Making sense in a fragmentary world

Communication in people with autism and learning disability

ILSE NOENS
Leiden, The Netherlands University of Leiden, The Netherlands University of

autism 2004 SAGE Publications and The National Autistic Society Vol 8(2) 197218; 042723 1362-3613(200406)8:2

I N A VA N B E R C K E L A E R - O N N E S

A B S T R AC T

The communicative capabilities of people with autism are impaired and limited in signicant ways. The problems are characterized by a lack of intentionality and symbol formation, which indicates that the deviant development of communication in autism is associated with a specic cognitive style. The central coherence theory can offer insight into the specic communication problems of people with autism, since a weaker drive for central coherence leads to problems in sense-making and, consequently, in communication. In the case of the comorbidity of autism and learning disability, the communication problems are aggravated. The crucial point is the determination of the level of sense-making, taking this comorbidity into account. Assessment and intervention have to be tuned to individual needs, in order to increase the communicative competence of people with autism and learning disability.

K E Y WO R D S

autism; central coherence; communication; learning disability

ADDRESS Correspondence should be addressed to: I L S E N O E N S & I N A V A N B E R C K E L A E R - O N N E S , University of Leiden, Faculty of Social Sciences, Department

of Child Care and Special Education, PO Box 9555, 2300 RB Leiden, The Netherlands. e-mail: noens@leidenuniv.nl

Introduction
Impairments in communication, together with impairments in social interaction and imagination, form Wings triad (Wing, 1996; 2001). The difculties involve both verbal and non-verbal communication. Many publications have been dedicated to these problems. Kanner (1943) mentioned prominent expressive speech deviations in his rst article on autism. Studies of verbal language in autism concern in particular high-functioning people, since there is a strong correlation between intelligence and verbal development. Follow-up research also emphasized the prognostic value of
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8(2) early speech (DeMyer et al., 1973; Howlin and Goode, 1998; Lord and Venter, 1992; Lotter, 1978; Nordin and Gillberg, 1998; Rutter et al., 1967). Since almost half of the core autistic population does not develop functional speech, non-verbal communication is just as important. Moreover the impairments in communication are characterized especially by a lack of reciprocity in verbal as well as non-verbal communication. The high correlation between IQ and verbal ability implies that most non-verbal people with autism also have a learning disability. Comorbidity of these two conditions aggravates the complexity and severity of the communication problems. The development of communicative skills is not only delayed due to the learning disability but is also deviant as a result of autism. Individuals with the two disorders exhibit some overlap in behaviour, which can cause differential diagnostic problems, but differ in cognitive functioning (see also OBrien and Pearson, this issue). Although these conditions are closely linked, they cannot be placed into one diagnostic category (Ghaziuddin, 2000; Kraijer, 1997; Rutter and Schopler, 1987). In our opinion it is the difference in cognition that particularly distinguishes between the disorders. Recent cognitive-psychological studies have tried to gain a better insight into the connection between observable behaviour on the one hand and neurobiological dysfunctioning on the other. Various constructs have been proposed, but theory of mind, executive functions and central coherence are currently the most prominent. Bailey et al. (1996) distinguish between theories with a narrow perspective and theories with a broad perspective. The former concern a deeper understanding of the behaviour of people with autism from the standpoint of a specic cognitive dysfunction. The best-documented account in this respect is theory of mind, which suggests that the social-communicative problems of people with autism are the consequence of an incapacity to attribute mental states to oneself and others (Baron-Cohen, 1995; Baron-Cohen et al., 1985). The two others are much broader and also try to explain the non-social features of autism. The executive functions theory suggests that shortcomings in planning, exibility, organization and self-monitoring are the core problems in autism (Ozonoff, 1995; 1997; Ozonoff et al., 1991; Russell, 1997). Bailey et al. (1996) describe the executive functions as an umbrella term for a constellation of mental operations, not all of which have yet been delineated. The central coherence account rationalizes autism as a weaker drive for the integration of information. Central coherence is the natural tendency to process incoming stimuli globally and in context, pulling information together to acquire the higher-level meaning. People with autism, however, tend to process incoming information locally and piecemeal (Frith, 1989; Frith and Happ, 1994; Happ, 1999).
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The mutual relationships between these theories are as yet unclear. One of the problems researchers encounter is the high frequency of comorbidity (Fombonne, 1998; Gillberg and Coleman, 2000; OBrien and Yule, 1995). Autism occurs not only with learning disability but also with ADHD, Tourette syndrome and many other disorders. With respect to explaining the enigma of autism, only individuals with the core syndrome should be considered before valid and reliable statements about the specicity of the different cognitive theories can be made. In our opinion, central coherence theory offers the best potential for explaining behavioural features in the event of the comorbidity of autism and learning disability, since problems encountered in theory of mind and executive functioning can also be the result of the learning disability (Noens and Van Berckelaer-Onnes, 2002a). The problems individuals with autism encounter when integrating stimuli they feel, taste, smell, see and hear have a huge impact on their sense-making and thus communication. The question is whether the weak drive for central coherence is a decit or a style (Happ, 1999). On the one hand the specic cognitive style leads to difculties in combining experiences into a meaningful whole, but on the other hand it facilitates special abilities or bright splinters of the mind, as described by Hermelin (2001). Whether cognitive style or cognitive decit, the problems in sense-making greatly hinder people with autism in their daily functioning. Although the comorbidity of autism and learning disability is so complex that it is very difcult to distinguish cognitive style and cognitive decit, it needs to be done. The learning disability as such is not a style but a general cognitive decit which, when comorbid with autism, is further aggravated by the weak drive for central coherence. Both disorders have a serious impact on daily functioning and have to be taken into consideration during assessment and intervention. In this article the following topics will be discussed: the main problems of communication in autism; the relationship between sense-making and autism; and nally the implications for assessment and intervention.

