Given the heterogeneity of the ASD population, what is the best approach to take in order to assess pre-linguistic skills? Typically, there are a number of standardized language tests, social/adaptive scales, and cognitive tools administered which may confirm a diagnosis of ASD, but these tools provide little valuable information relative to the development of specific language goals and where to begin the treatment process relative to the use of AAC. Most children diagnosed with autism have typically been evaluated using tools such as the Autism Diagnostic Observation Schedule, Second Edition (ADOS-2; Lord et al. 2001), considered the gold standard for sensitivity and specificity for the Autism diagnosis. The Autism Diagnostic Interview-Revised (ADI-R; Le Couteur et al. 2003) may also have been given, providing some picture into the history of the child’s development across key developmental domains and specific behaviors, providing useful information relative to acquisition of skills and any regression in skills. The Childhood Autism Rating Scale (CARS; Schopler and Van Bourgondien 2010) is also a typical screening tool used early in the diagnostic process that provides some information related to communication partners and style of communication in terms of gesture and verbal speech. These tools are all essential to diagnose autism and differentiate the disorder from other developmental delays; however, a useful tool to the speech-language pathologist for measuring communicative behaviors in the non-verbal child with ASD is the Communication Matrix© (Rowland 2004). This criterion-referenced tool breaks down very early communication skills ranging from pre-linguistic to abstract language use in four domains identified as the primary reasons for communicating: social interaction, obtain things, refuse things, and seek and share information. This tool breaks down communication into seven stages of language development, which begin at unconventional levels of communication in the absence of symbolic language, building in complexity from pre-linguistic behaviors to abstract language use, including verbal speech. The seven stages of communication measured on the Communication Matrix are outlined in Table 2.1. These behaviors should be observed in more than one setting over multiple observations, with more than one communication partner, in order to identify the most commonly used forms of communication.

Determining these baselines of communication ability allows the speech-language pathologist, together with the family and other team members, to determine stages at which to begin the use of AAC and to establish a path by which the communication system will develop relative to the individual’s use of existing pre-linguistic behaviors. Instead of looking primarily at communicative contexts and partners throughout the individuals daily routines, as most other tools for AAC assessment do, this analysis focuses on prerequisite skills needed to communicate with those partners in varying contexts, resulting in treatment goals that facilitate the incorporation of the AAC tool with the use of evidence-based intervention practices such as Pivotal Response Training (PRT; Koegel and Koegel 2006), Early Start Denver Model (ESDM; Rogers and Dawson 2009), or the Social Communication Emotional Regulation Transactional (SCERTS; Prizant et al. 2006) model to teach the necessary pre-linguistic skills. As previously mentioned, the AAC is the tool, and an evidence-based language intervention will need to be paired with it to yield positive outcomes related to its use. The assessment process within the initial stages of evaluation provides a foundation upon which to establish treatment goals for determining social interaction using pre-linguistic behaviors that promote effective use of the AAC for conventional use of communication and advancement toward more sophisticated development of language. Although the Communication Matrix© is a measure that explicitly describes levels of communication and language, meant to pinpoint where to begin AAC treatment goals, the comprehensive AAC evaluation should also include other measures of adaptive and cognitive tools as well. The reader is referred to Beukelman and Mirenda (2013) for a thorough review of cognitive tools available to supplement the AAC evaluation process, as well as other key features of a thorough AAC evaluation regardless of disability.

