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The Autistic Spectrum |
QUESTIONS AND ANSWERS ABOUT CHILD LANGUAGEWhat is language?
What makes up this language code?
What is speech?
How do children learn all these language rules?
How can parents help a child learn to talk?
How do you know that a child's language and speech are what they should be for a particular age?
When should I seek professional help?
Will hearing problems affect speech and language development?
Are there ever other physical causes of language disability?
How about other causes?
What can be done about language disabilities?
Where can I find a speech-language pathologist?
American Speech-Language-Hearing Association
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DEFINITION OF SPEECH AND LANGUAGE DISORDERS
Speech and language disorders refer to problems in communication and related areas such as
oral motor function. These delays and disorders range from simple sound substitutions to the inability to understand or use
language or use the oral-motor mechanism for functional speech and feeding. Some causes of speech and language disorders include
hearing loss, neurological disorders, brain injury, mental retardation, drug abuse, physical impairments such as cleft lip
or palate, and vocal abuse or misuse. Frequently, however, the cause is unknown.
INCIDENCE
More than one million of the students served in the public schools' special education programs
in the 1997-98 school year were categorized as having a speech or language impairment. This estimate does not include children
who have speech/language problems secondary to other conditions such as deafness. Language disorders may be related to other
disabilities such as mental retardation, autism, or cerebral palsy. It is estimated that communication disorders (including
speech, language, and hearing disorders) affect one of every 10 people in the United States.
CHARACTERISTICS
A child's communication is considered delayed when the child is noticeably behind his or her
peers in the acquisition of speech and/or language skills. Sometimes a child will have greater receptive (understanding) than
expressive (speaking) language skills, but this is not always the case.
Speech disorders refer to difficulties producing speech sounds or problems with voice quality.
They might be characterized by an interruption in the flow or rhythm of speech, such as stuttering, which is called dysfluency.
Speech disorders may be problems with the way sounds are formed, called articulation or phonological disorders, or they may
be difficulties with the pitch, volume or quality of the voice. There may be a combination of several problems. People with
speech disorders have trouble using some speech sounds, which can also be a symptom of a delay. They may say "see" when they
mean "ski" or they may have trouble using other sounds like "l" or "r". Listeners may have trouble understanding what someone
with a speech disorder is trying to say. People with voice disorders may have trouble with the way their voices sound.
A language disorder is an impairment in the ability to understand and/or use words in context,
both verbally and nonverbally. Some characteristics of language disorders include improper use of words and their meanings,
inability to express ideas, inappropriate grammatical patterns, reduced vocabulary and inability to follow directions. One
or a combination of these characteristics may occur in children who are affected by language learning disabilities or developmental
language delay. Children may hear or see a word but not be able to understand its meaning. They may have trouble getting others
to understand what they are trying to communicate.
EDUCATIONAL IMPLICATIONS
Because all communication disorders carry the potential to isolate individuals from their social
and educational surroundings, it is essential to find appropriate timely intervention. While many speech and language patterns
can be called "baby talk" and are part of a young child's normal development, they can become problems if they are not outgrown
as expected. In this way an initial delay in speech and language or an initial speech pattern can become a disorder which
can cause difficulties in learning. Because of the way the brain develops, it is easier to learn language and communication
skills before the age of 5. When children have muscular disorders, hearing problems or developmental delays, their acquisition
of speech, language and related skills is often affected.
Speech-language pathologists assist children who have communication disorders in various ways.
They provide individual therapy for the child; consult with the child's teacher about the most effective ways to facilitate
the child's communication in the class setting; and work closely with the family to develop goals and techniques for effective
therapy in class and at home. Technology can help children whose physical conditions make communication difficult. The use
of electronic communication systems allow nonspeaking people and people with severe physical disabilities to engage in the
give and take of shared thought.
Vocabulary and concept growth continues during the years children are in school. Reading and
writing are taught and, as students get older, the understanding and use of language becomes more complex. Communication skills
are at the heart of the education experience. Speech and/or language therapy may continue throughout a student's school year
either in the form of direct therapy or on a consultant basis. The speech-language pathologist may assist vocational teachers
and counselors in establishing communication goals related to the work experiences of students and suggest strategies that
are effective for the important transition from school to employment and adult life.
Communication has many components. All serve to increase the way people learn about the world
around them, utilize knowledge and skills, and interact with colleagues, family and friends.
