INTRODUCTION
This research was the dissertation phase of studies for an MA in autism.
The Checklist of Emerging Communication Skills (CHECS) has evolved since 1985, when I took up a post as Speech and Language Therapist (SLT) at a school for children with severe communication difficulties and associated challenging behaviours. The majority in fact, displayed Kanner's (1943) key features of early infantile autism. Previous experience had taught me that the conventional model of withdrawing a child to a quiet room once a week for 30 minutes of therapy would not be effective. A review of approaches that claimed success with pupils with autistic spectrum disorder (ASD) identified ten common factors as being important
Assessment, structure, early and intense intervention, and collaborative working were crucial as was the need to address core deficits of social emotional development, pragmatic aspects of communication, play skills, listening skills and comprehension.
I found myself picking and choosing from a wide range of assessment tools and programmes, adapting them, and writing up activities that could be implemented by teachers and support workers in the classroom. This proved to be a very time consuming and inefficient way of working. To try and resolve some of the difficulties, a senior teacher and I sat down together, to look at the programmes, and to collate a checklist of skills we believed were fundamental to the development of social interaction, communication, speech and language. We also wrote up teaching activities to relate to the checklist.
I continued to develop the scheme, which we are now using as an assessment tool and related scheme of work with pre-verbal children with complex communication difficulties. There is still much work to be done to fine tune the document and provide a more comprehensive range of activities. We related the 10 common factors to CHECS.
ASSESSMENT
I aimed to devise a flexible assessment tool that:
What I wanted was a tool similar to the Derbyshire Language Scheme (Masidlover & Knowles, 1982) that would address social interaction, pre-verbal and functional communication skills. So what we have at the moment is a loose-leaf document. At the front there are attainment targets related to coded key areas for language development. These are followed by cross-referenced suggestions for intervention. Outcomes are recorded on a form that lists the whole scheme, and/or there is a profile form to give an 'at a glance picture' of where the child is at.
STRUCTURE
Activities are designed to be fun, but acknowledge the need for sensitive structure that uses positive behaviour management strategies to enable the child to know what is expected of him/her while acknowledging his/her preferences. (Freeman, 1997)
EARLY INTERVENTION
The literature supports the importance of early intervention (Rogers, 1996; Sigman, 1998; Filipek, 1999). References to ASD in the original version of CHECS are, in fact, being replaced by the term 'social communication difficulties.' Those therapists, who took part in the pilot study, found CHECS to be useful in working with young children prior to disclosure of a diagnosis of ASD, as well as with children who did not have an ASD.
INTENSIVE INTERVENTION
The definition of intensity in the literature is unclear. No studies control for intensity of intervention (Jordan, Jones, Murray, 1998) but all approaches claiming success involve 'high dose input' (Rogers, 1996). CHECS suggests that activities should be rehearsed through play or daily living tasks at every opportunity throughout a child's day
COLLABORATION
To maintain this level of intervention requires active collaboration by all involved with a child. CHECS was designed to support multidisciplinary work actively involving parents. (Schopler, 1984, 1988)
SOCIAL EMOTIONAL DEVELOPMENT
CHECS starts at a pre-intentional level of communication, acknowledging that physical contact is the earliest way in which a mother communicates with her baby. (Locke, 1985). It aims to support those who become discouraged by trying to keep up a one-sided conversation with a child who rarely responds. This involves focusing a lot of early activities on attention control and joint attention skills. The need to acknowledge the dysfunctional attention control of children with ASD (Jordan & Powell 1995) and the importance of teaching joint attention skills (Dawson, et al.) was presumed in developing CHECS, however, therapists piloting CHECS have requested specific activities to this end but these have still to be written up.
