4-Year-Old with Autism with Severe Communication Needs

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I have the most challenging case I’ve come across so far and need some help.  I have a 4 year old boy, diagnosed with autism. He is the most sensory seeking child I’ve worked with and he is getting lots of OT. He is now biting, pulling hair, and scratching (peers and adults). I have worked with him for 5 months and have heard a few word approximations and slight groping when trying to imitate. (Side note: could this be apraxia?).  He has mastered basic requesting with PECS. He now opens his communication binder and wants to touch the Velcro or step on the binder rings. He loves iPads and books but only wants to read them or play with the iPad alone. He becomes upset, runs away, or bites if you try to read or play with him.  His mother has mentioned that at home he brings his communication binder to different people and hands them an empty sentence strip as if he wants to say something but the pictures are not there. She has asked me to move to the next step but I am having a hard time getting him to attend for longer than 10 seconds at a time to engage in different activities. He needs max assistance to follow 1-step directions and has trouble demonstrating understanding of common vocabulary words.  I know he has to be frustrated because he is having trouble communicating, what can I do next to help him and his family?

My Thoughts:

  • Work with the OT, co-treat if possible, to get sensory strategies right before and during your session that will help him focus
  • Look for the function of the inappropriate behaviors.  Are they sensory-seeking?  Avoidance?  Escape?  Wanting Something?  Attention Seeking?  Teach to use PECS to get those needs met instead
  • Could it be apraxia?  Yes, these two diagnoses do seem to go together sometimes, but there’s no way to tell until he starts talking more.  You can definitely use an apraxia approach to speech therapy though if you can get him to do it
  • If the binder is becoming a problem, eliminate it.  Just present him with a piece of cardboard with a few pictures on it for use with requesting
  • Teach him to use his PECS to request the ipad or books for independent time but don’t expect him to do joint attention with those things with you.  Try to find other activities to get joint attention with.
  • Make sure you’re using the PECS system exactly as it was intended.  If he has mastered a phase, go on to the next phase, but don’t give him the sentence strip yet unless he needs it for his current phase
  • I wouldn’t work on understanding vocabulary right now, focus instead on functional activities like using PECS to get what he wants and following one-step directions to get what he wants