RESOURCES
Berkowitz, S. (1994). The cleft palate story: A primer for parents of children with cleft lip
and palate. Chicago, IL: Quintessence. (Telephone: 1-800-621-0387.)
Cleft Palate Foundation. (1997). For parents of newborn babies with cleft lip/cleft palate.
Chapel Hill, NC: Author. (Telephone: 1-800-242-5338. Also available online at: www.cleft.com/cpf/cpffrm.html)
Eisenson, J. (1997). Is my child's speech normal? (2nd ed.). Austin TX: Pro-Ed. (Telephone:
1-800-897-3202.)
Hamaguchi, P. M. (1995). Childhood speech, language, & listening problems: What every parent
should know. New York, NY: John Wiley & Sons, Inc. (Telephone: 1-800-225-5945.)
------------------------------------------------------------------- ORGANIZATIONS Alliance for Technology Access
2175 E. Francisco Boulevard, Suite L San Rafael, CA 94901 (415) 455-4575; (800) 455-7970 E-Mail: atainfo@ataccess.org Web: http://www.ataccess.org American Speech-Language-Hearing Association (ASHA)
10801 Rockville Pike Rockville, MD 20852 301-897-5700 (Voice or TT) 800-638-8255 E-mail: actioncenter@asha.org Web: http://www.asha.org Cleft Palate Foundation
104 South Estes Drive, Suite 204 Chapel Hill, NC 27514 (919) 933-9044 1-800-242-5338 E-mail: cleftline@aol.com Web: http://www.cleft.com Division for Children with Communication Disorders
c/o Council for Exceptional Children (CEC) 1920 Association Drive Reston, VA 22091 703-620-3660 Easter Seals--National Office
230 West Monroe Street, Suite 1800 Chicago, IL 60606 312-726-6200 312-726-4258 (TDD) 800-221-6827 (For information about services for children and youth.) E-mail: info@easter-seals.org Web: http://www.easter-seals.org Learning Disabilities Association of America (LDA)
4156 Library Road Pittsburgh, PA 15234 412-341-1515; 412-341-8077; (888) 300-6710 E-Mail: ldanatl@usaor.net Web: http://www.ldanatl.org Scottish Rite Foundation
Southern Jurisdiction, U.S.A., Inc. 1733 Sixteenth Street, N.W. Washington, DC 20009-3199 202-232-3579 Trace Research and Development Center
University of Wisconsin - Madison S-151 Waisman Center 1500 Highland Avenue Madison, WI 53705-2280 608-262-6966; 608-263-5408 (TTY) E-mail: info@trace.wisc.edu Web: http://trace.wisc.edu/ Source: National Information Center for Children and Youth with Disabilities
Language-based learning disabilities interfere with age-appropriate reading, spelling, and/or writing. This
disorder does not impair intelligence; in fact, most people diagnosed with learning disabilities possess average to superior
intelligence. Learning disabilities are caused by a difference in brain structure that is present at birth, is often hereditary,
and often related to specific language problems. The term dyslexia has been used to refer to the specific learning problem of reading. Because of the
increased recognition of the relationship between spoken and written language, and the frequent presence of spoken language
problems in children with reading problems, the term language-based learning disabilities, or just learning disabilities,
is more accurate. Who Is At Risk Children at risk for dyslexia and other learning disabilities may have several of the following characteristics: Other Language Problems The child with dyslexia has trouble almost exclusively with the written (or printed) word. The child who has
dyslexia as part of a larger language learning disability has trouble with both the spoken and the written word. These problems
may include: Other Possible Problem Areas Speech-Language Pathologist As part of a collaborative team consisting of the parents and educational professionals (i.e., teacher(s),
special educators, psychologist), the speech-language pathologist has several responsibilities. He or she: Prevention The speech-language pathologist consults with both educators and parents to teach and model language activities
that promote success. He or she may: Speech and Language Assessment For preschool students, the speech-language pathologist gathers information about literacy experiences in
the home. For example, are there books and other types of reading material around the home? How frequently does the child
see family members writing letters, notes, lists, etc.? How often do family members read stories to the child? When evaluating a preschool child, the speech-language pathologist looks for awareness of print. Can the child
recognize familiar signs and logos, hold a book correctly and turn the pages, recognize and/or write his or her name, demonstrate
pretend writing (writing that resembles letters and numbers), and recognize and/or write letters. For the older child, the
clinician observes whether he or she can read and understand information on handouts and in textbooks. When evaluating a preschool student, the speech-language pathologist may have the child tap or clap out the
different syllables in words. He or she may have the child state whether or not two words rhyme or give a list of words that
rhyme with a specified word. When evaluating an older student, the speech-language pathologist may have him or her put together syllables
and sounds to make a word. He or she may have the child break up a word into its syllables and/or sounds (e.g., "cat" has
one syllable but three sounds c-a-t). The speech-language pathologist assesses the older child's phonological memory by having
him or her repeat strings of words, numbers, letters, and sounds of increasing length. The writing evaluation focuses on the student's ability to spell and write longer texts. Does spelling show
that the child understands the sounds that different letters make? Does he or she correctly use irregular spelling patterns?
