Autism: Three-Word Phrases to Supported Conversations in 18 Months

WebRTC conversations

Photo by Tsahi Levent-Levi

Just settling back in from the whirlwind trip to Atlanta, Georgia.  ASHA, once again surpassed itself in excellence.  My kitchen table is a mass of brochures, notes and folders; re-organized into priority piles.  The exhibit hall was replete with samples and gadgets.  Now, what to do with that little planter of wheat grass?  Yes, I live in northern California; one would think I’d blend that stuff right up in my morning “green drink,” but I think I’ll find another home for it instead.

And, reaching in my zipper-top ASHA bag, there’s more: a pink flamingo clip, a recycled “use your own” grocery bag, a pamphlet on social networking, plenty of memories.  Notwithstanding the seminars and short courses which offered a mountain of new information.

I contributed “my rock” of new information this year, too.  I had the honor of presenting a case study of an Autistic teen’s language development over an 18 month period.  Presenting at ASHA is not new to me, but each time it confirms the fact that we, “ in the trenches” daily clinicians, as opposed to university researchers,  have much to offer our colleagues.

ASHA is interested in what we are doing out in the field.  Small treatment programs and case studies contribute as much as research coming out of the more prominent universities.  ASHA is interested not so much whether a given treatment “worked” (as that word is nebulous in itself) but what did it change? And, how did it change?

So, this case study was a sequential presentation of video clips demonstrating an 18 year-old autistic male’s changes in sentence structure, vocabulary and vocal prosody as he learned from video feedback and the use of a speech generating device. The changes over time have been dramatic and offer us windows into understanding how communication skills can change via use of technology.

Treatment is evidence-based, as I took the best available research about children with autism and video monitoring and then applied my clinical best-practice knowledge, along with his values and interests. Computers enthralled him and Disney is his favorite subject!  His comments confirm this.

Combining the use of point-of-view virtual feedback, audio and video self-editing, self-modeling, repetition and practice speaking with a monitor rather than a person, we witnessed movement starting with our teen bolting perseverative repetitive words and phrases across to phases of dependence on written scripts or memorized lines through his success with short supported conversations.

The videos showed a continuum of his vocal changes and the sweet exploration of facial expressions related to his intentions of message delivery. We also watched his ever-growing vocabulary, including the use of temporal and spatial relationships.

Seminar attendees fell in love with this charming young man as they learned how he mastered the use of a speech generating device, including developing his own customized digital icon library as well as video editing and review. They learned how he independently wrote and recorded his own comments and attached them to his personal photos, all in an effort to share the events in his life.

Current Technology

This case study offered a readily-attainable speech and language treatment utilizing a speech generating device for delivering supported and self-study techniques.  The Lingraphica speech generating device (SGD)  offers immediate video feedback, a built-in icon library w/customizing capacity and ease of navigation which can promote patient self-use within this particular population.

Besides considering the use of a *Lingraphica SGD (utilized in the study), one might be creative and use a tablet, a laptop with a video camera, or an app which would lenditself to video modeling techniques.  The course demonstrated how existing research and the availability of developing standardized communication models for independent practice outside of the therapy environment, can substantiate a treatment model of cost efficiency.  The new formula of  “treatment / cost = value” is alive and well with this treatment model, which focuses on extensive independent study. 

Did you miss the session?  You may still be able to download the handout which gives an overview and bibliography.  I have been using some of the same techniques with my other patients and keeping close track of their changes.  Stay tuned; we may see significant outcomes with other populations as well.

I am in the process of developing an online CEU course which you could download with these wonderful video-clips.  So, to whet your appetite for more; here are two clips from the course.  First, a baseline and then a delightful supported conversation Talking about what?  Disney, of course.  Enjoy the videos.


*Disclaimer:  I have no fiduciary relationship with either Lingraphicare or Disney Productions.


Nancy Horowitz Moilanen, M.A. CCC-SLP; Private practice, Northern CA, 35 yrs.;  Director, Well Together Neuro Rehabtm, a group therapy program utilizing music and community-building as a rehab model;  Presenter ASHA, 2010 & 2012;  ASHAsphere Blogger, Communication Wellbeing and Social Wellbeing…an Aspect of Health, January 2011, Graduate ASHA Leadership in Health program, 2011; ASHA Leadership in Health program graduate presenter, 2012. A proud member of SLPeeps, Facebook’s social networking site.



Communication Wellbeing and Social Wellbeing….an Aspect of Health

Photo by Nancy Moilanen

Social Isolation is a common complaint of persons with neurogenic communication disorders.  Social Isolation is a negative aspect of “Social Wellbeing.”  The World Health Organization includes the concept of positive “Social Wellbeing” in its definition of “Health.” “Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. WHO, 1948.

The definition was created in 1948 and has not changed since.  If “Social Wellbeing” is an aspect of health; then, might the concept of “Communication Wellbeing” be a measurement tool to assist in defining one’s communication skills as pertaining to one’s health?  Might the concepts of “Communication Wellbeing and “Social Wellbeing” be measurement tools to define and support medical justification for Speech Pathology treatment?  Can we, as therapists create environments which allow assessment and treatment of communication disorders within social community-building settings?

