assessment is only as good as the instruments available to the SLP. It is not unusual for a receptive language assessment instrument to provide a visual array and the individual has to point to or touch that which the SLP says (e.g., touch the ‘wagon’). By providing a visual selection, the instrument is exploiting the autistic’s visual ability and the autistic student may be able to score relatively well, leading some to conclude that receptive language is not compromised. But this scenario does not mimic the typical spoken exchange of verbal communication. SLPs must employ informal assessment strategies to truly assess receptive abilities of persons on the ASC, and this is not always done or reported.

An SLP provided the results of her assessment of a young man with autism. She explained that she conducted a formal assessment of his receptive language and concluded that his abilities were within the norms for his age. However, he could not understand the teacher in the front of his classroom. Informal as well as formal assessments must be conducted to get a complete picture of someone’s abilities; until we acknowledge the deficit it will go without remediation.

Why beat this drum relentlessly?

Why erode the competencies parents/teachers/caregivers ascribe to those with ASC?

Aren’t we supposed to presume competence?

If you believe that the autistic comprehends EVERYTHING you say, and if they happen to respond intermittently or fail to respond to a directive, you need an explanation for this behaviour. Unfortunately, too often the explanation is that the autistic is being non-compliant, defiant or oppositional. We know well the consequences when one is thought of in such an unsavory manner. Such a dangerous assumption must be avoided; their comprehension of spoken language must be determined.

The explanations are numerous for how they can appear to have understood what has been said to them, even when they have not in fact grasped the meaning of the words spoken. The problem arises when they do not complete a verbal directive, and it is believed that they have understood the directive. If you believe that the autistic comprehends EVERYTHING you say, and if they respond intermittently or fail to respond at all to your directives, you need an explanation for this behaviour. Unfortunately, all too often the explanation is that the autistic is being non-compliant, defiant, oppositional or at a minimum stubborn.

“Kids do well if they can.”

– Ross Greene

The story doesn’t end there. Clinical anecdotes report that autistics rarely request clarification; they very rarely indicate that they have not understood something. If they regularly inquired “what do you mean?” or stated “I don’t get it” they would be signaling their comprehension failures, but they tend not to give their communication partner such feedback. In the absence of such feedback, communication partners make assumptions that comprehension has taken place. Sometimes someone may check for comprehension by asking, “What did I just tell you?” which, for an echolalic autistic proves nothing about their understanding, but rather how well they can repeat.

Even when comprehension has not taken place, autistics rarely REQUEST CLARIFICATIONThe literal and/or echolalic autistic individual may simply REPEAT; this doesn’t mean that they’ve understood.

Would it not be a tragedy if in fact we are assuming that they understand when in fact they do not? The consequences of this misunderstanding are the motivation for this toolkit. Autistics deserve our understanding and our assistance.

The ‘watch & listen’ opportunities should be completed with your favourite autistic person. Engage them in the activity to get a first-hand experience with the issues discussed herein.

Intent of the Toolkit:

The objectives for those who access this toolkit are:

• To understand the potential for language comprehension difficulties;
• To question the comprehension of someone they previously believed understood most things;
• To employ strategies to improve understanding;
• But most of all, to eliminate the assumptions that the autistic is being NON-COMPLIANT, DEFIANT, or OPPOSITIONAL when they do not follow a directive.

Autistic characteristics that contribute to the problem

Although what follows is rather technical, it is imperative to understand the various components that contribute to understanding spoken language; it is truly a complex task.

The autistic characteristics that should have alerted us to the potential for comprehension challenges abound. Frankly, we should have been sensitized to this potential problem all along. When we examine autistic characteristics, it becomes evident that understanding someone who is talking can be exceedingly difficult, especially long strings of directions, questions or conversations. There are so many autistic characteristics that can potentially impact the understanding of spoken language and cause communication problems.

This is an example of a written schedule for campers where all could read and understand the words. This would replace: “at 7:30 we have the Polar Bear plunge, followed by bug/sun protection, then meds at 8:05, followed by setting the table at 8:15, and breakfast at 8:30. Then at 9:30 we go fishing, with snack at 10:15, and waterfront at 10:30 and Fun Hill at 11:30.”

This is an example of a written schedule for campers where all could read and understand the words. This would replace: “at 7:30 we have the Polar Bear plunge, followed by bug/sun protection, then meds at 8:05, followed by setting the table at 8:15, and breakfast at 8:30. Then at 9:30 we go fishing, with snack at 10:15, and waterfront at 10:30 and Fun Hill at 11:30.”

Example B:

In this example, there are black and white line drawings indicating that the child would go to music, followed by lunch, followed by recess, and the TimeTimer™ indicates the time to transition to the next activity. This visual would replace written words.

Example C:

In Example C, there is a written schedule that can be checked off when completed with an integrated TimeTimer™ that indicates the total time allotted to the entire activity.

Example D:

In example D, there is a black and white line drawing used instead of words (Example C) for someone who would better understand pictures than words.

 

First/then set-ups can be very helpful.

• 

• Their application is endless (insert photos, line drawings or words):

  First: dinner Then: board games

  First: snack Then: brush teeth

• Feel free to make a sign and hang that reads: (Why Am I Talking?)

• While much of what we say is directing the autistic to engage in day-to-day activities, a lot of communication involves responding to their requests, to their inquiries which puts us in the role of responder.

• Responses: Responding to their requests in a manner they can comprehend

  oAffirming – rarely when you comply with a request is there difficulty, but

  oDenying/delaying compliance with a request is what will typically cause grief (much of the time because the response has been misunderstood)

• oThe answer to any ‘when’ question has to be visual because you cannot visualize temporal terms.

  Denying:

  “No” would seem to be fairly straightforward response to a request but actually ‘no’ has multiple meanings and truly it’s open to misinterpretation for the autistic individual.

When the adult says: “No” - permission denied (e.g., “you cannot have screen time”)  “No” - it’s all gone (e.g., “no more Cinnamon Crunch, I’m sorry”)  “No” – refusal (e.g., “I won’t open that up”) “No” – negation (e.g., “I don’t want that”)

But it is even more problematic because when we say something like “no more screen time” we mean for RIGHT NOW, but to interpret it that way you must bring a level of social understanding, and perceived intent to the situation. If, like the autistic, you rely solely on the word meaning, you conclude that NEVER, EVER, EVER will you get screen time EVER AGAIN, IN YOUR LIFETIME – cue meltdown – caused by a communication failure.