Do writing samples show evidence of planning? Are they organized, sequential, and coherent? Are correct grammar and vocabulary
used? Treatment The goals of speech and language treatment for the child with a reading problem target the specific aspects
of reading and writing that the student is missing. For example, if the student is able to decode text but is unable to understand
the details of what has been read, comprehension is addressed. If a younger student has difficulty distinguishing the different
sounds that make up words, treatment will focus on activities that support growth in this skill area (rhyming, tapping out
syllables, etc.). Individualized programs always relate to the curriculum. Therefore, materials for treatment
are taken from or are directly related to curricular content (e.g., textbooks for reading activities, assigned papers for
writing activities, practice of oral reports for English class). The student is taught to apply newly learned language strategies
to classroom activities and assignments. To assist the child best, the speech-language pathologist may work side-by-side with
the child in his or her classroom(s). Intervention with spoken language (speaking and listening) can also be designed to support the development
of written language . For example, after listening to a story, the student may be asked to state and write answers
to questions. He or she may be asked to give a verbal and then a written summary of the story. Articulation (pronunciation) needs are also treated in a way that supports written language. For example,
if the child is practicing saying words to improve pronunciation of a certain sound, he or she may be asked to read these
words from a printed list. The speech-language pathologist consults and collaborates with teachers to develop the use of strategies
and techniques in the classroom . For example, he or she may help the teacher modify how new material is presented
in lessons to accommodate the child's comprehension needs. He or she may also demonstrate what planning strategies the student
uses to organize and focus written assignments. Learning problems should be addressed as early as possible. Many children with learning disabilities that
are treated later, when language demands are greater, experience lowered self-esteem due to their previous academic frustrations
and failures. Learning problems that go untreated can lead to a significant decrease in confidence, school phobia (e.g., not
wanting to go to school, not wanting to do homework), and depression. For a speech-language pathologist near you, use Find a Professional . Links Source: American Speech- Language- Hearing Association
Milestones Activities to Encourage your Child's Language Milestones Activities to Encourage your Child's Language Milestones Activities to Encourage your Child's Language Milestones Activities to Encourage your Child's Language Milestones Activities to Encourage your Child's Language Milestones Activities to Encourage your Child's Language Source: LEARNING DISABILITIES ASSOCIATION OF AMERICA
LINKS TO PUBLISHERS OF SPEECH/LANGUAGE MATERIALS
In addition to materials, you may find forums, newsletters, and lesson ideas!! Academic Communication Associates American Guidance Service Shop their online catalog, find out about workshops and conferences, and read their informative newletters. Augmentative Resources Resources to enhance communication and language skills. Cognitive Concepts, Inc The makers of the popular Earobics educational software program for teaching the auditory and phonological awareness skills critical for reading and language development. Communication Skill Builders DataMorphosis WordWeaver Report Writing Software Edmark Check out their educational software including the Speech Viewer III which creates entertaining, interactive displays of speech, as clients focus on a single speech dimension such as pitch, or on complex speech patterns in running speech. So, clients can actually "see" what they say. Great Ideas for Teaching, Inc Request one of their catalogs online. They look great! Delightfully illustrated materials. Gus Communications, Inc Speech output and computer access software The Hanen Centre Resources for language development, birth through 6 years Kay Elemetrics Corp. Learning Fundamentals Lindamood-Bell Homepage Linguisystems Excellent tests and companion remedial programs. Phonics Game Playful Puppets These puppets are just too cute! They even have articulable tongues and teeth! Pro-Ed Remedia Publications Sonida, Inc - Software for Speech, Language, and Auditory Processing Therapy Speech and Language Video Company Videos for home practice Speech Bin Speech Dynamics, Inc. Super Duper Publications TheraDat Data collection tablets for articulation. Thinking Publications
Qualitative impairments in communication as manifested by at least
one of the following:
a) Delay in, or total lack of, the development of spoken language
(not accompanied by an attempt to compensate through alternative modes of communication such as gestures or mime);