Autism and communication

The dual diagnosis of autism and learning disability implies a complex communication problem. Qualitative impairment in verbal and non-verbal communication is generally recognized as a key feature of autism. Early delay or regression in the development of language is often among the rst problems encountered by parents of children with autism (Howlin and Moore, 1997). Prelinguistic communication behaviours, such as babbling, eye contact, facial expressions and gestures, are usually more limited in 199

8(2) range and complexity and often are not used to initiate or maintain interactions with signicant others (Howlin, 1999). Approximately one-third (Bryson, 1996) to one-half (Lord and Paul, 1997) of the individuals with autism do not develop sufcient natural speech to meet their daily communication needs. The spontaneous speech of verbal people with autism is frequently idiosyncratic. They display striking features like immediate and delayed echolalia, the use of metaphors and neologisms, pronoun reversal and prosodic peculiarities (Howlin, 1999; Jordan, 1999; Lord and Paul, 1997; Van Berckelaer-Onnes, 1996; 1997). Most literature covers the expressive speech problems of people with autism. Little attention has been directed to their comprehension problems. Even among those with functional speech, understanding is frequently more limited than what would be expected on the basis of the expressive vocabulary (Lord and Paul, 1997). The extent to which people with autism understand speech is usually overestimated. Schuler et al. (1997) postulate that language is often only understood in highly familiar contexts; probably the individual is not really responding to the speech itself but is responding to the routine within its situational context or to other cues such as the location in space. Some people with autism have no speech at all; in other cases the speech consists of a few words only; others are very long-winded; but in all cases reciprocal communication is very poor (Lord and Paul, 1997; Tager-Flusberg, 1999; Wetherby et al., 2000; Wing, 2001). Language is seldom used as a communicative means; it seems like a monologue instead of a dialogue. In this respect it is comprehensible that communication problems play a crucial role in the interaction problems that are so characteristic of autism. There are a few strong reasons to pay attention specically to the complex communication problems of people with autism and learning disability. In the rst place a recent follow-up study (Howlin et al., 2000; Mawhood et al., 2000) has conrmed that the communication problems are very persistent and closely related to subsequent prognosis. The level of communicative competence thus seems to be an important outcome predictor. A second reason is more clinical in nature. Research has shown that the impairment in communication is one of the greatest sources of stress for parents (Bristol, 1984). Therefore communication enhancement should be a major focus of education and intervention (Wetherby et al., 2000). Finally, in many cases the challenging behaviour of people with autism appears to be the result of communication impairments (Van BerckelaerOnnes et al., 2002). The study of Sigafoos (2000) shows that decits in receptive language, in comparison to expressive language skills, are more strongly associated with severe aberrant behaviour. In that respect people with autism and learning disability constitute an especially vulnerable
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group. As mentioned above, their receptive communication is usually weaker than their expressive communication. Subsequently, people with autism are often approached from a level above their general level of understanding, which is a major pitfall in education and intervention. In the past decades a growing body of literature has appeared on the specic communication problems of people with autism. In recent publications (Travis and Sigman, 2001; Wetherby et al., 2000) two core problem areas have been identied: intentionality and symbol formation.

