Social Communication Interventions

Common features of the interventions pre-school are the creation of a pattern of dyadic communication within play that tends to follow the child’s lead and interest in activities, talks about what the child is doing, repeating back or expanding on what the child says, giving sensitively timed corrective feedback, sitting close to the child and making eye-contact, and making environmental adjustments to engage the child. There is use of mirroring or imitation of the child’s actions on toys, and using the child’s activities as a prompt to develop play routines. In the early school years a similar communication environment is established but adapted into the school and peer setting.

This alteration in the dyadic communication context for the child can be initiated either through direct work with the child by a trained professional, or by professional work with the parent using video-aided methods to enable them to create an equivalent enhanced communication environment for their child. Direct work with the child and work through the parent can also be combined. Additional practice tasks are used to reinforce changes beyond the therapy context into home. In school, work is with teachers or teaching assistants on social engagement and skills, along with use of peer ‘buddies’.

Each delivery method has theoretical advantages. Direct professional work with the child benefits from professional expertise and confidence and can model good practice for the observing parent. Child communication gains from such direct work have been shown to generalize into improved child dyadic interaction with the parent. ‘Parent-mediated’ work on the other hand has the advantages of directly improving parental confidence and morale and maximising potential generalization into the home by working naturalistically with the child’s regular communication partner.

The interventions typically will build on an assessment of the current developmental level of the child with staged goals in line with social communication developmental theory. For early developmental stages there is a focus on pre-language skills such as joint engagement, joint attention, triadic attention, shared enjoyment, and sensitive responding. The professional or trained parent maximizes the contexts for communication, are highly observant of the child’s verbal & non-verbal signals, make inferences about the intentions/ goals behind the child’s communication and are alert for opportunities for mutual shared attention. There is then a focus on reducing adult initiations while increasing synchronous response to child’s communication and adaptation to the child’s pattern of language processing. Further stages include adjusting communication to child’s development, including language mapping, modelling, repetition and semantic contingency; use anticipation of familiar routines/ rehearsed play to initiate communication use repetition and generalise to daily life routines. Later stages of language-focused interventions of this kind use specific techniques including pauses, disruptions, breaks in the flow, sabotage, planned mistakes to reinforce language flow, developing semantic expansions and narrative flow.

Structured studies of the parent-mediated approach suggest that changes in the communicative environment that the adult provides for the child lead to significant improvements in child’s dyadic social communication initiations and these in turn are causally related to (modest) improvements in generalised autism symptoms. Trials of direct therapist work with the child have shown enhanced child language communication outcomes. These effects are in line with independent longitudinal cohort studies showing that early synchronous parent-child dyadic communication positive language results in enhanced later language and communication outcomes for children with autism.  

Intensity of these interventions is typically moderate, ranging from clinic visits every 2 weeks to daily short intervention dosages. While there has only been limited study of ‘dosage’, there is no evidence currently linking greater intervention intensity to enhanced outcome.

“Meta-analyses of this kind of social-communication intervention with blinded outcome assessment shows small to moderate effects of caregiver- or preschool-teacher-mediated social- communication interventions on social interaction (as measured by the ADOS), communication acts, parent-child joint attention and parent-child joint engagement, for young children with autism. There is also evidence from a meta-analysis with a blinded outcome assessor for a moderate effect of peer-mediated social- communication interventions on peer-child joint engagement for older children (mean ages of 8-9 years). Based on this positive evidence, the NICE GDG judged that social-communication programmes may help to address significant issues for children with autism, including social isolation and should be recommended for children with autism and, where they are delivered, should include common core elements of being play-based and including training for the intervention administrator/mediator (caregiver, teacher or peer) on strategies for increasing reciprocal social communication and interaction.”

“The PACT intervention, which includes many of the common features for caregiver-mediated social-communication interventions, has been evaluated for its cost effectiveness. On the basis of economic evidence PACT is unlikely to be cost-effective within the NICE decision-making context when a service perspective is adopted. However, the intervention may be cost-effective under a societal perspective. It is possible that the PACT intervention was too intense (and therefore too costly) and that lower intensity of the intervention (i.e. lower intervention cost) might result in similar clinical outcomes, thus improving its cost effectiveness relative to TAU.”*Text from ‘Evidence to Practice’, psychosocial interventions for core symptoms by Odette Megnin-Viggars (NCCMH) in the NICE full guidance