b) In individuals with adequate speech, marked impairment in the ability to initiate or sustain a conversation with others; c) Stereotyped and repetitive use of language or idiosyncratic language; d) Lack of varied, spontaneous make-believe play or social imitative play appropriate to developmental level.(American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC, American Psychiatric Association, 2000) Communication problems in children with autism present in a number
of different ways with different outcomes according to the problem type and severity. Some children have severe communication
problems and do not speak at all. Other children have very delayed and unusual speech that makes it difficult for them to
make themselves understood. A smaller group of
children have superficially better speech but they still have problems knowing how to use language to communicate well with other people. Recently, more attention has been paid to the effects of communication
problems on children’s behaviour. It is important that parents and professionals understand the type and severity of
the communication problems a child has, in order to work out more effective ways of communicating together and also finding
possible explanations of behavioural problems that may be linked with communication problems.
Verbal Children
Some young children with autism will acquire functional speech.
Typically, they will begin to speak later than is normal and will acquire speech more slowly and unevenly. A distinction is
made between the ability to speak and ‘functional speech’ because some children use words but the words are not
used to communicate effectively and therefore are not seen as being
functional. Expressive language problems
(i) Development of speech may occur very slowly and some previously learned words may disappear once learned. (ii) Speech may come in chunks or complete sentences may be spoken out of the blue. (iii) Echolalia, the repeating of words and phrases, may be present in a number of forms. For example, the child may immediately repeat what you have just said to him/her. Echolalia may also be delayed, with the child repeating a word or phrase heard previously. Echolalia may also be mitigated, with the child using some repeated words but adding some of his/her own to get his/her message across. (iv) The same word or sound may be repeated over and over. (v) A word may be used out of context or a made up word used for a particular object. (vi) Pronouns are often reversed and confused. (vii) Tone, pitch and modulation may be unusual. The child’s voice may sound flat, may have an unusual accent or may be too loud or too soft. Receptive language or comprehension problems
(i) Difficulty understanding the meaning of what others say. (ii) Difficulty understanding a sequence of instructions. (iii) Lack of understanding of metaphor, e.g. “shake a leg”. (iv) Literal use of language and interpretation of what others say, e.g. “pull your socks up”. There is also a range of difficulties that verbal children have
with conversation. Children with autism usually have difficulty attending to other people. Conversation relies on two people
listening to each other and taking turns to speak. For children with autism, this is a particular problem. Although they may
have a lot of useful speech, they do not speak conversationally. The child with autism is more likely to talk at you rather
than with you. Initiating and sustaining a conversation are also areas of difficulty. Some verbal children may have special
topics they
want to talk about to the exclusion of all else, or may bombard you with questions that no answer you give seems to satisfy. Non-verbal Children
Some children with autism do not acquire functional speech. It
is still not clear why this is so. Some argue that it is because children with autism have such strong underlying social deficits
and problems with joint attention. Others argue that it is because in autism there is a basic lack of understanding that people
have thoughts and feelings that can be related to in the first place. Whatever the cause, children who are non-verbal must
be able to convey their needs and desires to others in some way other than speech. It is important to assess how the non-verbal
child expresses his/her needs and gets his/her message across to others.
Improving Non-verbal Communication using Augmentative systems.
Follow up studies have shown that for most children with autism
who do not have useful speech by about the age of 7 years, it is likely that their ability to communicate verbally will remain
severely impaired. It is important for these children to have some form of augmentative communication system.
Augmentative communication helps children who don’t have
speech to communicate by using other systems. These systems are called “augmentative” because they augment or
increase the strength of the child’s power to communicate. Simple pictures and line drawings such as CompicŪ or PCS/BoardmakerŪ,
signing systems such as Makaton and also photographs are often used to augment communication for children with autism.