Limited intentionality and symbol formation According to Bates et al. (1979) there are two main transitions in early childhood that precede the development of language. The rst is the development of communicative intentionality. During the last 3 months of the rst year, most infants begin to show awareness of the fact that their signals inuence the behaviour of other people (Warren and Yoder, 1998). The second transition concerns the understanding of symbols. Around the age of 11 to 13 months, children start to realize that signs are both substitutable for and separate from their referents, which enables them to acquire symbolic gestures, words and play (Wetherby et al., 1998). Communicative intentionality is usually rst seen in protoimperative (requesting) and protodeclarative (commenting) situations. Both functions require the infant to shift attention between a partner and an object. Requesting behaviour indicates that the child wants something and is usually sustained until the goal is reached or becomes unreachable, while commenting behaviour is the act of drawing someones attention to an object or event (Warren and Yoder, 1998). The emergence of pointing is a very important milestone because it is a precursor of joint attention (Mundy et al., 1994). In children with autism, grasping does not spontaneously pass into pointing, and if pointing develops, it is usually pointing to get (protoimperative) rather than to share (protodeclarative) something (Baron-Cohen, 1989; Carpenter et al., 2002; Goodhart and Baron-Cohen, 1993; Newson, 2001; Newson and Christie, 1998; Noens and Van Berckelaer-Onnes, 2002a). Most publications about communication in autism focus on communicative means (such as gestures, speech and language). More crucial, however, is the fact that people with autism have a restricted grasp of the concept of communication, which severely limits their communicative competence (Prizant and Schuler, 1997). People with autism not only encounter difculties in communicating intentionally, but usually do not understand sufciently the symbolic aspects of communication. According to Bates et al. (1979) the use and comprehension of symbols implies an understanding of the relationship between a sign and its referent. A sign is something that represents something else;
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8(2) a symbol is a sign where the relationship between the sign and its referent is arbitrary and agreed upon by convention. The symbol belongs to the referent and can replace that referent in a variety of situations. Essential is the awareness that the symbol and the referent are two completely distinct entities. In normal development, the rst conventional gestures (i.e. waving and pointing), the rst words and the beginning of functional play are gradually less dependent on a specic context, which announces the transition to symbolic behaviour (Travis and Sigman, 2001). In autism, these protosymbolic behaviours take longer to develop, or they may disappear having once emerged. Children with autism often use primitive presymbolic gestures, such as taking someones hand. At both emerging and more advanced language levels, children with autism frequently display a long period of context dependent, echolalic and idiosyncratic use of language (Prizant et al., 1997; Wetherby et al., 2000). The problems in symbol comprehension are also recognizable in higherfunctioning people with autism, since they rarely realize that communication is about intended rather than literal meanings (Tager-Flusberg, 1999). They tend to have great difculty understanding non-literal or gurative speech (such as metaphors, idioms and irony) and their own language is usually described as being rigid and concrete (Happ, 1995). The two identied problems inevitably constitute the major challenges in the education and treatment of people with autism and learning disability. It is not the mere acquisition of verbal or other communicative behaviours but rather the stimulation of communicative competence that should be the primary focus of attention. When communicative competence is increased, quality of life can improve substantially. On the basis of the limited symbol formation, it is presumed that the abnormal development of communication in autism is correlated with a specic cognitive style. In order to stimulate communicative development effectively, communication decits should be conceptualized in terms of a problem in the perception of meaning.
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Perception, sense-making and communication

The central coherence theory mentioned above can offer insight into the specic language and communication problems of people with autism, because communication is considered a cognitive process in which perception plays a crucial role (Noens and Van Berckelaer-Onnes, 2002a). Communication is in essence sense-making, the exchange of meanings. Because of the weaker drive for central coherence, sense-making in particular is problematic in autism. Consequently, people with autism experience serious language and communication problems. 202