As cited previously, often the individual with ASD may begin with AAC to benefit from intensive early intervention, and as the speech-language pathologist works with the child, emerging language begins, often resulting in the use of verbal speech. A second form of dynamic assessment for AAC that may be embedded within the preliminary intervention approach is the use of the Picture Exchange Communication System (PECS, Frost and Bondy 2002), which can be used to observe pre-linguistic behaviors and early emerging skills related to competent AAC use, such as cause and effect, visual discrimination, early syntax use following a developmental sequence for oral speech, and left-to-right correspondence for emerging literacy. As treatment goals are established, the PECS system may be used to introduce the concept of AAC to the child in order to obtain desired items and activities, and to socially interact with others. Frost and Bondy (2002) report that PECS was not designed with an outcome of verbal speech as the goal; however, it is often the case that verbal speech begins to emerge when the PECS system is followed. The PECS system relies heavily on principles of applied behavior analysis, and is considered an emerging evidence-based practice within ASD interventions (National Autism Center 2015). When used with fidelity, the PECS system often results in one of two decision-making outcomes on the part of the clinician: (1) continue language development using the verbal speech modality if verbal speech has emerged or (2) continue language development using a more advanced AAC device once initial behaviors such as initiating, requesting, commenting, visual discrimination, and combining symbols have been observed with the PECS system. PECS is a low-tech AAC tool that facilitates the transition to more advanced AAC options because the system addresses the necessary pre-linguistic skills needed for AAC use and communicative competence through an explicit, sequenced hierarchy, and structured teaching approach. In addition, the key component of PECS that lends itself well to bridging skills for AAC use is the emphasis on initiating communication attempts to others. Without that essential communication skill, an AAC tool will be of little use to the child with autism. Often clinicians or parents may indicate that PECS had been tried in the past, with no success; however, it is critical to reassess the child’s use of PECS taking the strict sequencing and prompting approach outlined in the system, in order to ensure it has been implemented with fidelity before assuming the system “did not work.” This process can be done in a very short period of time and lays the ground work for moving the child forward with AAC that is meaningful and predictable following a similar pattern of communication the child had been trained on. Children performing at Phase 4 of the PECS system, which requires putting symbols together independently on a PECS sentence strip and initiating an exchange with a communication partner, should be able to transition to a SGD with little difficulty if the child will physically point to each symbol on a PECS strip as the communication partner reads the message out loud. If the child is not yet pointing, this behavior can be encouraged through physical prompting and positive reinforcement using preferred items and activities paired with verbal modeling (Frost and Silverman-McGowan 2014).

It is of paramount importance that in attempts to create AAC for basic communication needs throughout the child’s day that clinicians not inadvertently ignore the development of more sophisticated forms of language as the child demonstrates progress with any AAC device. It is still very important that the team of professionals working with the child consider how the child is using language relative to the sequence of language development observed in typically developing children. Given a critical window for developing language, the reader is encouraged to review Brown’s (1973) stages of morphological development in order to understand the complexity of the early developing language system, whether oral- or AAC-assisted. These morpho-syntactic features of language are essential in building and expanding expression and comprehension of language. The AAC must encompass the use of these morpho-syntactic features as part of its design and should allow flexibility in developing the system in accordance with the level of language development the child demonstrates. The speech-language pathologist should be consulted as the AAC system evolves in order to align with the language level of the child as these skills emerge.

As the area of technology is constantly changing, new approaches to its use for AAC will grow in scope, as it applies to autism. By the time of this publication, it is feasible that a number of new developments will have been made, thus a brief overview of existing high-tech tools will be discussed to illustrate the current technology. An emerging area within the realm of augmentative alternative communication and assistive technology includes software programs and apps that capitalize on recent autism research related to visual attention and eye tracking. Innovative technologies to increase the child’s response to visual stimuli have emerged with the promise of promoting increased attention to verbal speech and increased observation of socially appropriate behaviors. Just as in the case of AAC for communication, the use of these therapy tools for teaching oral speech requires that the child possess some basic pre-linguistic skills such as engagement with tasks and activities, joint attention, and initiations before implementing them. Such technology includes apps that focus on the mouth as verbal speech is successively increased through the introduction of phonemes, then to full communication messages, combining two words, then sentences, with a video model to support the teaching process. An example of this technology is the app known as Inner Voice©, which is based on empirical research related to the use of video modeling (Cardon and Azuma 2012; Charlop-Christy et al. 2000; Vivanti et al. 2008) as the basis for the AAC technology. This SGD app not only includes dynamic displays with basic icons for functional communication, but also includes the added feature of a video image of the child producing the verbal message as the message is spoken. Research in the area of video self-modeling indicates that when the child with autism observes him- or herself performing a given behavioral act, as with other forms of video modeling, the likelihood of the child exhibiting the behavior increases (Bellini and Akullian 2006; Wert and Neisworth 2003) when compared to other methods. The Inner Voice© app is also based on emerging research indicating that individuals with autism respond to intervention utilizing avatars, resulting in an increase in social interaction and emotion recognition (Hopkins et al. 2011), providing the rationale for including the option of adding an avatar or character performing the messages if desired. It has been suggested by the makers of Inner Voice© that this app may promote an increase in verbal speech, taking the focus off of the therapist for learning the communication targets, while utilizing highly motivating visual stimuli based on basic research in the area of visual processing and eye gaze in the ASD population. This area of AAC research is relatively new, and although based on empirical evidence to support the approach to gain visual attention and focus, outcomes regarding clinical trials using this specific app have yet to be completed.