1. Signing
Signing was probably the first alternate system used with non-verbal
children with autism. At first, the signing systems used by the deaf were taught, but these are complex systems that require
finger spelling of words and use abstract concepts. In the early 1980’s, a simpler system called Makaton was devised
to use with children with intellectual disability. This system has
varying degrees of difficulty, but at its earliest level, signs are simple, concrete and do not require difficult finger spelling. Many of the first signs use only one hand. For example, the sign for ‘drink’ uses one hand in the shape of a cup that is lifted to the mouth and tilted as if the child were having a drink. One advantage of signs is that they are very portable and do not require the child to carry around equipment. Another advantage of establishing a signing system is that it has been found to encourage speech in children contrasting to what some parents fear, that signing might reduce the chance of their child talking. However, signing is not widely understood in the community and the child may not always be well understood outside the circle of those who can sign with him/her. Signing also requires that the child attends to the person teaching the signs and is able to imitate an action. 2. Pictographs (line drawings)
There are a range of computer generated pictographs that are available
and in use in Victoria, including CompicŪ and PCS/BoardmakerŪ. These pictures consist of simple and clear line drawings that
represent a wide range of objects, actions and feelings. They can be used initially at a very simple, but practical level
with young children who learn to point at the picture or show the picture to indicate their needs. When children are familiar
with a number of these pictures, they can be put into a wallet/book of pictures that the child carries with him/her and uses
to indicate his/her needs. The child gradually builds up a vocabulary of pictures to meet his/her own special needs.
Pictographs are widely available in both computer software and
loose-leaf book formats. Pictographs are easily understood by everyone and do not require the child to learn and remember
complex actions, as does signing. Children who have low cognitive skills can generally use a picture system in a simple way
to communicate more effectively.
3. Photographs and Objects
Photographs of objects, activities and people in the child’s
world can also be used effectively with low functioning children who cannot master the use of symbols or line drawings. Use
of photographs usually requires that the child first learns to match an actual object with an exact photograph of the object.
The child learns that the photograph represents the object. The
photograph must be simple, clear and uncluttered. After the child has learnt to match photographs and objects, the more complex concept of matching photograph and activity or action can be taught. Once the child is able to recognise a number of photographs, a photo vocabulary can be built up in the same way as a pictograph vocabulary. Photographs can be used to help the child understand timetables or the steps involved in completing an activity. For example, the playroom may have photographs of the day’s activities pinned to the wall. When each activity finishes, the child may put away that photograph. Similarly, when the child is required to get dressed, the steps involved may be pinned to his/her bedroom door in the correct sequence and easily followed. Objects can be used in a similar way to photographs with children
who have difficulty understanding photographs. Object time-tables are useful. Objects that represent activities can be laid
out or stuck on the wall to show the child what happens next. For example, a crayon means work at the table, and the next
object is a juice box straw to indicate that snack time comes after work.
A great advantage of photographs and objects is that the child
can attend to them for as long as he/she needs to, and also return to them to refresh his/her memory. This is not possible
with a hand sign which is gone once it has been demonstrated.
4. Picture Exchange Communication System (PECS)
The Picture Exchange Communication System (PECS) (Frost and Bondy,
1994) is another augmentative communication system. Developed in the early 1990s, PECS is widely used in early intervention
and school programmes to teach children how to initiate communication. An advantage of this system is that it does not require
complex or expensive materials and can be used in a variety of settings by parents, carers and teachers. PECS begins with
teaching a student to exchange a picture of a desired item with a teacher who immediately honors the request. Verbal prompts
are not used. Once this step is mastered, the system goes on to teach discrimination of symbols and later simple 'sentences'
are made from stringing together these symbols. Children can also learn to comment and answer direct questions using the Compic
system symbols.
Each child must be carefully assessed to determine which system
will suit best. The majority of children with autism have delayed imitation skills but better developed visual recognition
skills. Therefore a picture based system may be more suitable than a signing system. Ultimately, the choice of system to help
improve the child’s communication will depend upon his/her level of cognitive and language ability and developmental
profile of strengths and weaknesses.
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Autism: Communication and Behavior Links By Linda Fielding At this time it is believed that autism is a developmental disability
with multiple causes (Batshaw & Perret, 1992). As there are no specific assessments for autism, the diagnosis of this
disorder is usually based on characteristics which are exhibited by the individual (in relation to their developmental level).