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Before linking the central coherence theory to the specic features of communication in autism, it is useful to make a distinction between sensation and perception. According to Levine (2000), sensation is the process of detecting a stimulus (or some aspect of it) in the environment. Perception refers to the way in which the information gathered by the senses is interpreted; it is the central processing of incoming stimuli (Goldstein, 1999). Autism is not a disorder of the sense organs. In principle people with autism feel, taste, smell, see and hear. The way they do so differs individually. For some individuals mere sunlight or the label in a jumper can be very troubling; others cannot stand the sound of a vacuum cleaner. On the other hand, people with autism sometimes show hardly any reaction to striking stimuli such as loud noises or pain. The phenomena of hyperand hyposensitivity occur more frequently in autistic people, possibly because of their difculties with the integration of experiences (perception). Adequate sense-making is missing or needs to be constructed step by step, as the following example illustrates. Van Dalen (1994), a high-functioning man with autism, describes the successive steps he needs to reach the functional concept of a hammer. First, he perceives details (wood and iron). Next, the details are combined into a coherent whole, which leads to the association with a label (hammer). Finally, he can imagine the functional and invisible meaning of the hammer (its a thing to use in carpentry). People without autism perceive the functional meaning of the hammer at a glance. Van Dalens description underlines the weak drive for central coherence and, therefore, sense-making, which implies serious consequences for communication. In the event of comorbidity of autism and learning disability, the problems in sensemaking and communication will be even more serious. Verpoorten (1996) described communication in a multidimensional model as a subtle interplay of different modalities (vocal and non-vocal), wherein messages (content) are being shared with a specic function (intention). Furthermore communication always includes a social aspect (reciprocity). And, nally, the style of communication partly denes the effectiveness of communication. People with autism cannot spontaneously achieve full integral perception of all dimensions in communication (Noens et al., 2000). Their perception of communication is rather fragmentary. As already mentioned, people with autism primarily perceive the world in fragments (Frith, 1989; Frith and Happ, 1994; Happ, 1999); details seem to have the highest priority. For adequate sense-making, however, the context is indispensable. By nature, our communicative modalities (speech and non-vocal cues) are very transient (Prizant and Schuler, 1997; Wetherby et al., 2000). They require extremely fast, sequential and multimodal processing of auditory 203

8(2) as well as visual information. After all, each communicative interaction is different from the preceding one. A massive number of factors needs to be taken into account simultaneously in a specic context (Frith, 1989). In this respect, it is not surprising that people with autism learn to communicate intentionally only with great difculty. The specic perception style also explains the problems in symbol formation. Many people with autism are not able to understand objects, gestures and words functionally, especially if they also suffer from a learning disability. For example Peter, a 5-year-old boy with autism and severe learning disability, suddenly didnt want to drink anymore. He lost sight of the concept of drinking because the green beaker was replaced by a red one. Over-selectivity characterizes the perception style of people with autism (De Clercq, 1999). Even for verbal people with autism, sense-making is often fragmentary and literal. A few examples might illustrate this notion. Phillip, a 5-yearold boy with autism, was playing tennis. Before hitting the ball, he pushed the ball against his eye. To the question of why he was doing so, Phillip replied: Mummy told me I had to keep an eye on the ball! Phillips answer shows that the literal understanding of language inevitably causes problems with the comprehension of idioms. The occurrence of neologisms can be viewed in the same light. Aaron, a 10-year-old boy with autism, consistently asked for the tankshon in the bathroom every morning. His mother had really no idea what he wanted and Aaron did not know how to explain it in other words. Aaron is verbally able but has serious communication problems. He was asking for hair gel. How could he substitute tankshon for gel? Within the framework of the central coherence theory this is explainable. Aaron associated the word gel with Shell (the Dutch oil company), which was further connected with petrol station or in Dutch tankstation. The sense-making, again, is very fragmentary, associative and literal. Look, the birds are ying over! This seemed a senseless echolalic utterance by Nico, an 8-year-old boy with autism and severe learning disability. Then his parents found out that he always said it when he wanted something to eat, for he had seen a video in which the same sentence was uttered in a conversation during a meal. The sentence and the eating scene were literally perceptible at the same time. The sentence turned out to be a metaphor, which occurs regularly in autism. In this respect, the publications of Prizant, Rydell, Schuler and Wetherby (Prizant, 1983; Prizant and Schuler, 1997; Prizant et al., 1997; Schuler, 1995; Wetherby et al., 1997; 2000) on gestalt language and cognition in autism offer an interesting approach. Prizant conceptualizes gestalt language forms as multiword utterances that are learned as memorized
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forms or whole units but may appear to be the result of productive linguistic processes or the application of combinational rules (1983, p. 299). He presumes that the speaker who uses such forms is not acquainted with their internal semantic-syntactic structure. Gestalt language forms refer to a gestalt mode of cognitive processing, in contrast to an analytic mode in which experiences and events are analysed and segmented into meaningful components. Individuals with autism tend to use gestalt forms and gestalt acquisition styles in language and communication. Immediate and delayed echolalia can be understood as manifestations of such a gestalt processing style. The ideas on gestalt language in autism may appear contradictory in relation to the detail-focused processing style as predicted by the central coherence theory. Yet this is not the case, because adequate sense-making is a prerequisite for meaningful analyses and segmentation. If one is unable to interpret multiword utterances meaningfully, it is impossible to split them into signicant components. Consequently, they can only be learned as memorized chunks (or gestalt language forms as dened by Prizant, 1983). The relationship between perception and communication might also contribute to the explanation of pronoun reversal in autism. Who is I and who is you? The answer is relative and can only be given when a specic context is taken into account. Pronoun reversal presumably reects a more general problem with deixis, the change of referent (as conceptualized by Bates et al., 1979) depending on the point of view of the speaker (Lord and Paul, 1997). Other relative notions like upstairs, yesterday and the tenses of verbs might be just as difcult because their meaning depends on the position in space or time. The examples above illustrate the strong association between perception, sense-making and communication. The exact level of sense-making should be determined for a more differentiated approach. Sense-making and communication can take place roughly at the following four levels: sensation, presentation, representation and metarepresentation (Verpoorten, 1996).