PRAGMATIC ASPECTS OF COMMUNICATION
CHECS suggests strategies for encouraging:
The emphasis is on functional communication skills such as gesture, eye gaze, reaching and leading an adult, pointing, using objects of reference, picture symbols or signs. (Prizant & Wetherby, 1993; Bondy & Frost, 1994; Dawson, et.al., 1998; Christie & Wimpory, 1988; Jordan & Powell, 1995; Howlin, 1998; Koegel & Koegel, 1995)
PLAY
CHECS builds on visual motor activities and sensory exploration to develop simple functional play skills that can be shaped into symbolic understanding. The importance of mother/child interaction and of the value of having fun is recognised. (Howlin, 1987; Watson, 1985; Dawson & Galpert, 1990; Kaufman, 1976, 1994).
LISTENING
The significance of auditory-processing problems for children with ASD (Berard, 1993; Grandin, 1996) is acknowledged. The value of music in encouraging engagement and interaction in people with ASD is well-documented (Alvin, 1980; Prevetzer, 1998). CHECS activities focus on response to sound, co-operation in sound making activities, and on making sound meaningful.
VERBAL COMPREHENSION
In typically developing children verbal comprehension emerges as infants begin to associate communicative gesture and vocalisation with referential speech. The pervasive perceptual difficulties of children with ASD limit their ability to make sense of non-verbal behaviour and the function of communication thus impinging on the development of verbal comprehension. The relevance of verbal comprehension to the development of speech and language for communication is well documented (Brown, 1973; Cross, 1977; Wells, 1985; Ingram, 1989). Some children respond well to the early intervention offered by CHECS and progress to develop verbal language. For these children the comprehension section of CHECS provides a bridge to other programmes.
THE STUDY
The aim of the study was:
The objectives were to test claims that CHECS:
METHODOLOGY
This was practitioner research, by a full-time speech and language therapist, using a case study strategy that analysed qualitative data from 20 therapists across Wales who had been asked to evaluate the usefulness of CHECS to their usual therapeutic process. Ethical reasons precluded random control trials for such a small study. Therapists initially attended a workshop to ensure a consensus agreement on planning intervention and scoring outcomes. They were then asked to use CHECS for a minimum of three months with at least one child, who met the criteria of the target client group, i. e. preverbal children, under 10 years of age who met the diagnostic criteria for Pervasive Development Disorder. The study did not investigate the cause and effect relationship of using CHECS but explored whether therapists found CHECS helpful in determining targets for intervention and in achieving those targets while working collaboratively with parents and other professionals. Therapists were asked to complete a questionnaire.
QUESTIONNAIRE
Part one was designed to elicit factual information about how, where, and with whom CHECS was used. Part two was to explore attitudes in terms of helpfulness and unhelpfulness. A final section asked for suggestions for the improvement of CHECS.
KEY RESULTS
Descriptive statistics were compiled from frequency analyses of therapists' working practice with CHECS in relation to the variables completed and recorded on matrices.
The agree/disagree scores from the attitude scale were reversed, with 1 representing a very unhelpful value and 5 representing a very helpful value, and placed on a data matrix. Total scores, levels of distribution, and spreads of distribution were calculated in relation to each therapist and each conceptually clustered set of questions. Percentages of therapists, who found CHECS helpful or unhelpful with regard to each variable, were calculated.
Data from 20 SLTs working with 87 children in a range of therapeutic, including community settings, agree that CHECS is helpful in working collaboratively with teachers, establishing targets, supporting parents, and providing a means for measuring improvement.
Out of a possible total of 520 scores 74% were positive, 14% were undecided, 6% were negative and 6% were not applicable.
DISCUSSION
While the results support the claims made for CHECS, the interpretation of the data must be cautious. The total sample size of twenty is sufficient for a small-scale study but the sample size for some of the variables is small. Those therapists who volunteered for the pilot study may have been biased towards CHECS and may have been predisposed to give positive results. The results need to be substantiated. However, during recent years there has been an increase in knowledge about autism, and more specialists have the expertise to recognise and diagnose this. Thus, autism is more frequently identified at an early age. Recent research indicates that early and intensive intervention is vital for the future development of these children. Parents are understandably demanding this level of support. This study suggests that CHECS is a valuable tool in supporting early intensive intervention.
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