The most common characteristics displayed by individuals with autism may include any or all of the following: a lack of social-communicative
skills, engagement in repetitive behaviors, the demand for sameness, abnormal preoccupation with specific objects, self injurious
and/or aggressive behaviors, and language delays. While an individual may exhibit a combination of these characteristics,
a number of authors support the idea that core underlying problems with communication are the primary disability of individuals
with autism and other behavioral problems are secondary symptoms (Koegel & Koegel, 1995). Both the expressive and receptive communication impairments exhibited
by individuals with autism can be severe. About half of this population never gain useful speech (Schopler, 1978), and those
children who do develop speech tend not to use their language in a communicative way (Donnellan, 1985). This inability to
effectively use communication can lead to challenging behaviors. Recent literature substantiates the premise that a relationship
exists between communicative intent and the function of the behavior. The function of a challenging behavior can usually be
determined to be related to one or more of four specific communicative purposes: 1) to obtain attention; 2) to escape or avoid
a request, activity, or person; 3) to procure an object (or tangible); and/or 4) to receive sensory feedback (Durand, 1990). Programming practices for students with autism have also begun to
reflect this linkage. Less emphasis is being placed on developing strategies to "manage" behavior while more attention is
focusing on interpreting the purpose of the behavior and providing students with additional opportunities to enhance their
communicative abilities. It is important to consider that no matter what the age of the individual with autism, teachers can
actively plan programs (and offer parents suggestions) which will encourage communication, and perhaps, decrease the occurrence
of inappropriate behaviors. Koegel and Koegel (1995) have suggested four strategies that can
be implemented throughout the school day to assist with the development of communication in individuals with autism. The remainder
of this article profiles these strategies and provides illustrations of each. 1. Increase awareness of and respond to all communication attempts.
In order to accomplish this, teachers must begin to interpret all student actions (and behaviors) as having communicative
intent. For example, Sam (a student in your classroom) is sitting on the floor. You ask Sam to go get his coat so the class
can go outside. Sam grabs his knees and begins to rock. As opposed to labeling Sam as "noncompliant", perhaps we need to consider
that Sam may be telling us that he does not want to go outside today. 2. Teach students with autism that their actions have distinct
consequences associated with them. No second guessing the individual! He or she must learn that communication can be used
to influence the environment. Kate is moving through the lunch line in the school cafeteria. The vegetable choices for the
day are green beans (which she hates) or french fries (her favorite food!). Kate selects the green beans. Instead of being
prompted to again choose which vegetable she wants, Kate should be given the green beans. If she screams or pushes them away
she has communicated that she does not want them and should then be given an opportunity to choose another item. 3. Provide positive supports and learning opportunities. Identify
and arrange communication opportunities in natural contexts throughout the school day. Sabotage the environment! Create circumstances
which stimulate communication. For example, hide Sarah's favorite drum in the closet, "forget" to pour Justin's juice at snack
time, "lose" Tommy's knapsack before it's time to go home, or give Ashley the incorrect amount of change needed to purchase
a soda from a vending machine. 4. Encourage interactions by providing individuals with autism
the opportunity to socialize in environments with age-appropriate peers. The experience of participating in a social group
is essential to developing social-communicative skills. Exposing children with autism to situations in which good communication
and social skills are modeled may assist with developing more appropriate interactive behaviors. Engaging in communicative
interactions helps to teach students that positive outcomes can occur through communication. By employing these communication strategies, will all challenging
behaviors in individuals with autism be eliminated? Probably not. But by increasing a student's understanding and use of communication,
we can reduce his/her use of challenging behaviors to "get their message across". References Batshaw, M. L., & Perret, Y. M. (1992). Children with disabilities: A medical primer. Baltimore: Paul H. Brookes. Donnellan, A. (Ed.). (1985). Classic readings in autism. New
York: Teachers College Press. Durand, V. M. (1990). Severe behavior problems: A functional communication
training approach. New York: The Guilford Press. Koegel, R., & Koegel, L. (1995). Teaching children with autism:
Strategies for initiating positive interactions and improving learning opportunities. Baltimore: Paul H. Brookes. Schopler, E. (1978). On confusion in the diagnosis of autism. Journal
of Autism and Childhood Schizophrenia, 8, 137-161.
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