The level of sensation At rst infants experience their world at the level of sensation. They express themselves, for example, by crying or sucking. They learn to react to their environment and spontaneously recognize the relationship between action and reaction, such as crying and getting attention. In a very natural way interaction and communication become more and more reciprocal. The level of presentation At the level of presentation the child perceives information in a concrete context. The child gradually learns to communicate actively in the present
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8(2) situation. At rst the child reaches towards a desired object, for example a beaker, trying to grasp it. Later he or she learns to point. The child looks at the cookie, points at it, makes eye contact and babbles to emphasize his or her request. At this stage the child is already able to combine the complex tasks of looking, pointing, making eye contact and babbling.
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The level of representation When language in the sense of speech exists, the level of representation is approached. The word beaker represents the object. If children do not speak but know that an object, a gesture, a photograph or a pictogram refers to the action to drink (while the drink is not within sight), then the level of representation has been reached. They understand the hidden meaning, the reference function of the object, the gesture, the photograph or the pictogram. The development of object permanence is a necessary condition to achieve the level of representation. By using a symbol, one needs to be able to represent (or imagine) the referent while that referent in the concrete form is not present (Piaget, 1952; Werner and Kaplan, 1963). The referent presents the meaning of the symbol, which can be a perceptual or a conceptual object. The referent and the meaning are thus directly related, while the symbol and the referent are only indirectly related (Bates et al., 1979). Representation implies a certain amount of awareness that the symbol and the referent are not identical, but two clearly different entities. The level of metarepresentation Metarepresentation is reached when information is given beyond the literal meaning, for example by saying a sentence in a way that others know that it is a joke. Human language is full of metarepresentations hidden in proverbs, expressions, irony etc. Primary messages often contain a secondary message. In fact, messages in which only the primary content counts are so rare in common conversations that people usually tend to attribute secret messages to the primary content, even if that is absolutely not necessary (Frith, 1989). People with autism rarely reach the level of metarepresentation, as illustrated by the examples above, but in the case of the comorbidity of autism and learning disability even the levels of presentation and representation are not always mastered. They remain at the level of concrete literalism. A huge pitfall lies in the fact that some people do have speech at their disposal but fail to communicate with speech at the level of representation. As such, some are able to label objects, photographs or pictograms, while they cannot imagine their functional meaning. This means that they would succeed in naming a beaker or even a photograph of a beaker, without understanding that they were going to get a drink. One could consider
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these utterances indexical rather than symbolic, since they are an index of or associated with the (photograph of the) beaker. In true symbolic communication, the symbol stands for and is separate from its referent (Werner and Kaplan, 1963; Wetherby et al., 2000). This does not imply that people with autism are not able to communicate. Even at the levels of sensation and presentation, communication is possible. However, for individualized intervention, the crucial point is determination of the level of sensemaking.

