Barry Gordon, MD, PhD
Professor, Department of Neurology
The Johns Hopkins Medical Institutions
Department of Neurology Cognitive Neurology/Neuropsychology
Baltimore, Maryland, USA
Date Published: April 2, 2007
A Neurologist's Perspective/A Parent's Perspective
Problems with speech and language are one of the defining characteristics of the Autism Spectrum Disorders. However, the difficulties that individuals with autism have with speech and language are very heterogenous and probably have a number of different causes or contributing factors, even in the same individual. My colleagues and I have been trying for some time both to investigate the speech and language problems that can occur in autism and to develop possible treatments for them. In addition, I am the father of a nonverbal 14 year old with autism. What follows is a general overview of my perspective on these problems and how they can be assessed and approached for what treatment is possible. Any actual assessment and treatment plan of any particular individual needs to be far more detailed and follow much more detailed logic than this overview allows. However, I am hopeful that it will still be useful for helping parents and teachers interpret what is wrong, what is right, and what can be done to possibly make things better for such individuals.
Normal Speech and Language
The fullest expression of normal human speech and language requires the desire or intent to communicate something. Also, in its fullest form, it also requires an appreciation of what the other individual understands about a situation and how they are supposed to react to what is being communicated. As the next stage beyond the formulation of an intent or goal in communication, speech and language normally require a mental representation of the message (semantics), next, a representation of the message in terms of words (mentally), and, finally, an articulation of the mental words as physical sounds (articulation of speech). Other ways of expressing mental words are possible, such as gesture (including sign language) or typing. Messages may also have an emotional component that, in English, is signalled by changes in the volume or pitch. Comprehension of speech and language is normally done through sound. This requires paying attention to the sounds, then being able to decipher the sounds in terms of words, then being able to understand the words in terms of intended meanings, and, finally, appreciating the meanings in terms of intentions, actions, or what have you. Vision (perception of gestures and signs or of printed words) and touch (Braille) can also be used as alternative or additional routes into the perception of letters and words.
Impairments in Individuals With Autism
Individuals with autism can have problems with any or all of these aspects involved in producing or understanding speech and language. In particular, for example, because of their deficits in appreciating social situations, they may not feel any need to communicate and may very well not have any understanding of how other people might respond to a communicated message. Individuals with autism frequently appear to have deficits in paying attention to auditory information. They frequently have to be trained to pay attention to sounds. Even when they are paying attention, many individuals with autism seem to have difficulty in decoding what sounds mean and in matching them to words or thoughts. In some individuals with autism, this may be because they actually have difficulties with words and thoughts themselves. In others, it may be more because of a mapping problem. Individuals with autism frequently have difficulties with articulation, often as part of a broader problem of difficulty with oral-motor functions (movements of the lips and tongue and associated breath control). On the plus side, however, individuals with autism are frequently very good with paying attention and appreciating visual materials. Therefore, the visual route is often one way of getting access to their minds and giving them a way of expressing themselves, in turn.
In any given individual, which particular problems they have and which problems are hampering them most in any particular stage of development can only be determined by a careful assessment. Standardized testing can help to some extent, but it requires careful administration and interpretation, in part, because many standardized tests were not developed with a consideration of the kinds of deficits that individuals with autism may have. Therefore, both the administration and the interpretation of such tests may be problematic because of the unusual pattern of performance. To give just one example, because of their markedly restricted interests, individuals with autism may only rarely show any particular verbal ability and may never show the ability when placed in an unusual testing situation with an unfamiliar examiner. In such a case, the reports of parents and teachers who are more familiar with the child’s capabilities can provide an important clue to what is possible for them and what is not.
In our research and educational program, we try to construct for each child an individualized map of their abilities and disabilities. Is the child aware that he or she is being spoken to? Do they ever try to communicate by any means? Are they echolalic (that is, do they repeat sounds or words spoken to them)? Echolalia, for example, is a clue that the child can perceive speech and articulate speech, so any problems that they may be having with speech and language must be beyond those levels.
Individuals with autism may have problems impeding their development of speech and language that are well outside the scope of traditional speech and language therapy (such as social deficits) or, at the very least, in the very frontiers of clinical knowledge as to appropriate treatment (developmental articulation disorders). Parents and teachers are confronted by a bewildering range of options and apparent philosophies of treatment of these individuals. However, what really matters most is the empathy, energy, and flexibility of the particular therapist or therapists. In many cases, for example, therapists with seemingly very different philosophies will have surprisingly similar treatment plans because of the realities of the particular individual they deal with.