The Well Together Neuro Rehab program has accomplished just that.  The program supported by, Frank Howard Memorial Hospital in Northern California has been providing community-building, multi-sensory, intensive, integrated group treatment since June, 2007.  Well Together Neuro Rehab is an Evidenced Based Practice applying cutting edge research to individualized treatment plans.  We meet in one month block sessions; two days a week for four hours.  Individual and group treatment are provided on each day; with a follow-up individual session one time weekly on a third day.

Speech Pathology professional literature is full of intensive and group therapy research programs demonstrating positive outcomes for increased communicative effectiveness and quality of communication life.  (Elman, R. J., Group Treatment of Neurogenic Communication Disorders, 2007). The Well Together Neuro Rehab program has utilized this past research in program development and has reached further, applying new research to its programming.


The Well Together Neuro Rehab program utilizes music and singing as a major treatment component.  Singing taps into a multitude of skills such as rhythm, prosody, pitch, oral-motor awareness, coordination and strength, visual tracking & reading, respiratory function & body awareness, cognition: memory, focus and following directions…not to mention how singing is just “plain fun” and socially bonding.  As Speech Pathologists, we have experienced the benefits of singing as a part of treatment for communication disorders; however, now fMRI studies demonstrate specific evidence “Music engages huge swathes of the brain – it’s not just lighting up a spot in the auditory cortex;” states Dr. Aniruddh Patel, neuroscientist, Neurosciences Institute in San Diego.

We now know when we sing…..our entire brain lights up!  The implications for stimulation to both parts of the brain remain wide open.  For right now, we are seeing Well Together participants change and develop in all of the above areas.  Along with these changes outcome studies are showing an overall increase in Social Wellbeing.


In addition to music, participants of Well Together have social time eating lunch and spending time, through language/communication exercises getting to know one another.  Participants learn how to support one another.  Essentially, we form community.  Each person discovers that he/she has valuable life experiences to share. Each person develops a sense of positive self worth, a sense of commonality and knowledge that they can positively impact someone else’s life. They learn that supporting one another becomes a significant contribution to their own wellbeing, other participant’s wellbeing and the overall wellbeing of the group.  According to the World Health Organization, community involvement is an identified aspect of Wellbeing. “Social Wellness is the process of creating and maintaining healthy relationships through the choices we make.  It embraces relationships at home and work, friendships, and our relationships with all people and future generations.  The social dimension encourages contributing to your human and physical environment for the common welfare of your community.”

Themes, Movement & Daily Structure

Treatment sessions are designed with a daily theme and predictable structures. This offers participants (who need it) cognitive support.  They have an idea of what to expect.  Since the theme is repeated throughout the day, recall becomes easier.

Examples of theme days are: “Animal Day,” “Shopping in Red,” “Flag Day,” “Everyone Loves a Flea Market” “I’ve Got a Talent,” and so on.  Themes are only limited to the therapist’s imagination.

Movement is an integral portion of each day.  In addition to Physical Therapy, we spend time focusing on posture, respiratory support, stretching and balance (proprioception).


To measure Well Together’s efficacy; industry Gold Standard Measurements tools were utilized: The Communicative Effectiveness Index, (Lomas, J., et al) The Quality of Communication Life Scale (Paul, D. R., Holland, A.L., et al) and The American Psychology Association’s, Fordyce Happiness Measures (Fordyce, M). Outcomes of these tools were compared to outcomes of the Communication Wellbeing Index, Horowitz Moilanen, 2009.

The Current study (prospective), What are the links between “Communication Wellbeing” and “Social Wellbeing”?  How do communication skills change when patients receive intensive multi-sensory therapy in thematic community-building environments?; was presented this past November in Philadelphia at ASHA’s national convention.  Outcome trends showed increases over 30 days, 60 days and 90 days in Communicative Effectiveness, Quality of Communication Life; overall “Happiness” and “Communication Wellbeing” with a concurrent reported decline in Social Isolation.

With a decrease in “Social Isolation” an increase in Social Wellbeing occurs, and thus an increase in health.  It is reasonable to suggest, based on treatment outcomes of this Evidence Based Practice and the World Health Organizations’ definition of Health; Well Together Neuro Rehab treatment impacts health (via Social Wellbeing) and is therefore, “medically necessary” as a form of health care and rehabilitation. Further, this treatment may act as a form of prevention of further medical complications. The Well Together Neuro Rehab program offers a prevention and rehabilitation treatment model for Health Care Reform.

Continuing Education

An expanded version of the ASHA presentation/course will soon be offered for continuing education.  Course work will include lecture and hands on participation/observation of treatment with support for developing a similar program in one’s own practice.  For details please visit Well Together’s website or email me.  I welcome and look forward to your comments and, perhaps, meeting you.

Nancy Horowitz Moilanen, M.A. CCC SLP, Licensed Speech Pathologist, California; private practice in rural setting since 1979; Founder/Director, Well Together Neuro Rehab and Speech Pathology Department, Frank Howard Memorial Hospital, Seminar Presenter at ASHA convention, 2010.