Implications for assessment

With respect to the identied core problems of limited intentionality and symbol formation, two themes deserve extra attention in the assessment of the communication problems of people with autism and learning disability. First, the communicative competence should be evaluated thoroughly. Whereas in the past the communicative means were the main focus, at present the tendency is also to emphasize the communicative functions (Prizant and Schuler, 1997; Schuler et al., 1997; Tager-Flusberg, 1999; TwachtmanCullen, 2000). The question of which means an individual has at his or her disposal to pass on a message is really relevant, but the ultimate question to answer is what the intention of the individual is at that moment. For instance, assessment concerns not only whether someone is pointing, but also whether he or she is doing so to get something or to comment on what is happening in his or her environment. Communication is an adaptive skill, which should be considered against the background of the overall individual functioning. Many different methods can be used for the information-gathering process. Observations of the communicative behaviour in a variety of natural environments are very valuable. It is important to observe structured as well as unstructured situations, since the behaviour of people with autism can differ considerably. Conversations with parents, caretakers, teachers and similar signicant others can offer a valuable contribution. Semi-structured interviews such as the Vineland Adaptive Behavior Scales (VABS: Sparrow et al., 1984), the Diagnostic Interview for Social and Communication Disorders (DISCO: Wing, 1999) and the Autism Diagnostic InterviewRevised (ADIR: Lord et al., 1994) are very suitable within the framework of evaluation of overall functioning. All three instruments contain questions covering the domain of communication. Where the VABS is focused on adaptive functioning, the DISCO and the ADIR mainly assess maladaptive behaviour patterns. Second, the capacity for symbol formation must be the focus of attention. Within the scope of central coherence theory, determination of the level of sense-making is extremely important. Clinicians tend to use referring 207

8(2) communication systems, such as pictograms or photographs, too easily, without rst checking whether the individual is functioning at the level of representation. A level of approach that is too high can lead to severe challenging behaviour. An instrument for the evaluation of perception and sense-making in relation to communication is under development at the University of Leiden, Department of Child Care and Special Education. The Forerunners in CommunicationExperimental Version (ComFor: Verpoorten et al., 2001) is a test to obtain a precise indication of individualized communicative interventions, in particular augmentative means adapted to the level of sense-making. The target group consists primarily of people with autism lacking or with only limited verbal communication. The ComFor tries to measure sense-making in connection with the central processing of stimuli (perception) at the levels of presentation and representation. At the level of presentation, associations have to be made on the basis of literally perceptible information (i.e. sorting of identical knives, spoons and forks); whereas on the level of representation, sense-making goes beyond the literalness of information (i.e. sorting knives, spoons and forks from different types of cutlery). The levels of sensation and metarepresentation are left out of consideration. However, if an individual does not meet the conditions for the level of presentation, communication should be realized at the level of sensation. Full details of the ComFor will be given in a separate publication (Noens et al., in preparation).
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From insight to intervention A single intervention for the communication problems of people with autism and learning disability does not exist. Not only large differences between individuals with autism and learning disability, but also differences in theoretical approaches, lead to a great variety in intervention methods. According to Prizant et al. (2000) the different orientations are situated on a continuum, with traditional behavioural approaches (such as discrete-trial training) at one extreme and developmental social-pragmatic approaches at the other extreme. The traditional behavioural treatment programmes that predominated in the 1970s and 1980s provided training in all sorts of abilities (including speech, language and communication) in a one-to-one situation by the application of imitation, prompting and reinforcement techniques. The rationale was Lovaass (1977; 1981) postulate that people with autism would not learn enough in more natural environments, on the one hand because they experience serious attention and learning decits, and on the other hand because there is no opportunity to exercise and reinforce systematically in spontaneous interactions. Wetherby et al. (1997) noted
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the necessity to distinguish between cued response and the acquisition of true communicative behaviour. Many individuals with autism do quite well in the situation-specic recall of unanalysed chunks (gestalt forms), but these responses should not be mistaken for truly communicative behaviour. Viewed in the light of developmental social-pragmatic approaches, the development of communication requires the social context of spontaneous events in everyday life, for the ultimate goal is the stimulation of communicative competence (Prizant et al., 2000; Wetherby et al., 1997). Individuals with autism can make great progress in individual training sessions, but that does not imply that they are able to apply the learned skills in daily life. The generalization problems in autism demand interventions within everyday situations. A recent review of eight studies comparing discretetrial and normalized behavioural language intervention for children with autism (Delprato, 2001) shows that normalized training was more effective than discrete-trial training. In addition, studies in which parental effect was measured favoured normalized treatment. In our opinion, a developmental approach is preferable to a traditional behavioural approach (Noens and Van Berckelaer-Onnes, 2002a; Prizant et al., 2000). Taking the central coherence theory as a starting-point, the developmental social-pragmatic approach meets the needs of people with autism better with respect to the problems in sense-making, although normalized behavioural principles can be useful tools within a broader socialpragmatic approach. In order to facilitate communicative competence, the intentionality of communication should be the primary focus of attention. Protointentional skills such as turn-taking and pointing are of considerable importance (Newson, 2001; Newson and Christie, 1998). A common fault in the treatment of people with autism is to try to teach them a variety of skills, while the individual has not mastered the prerequisite fundamentals for these skills. In intervention programmes one should make allowances for the limitations in symbol formation, which are, as mentioned before, connected with a fundamentally different perception style. Mere verbal communication is insufcient to lead to correct sense-making. Augmentative communication is an indispensable aid for individuals with autism and learning disability, irrespective of their level of functioning.

Individualized augmentative communication The term augmentative communication refers to the totality of strategies and techniques to augment communication, in addition to the natural gestures, vocalizations or speech of the individual. Traditionally, augmentative communication was mainly used to augment expressive communication; more recently, it has also been used to support comprehension
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8(2) (Light et al., 1998). For people with autism the latter is of crucial importance, since receptive communication is usually even weaker than expressive communication. Augmentative communication should be realized in an individualized manner. To do so, two core issues need to be addressed: rst, the most suitable ways to augment communication; second, the level of sensemaking at which the means chosen can be offered (Noens et al., 2000). With respect to the question of the form of the augmentation, communicative means with a concrete, spatial structure such as objects, pictograms, photographs, line drawings and written text are preferable within the framework of central coherence theory. Means with a temporal structure such as gestures are much harder to perceive for people with autism because they are transient and require sequential processing. Furthermore, people with autism usually have problems with imitation, planning and coordination, which are essential skills for learning gestures (see also Mirenda and Erickson, 2000). The ComFor helps to determine which non-transient, spatial communicative form (objects, pictograms, photographs, line drawings or written language) is the best t. Naturally, this is also dependent on the level of functioning of the individual. A common misconception in clinical practice is the idea that photographs are easier than pictograms. For people with autism this often is not the case. In photographs the connection between the symbol and the referent might be more self-evident (i.e. have greater iconicity: see Lloyd and Blischak, 1992), but they also contain more distracting details. With respect to the second question it is necessary to realize that the use of augmentative communication should be adapted to the level of sense-making. In practice objects are usually used as symbols (such as passing an empty beaker to announce drinking coffee in the canteen), even for people who cannot imagine the functional meaning of the object. One must not ignore the fact that the use of objects as symbols at least requires sense-making at the level of representation, for the meaning (drinking coffee in the canteen) is invisible (hidden in an empty beaker). An individual functioning at the level of presentation only understands the functional meaning of an article of use (the beaker) within the concrete situation (standing before the coffee machine in the canteen). At the level of sensation the beaker is no more than a smooth something, which makes a nice sound when tapped. The same misconception applies to the use of pictures. Too often people with autism and learning disability are confronted with symbol communication systems they do not understand. The use of pictures as symbols clearly parallels the use of words as symbols and thus links language development to the development of picture use (Stephenson and Linfoot,
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1996). According to Sigel (1978), it is useful to distinguish between picture recognition and picture comprehension. Recognition of a depicted object is not equivalent to understanding the nature of pictures or the relationship between a picture and its referent (DeLoache and Burns, 1994). As mentioned before, an important pitfall is the fact that some people with autism are able to label photographs or pictograms, while they cannot imagine their functional meaning. Symbolic communication techniques are only useful for individuals functioning at the level of representation. That does not imply, however, that augmentative communication is useless when making sense at the levels of sensation and presentation.1 At the level of presentation, the use of functional objects is limited to the specic here and now of the concrete situation, which implies that it is not possible to predict any future events. Matching and assembling procedures (i.e. tting two pieces together as in a jigsaw puzzle) are valuable in order to avoid this problem. For example, comprehension of a pictogram is not required for matching a pictogram of a lavatory with an identical pictogram xed at the door of the lavatory. The same applies for placing a roll of toilet paper on a holder in the lavatory. When teaching augmentative communication at the level of presentation, it is essential that the object or the picture be introduced at the place of the destination. The activity has to start immediately after matching or assembling, so that the correct association can take place. Afterwards, the distance can be enlarged via backwards training. For example Chris, a 4-year-old boy with autism and severe learning disability, learns to bring a beaker to the holder on the table. The rst time he is allowed to place the beaker in the holder together with the caretaker. Immediately after the caretaker gives Chris a drink. The next time Chris places the beaker in the holder all by himself. Each time he is given the beaker a little bit earlier. Step by step the distance between the beaker and the holder increases. How far the distance between the beaker and the holder can be enlarged depends on the level of functioning of the individual. The capacity of object permanence is very signicant. Lower-functioning people are only able to match or assemble when the goal is within sight, whereas others can bridge large distances. For people making sense at the level of sensation, announcing an activity is impossible, but sensory experiences can gain a signalling function. Catherine, an 8-year-old girl with autism and severe learning disability, understands the world primarily at the level of sensation. She relies on sensory experiences which trigger an association with an activity. For eating she wears a bib, for gym a jacket and for playing outside a hip-purse. The sensations should be considered as mere signals, making the situation recognizable, not as symbols making the situation predictable. 211

8(2) Some considerations on PECS and TEACCH Within the scope of augmentative communication it is useful to consider further some common intervention programmes. The Picture Exchange Communication System (PECS: Bondy and Frost, 1994; 2002) ts within the framework of applied behaviour analysis and makes use of discrete trial and incidental learning formats. An individual is taught to exchange a picture for a desired item or activity. Once he or she masters that principle in a variety of requesting formats, other communicative functions such as commenting are addressed. PECS makes use of pictures as symbols which, in our opinion, indicates that sense-making on the level of representation is a prerequisite for the programme. This consideration applies for all sorts of existing communication systems such as Makaton (Walker, 1980). It cannot be emphasized sufciently that augmentative communication should be adapted to the precise level of functioning. A second consideration is the fact that the primary focus of attention in PECS is the teaching of expressive communication. It must not be forgotten that people with autism and learning disability also need augmentation of receptive communication in order to make their environment surveyable and enhance their grip on the surrounding world. TEACCH (Treatment and Education of Autistic and Communication Handicapped Children) was developed in the 1970s in North Carolina by Schopler and Mesibov and is one of the most commonly known and used intervention programmes (Schopler and Mesibov, 1995). It is a whole life approach to helping people with autism, based on the principles of structured teaching and using the individuals visual strengths to augment comprehension. A main principle underlying TEACCH is that if the person can see it, he or she is more likely to understand it and be able to do it. There are four main strategies: physical structure; daily schedules or timetables; work systems; and visual clarity within tasks. Emphasizing comprehension is commendable within the context of the central coherence theory, but again more attention should be directed to the way the individual makes sense of the world. For many lower-functioning individuals with autism, seeing would not be enough. TEACCH then advises tangibles, but these are also mainly used as objects of reference at the level of representation or within their direct functional context at the level of presentation. As we noted earlier, the use of functional objects is limited to the here and now of the present situation; the prediction of future events is impossible. Since people with autism and learning disability perceive the world primarily in fragments, the natural sequence is missing. Therefore they have to be taught the sequence step by step. Daily schedules are usually indicated
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on shelves or in cupboards (objects), on boards or in diaries (pictures and words). The top-down or leftright orientation of these schedules is representative by nature, consequently causing problems for lowerfunctioning individuals. It is clearer to use stacked boxes to indicate the order of activities at the level of presentation. When the top box is empty and further removed, the next box shows the following object or picture. Summarizing, TEACCH is a very valuable intervention approach, which has a major positive impact on the treatment of people with autism. However, as far as communication enhancement is concerned, it should be reviewed critically with respect to current knowledge about perception, making allowances for the various levels of sense-making.

Conclusion
Although autism can only be diagnosed at the behavioural level, research at the level of cognition has generated very useful information. The central coherence theory offers insight into the complex communication problems of people with autism and learning disability. A clear understanding of their fundamentally different way of making sense of the world offers startingpoints for assessment, but is especially of interest for the stimulation of communicative competence. If communication is tuned to individual needs, the quality of life for people with autism can increase substantially.

Acknowledgements During the period of this work the rst author was supported by a grant from Foundation Effatha-Guyot. This article was submitted in part fullment of her PhD degree at the University of Leiden. Notes
1 The video production In OTHER Words: Augmentative Communication for Children with Autism and Learning Difculties (Noens and Van Berckelaer-Onnes, 2002b) shows how to augment communication at the levels of sensation and presentation. Copies of the video can be obtained from the authors.

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