Speech and Language Therapy. A Guide to Social Communication Difficulties and Autism

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1 Speech and Language Therapy A Guide to Social Communication Difficulties and Autism Looking after you locally

2 Norfolk Community Health and Care NHS Trust A Guide to Social Communication Difficulties and Autism 2 The Communication Pyramid... Communication is more than just talking; early development of social interaction, play, listening and attention skills form the foundations of language. Children usually develop these skills from the bottom to the top of the Communication Pyramid, though all of them continue to develop over many years. Social interaction is an essential foundation for all other learning, helping us make and maintain relationships, give our attention to other people and what they may be telling or showing us and engage meaningfully with others. If children struggle with social interaction, one of the foundational skills in the communication pyramid, then it is likely that they will struggle with skills further up the pyramid. See our other guides for how to support children with their attention and listening, their understanding of language and their talking. Speech sounds Talking Understanding Play Attention, looking, listening Social interaction

3 Norfolk Community Health and Care NHS Trust A Guide to Social Communication Difficulties and Autism 3 Social communication skills... How social communication skills normally develop Babies 5 weeks: Are most interested in faces and coo in response to their parent 8 weeks: Smile and copy faces 3 months: Take part in simple turn taking 6 months: Recognise facial expressions and tones of voice; anticipate what will happen next in familiar games 9 months: Use their gaze to direct parents attention; play peek-a-boo; clap their hands 10 months: Point and look to a parent; follow the gaze of an adult 12 months: Enjoy playing with adults; wave bye bye 15 months: Explore how things work and have some functional play Toddlers 18 months: Echo adult words and have some simple pretend play 2 years: Listen with interest to conversation; join in songs; begin to take turns, with support; engage in parallel play 2 ½ years: Talk about things they re interested in to an adult; are more flexible in their pretend play Children 3 years: Understand turn-taking; take part in make-believe play with peers 4 years: Enjoy jokes; use language to argue; seek the companionship of other children; show empathy 5 years: Play cooperatively; show a sense of humour; understand rules and fair play

4 Norfolk Community Health and Care NHS Trust A Guide to Social Communication Difficulties and Autism 4 Social communication diff iculties... Why do some children have these difficulties? When looking at a child with social communication difficulties, it is tempting to assume that they have autism. It is essential to remember that there is a lot of overlap with autism and other communication difficulties. When we work with a child we must not jump to conclusions and try to diagnose them. Observation, liaising with parents and working closely with other professionals are all essential when working out a child s difficulties. Children may struggle with their social interaction for any of the following reasons: Autism Environmental factors, such as few opportunities to build relationships with a responsive adult Lack of experience with others ADHD (attention deficit hyperactivity disorder) Attachment disorder, where the child has been unable to make a secure attachment with a caregiver early on in life Global developmental delay, where all of the child s development is delayed. These children may be delayed in their development of social communication

5 Norfolk Community Health and Care NHS Trust A Guide to Social Communication Difficulties and Autism 5 Identifying diff iculties... Children with social communication difficulties may struggle with a range of different skills which would normally develop naturally through interactions with other people. For children who have social communication difficulties without autism, they may struggle with just a few aspects of their interaction skills. For children with autism there is a triad of impairment, which means that the child has difficulties with their social communication, their social interaction and their social imagination. As well as these difficulties, children with autism are likely to have sensory difficulties. These can be quite mild or very severe. Sensory difficulties can affect all of the child s senses. They may be oversensitive or undersensitive to: sight sound touch taste smell balance ( vestibular ) body awareness ( proprioception ) Over the page you will see some of the things which any child with social communication difficulties might find hard. For a child with autism they will find things difficult in each area.

6 Norfolk Community Health and Care NHS Trust A Guide to Social Communication Difficulties and Autism 6 Identifying diff iculties... Social communication difficulties A child may Consistently interrupt Use pedantic or overly formal language Use a different accent Treat peers and adults in the same way Repeat other s speech (echolalia) A child may struggle to Understand sarcasm, metaphor, idiom and double meaning Make inferences Follow instructions Use creative language Use pronouns (me, you) Understand and use social greetings Social interaction difficulties Be passive or invasive Be withdrawn and solitary Interact on own terms only Interact only to have needs met Point to things to request them, but not to share interest Respond to, but not initiate interactions A child may struggle to See things from another s point of view Empathise Use eye contact Social imagination difficulties A child may Line things up Show good attention to detail Have repetitive play which lacks imagination Have obsessive behaviours or routines Have a limited range of interests Prefer activities with adults rather than playing Struggle to show creativity with construction, may follow the manual Prefer factual books to fiction A child may struggle to Play let s pretend games Separate pretence from reality (eg, thinks Sponge Bob is a real friend) Play a role (eg, in drama or PE) Write or tell creative stories Manage change to his/her usual routine

7 Norfolk Community Health and Care NHS Trust A Guide to Social Communication Difficulties and Autism 7 How you can help... The following advice is useful for all children with social communication difficulties. Use concrete language Be clear with the words you are using, say what you mean and mean what you say. Try to avoid idioms (eg, pull your socks up, let s get cracking ). Use positive directive language Rather than telling a child what not to do, tell them what you would like them to do, remembering to be specific. For example, rather than saying stop fidgeting and annoying Harry, say hands still, bottom on the floor. Simplify language, make it specific Be aware that children may well struggle with indirect requests you need to tell them exactly what you want them to do. For example, rather than Can you help me tidy up?, say Put the bricks away. Rather than saying It s got very cold in here, say Leah, please close the door. Extra time for processing When you give an instruction or ask a question, be aware that the child may take a while to process what they have been asked. Some children need 10 seconds or more try pausing and seeing if they can answer with enough time. By jumping in and repeating or rephrasing the question, you will find they have to start processing the question or instruction all over again. Get their attention first This is good practice for all children, but for children with social communication difficulties they may not realise that a whole class instruction applies to them. Try saying Everybody listen, Michael I want you to listen too. Use visual information / gesture as well as language Children may have difficulties processing language. Using visual support (through pictures, gesture, showing them what you want them to do) can support their understanding. Using a visual schedule for everyday activities can help children learn how to do them.

8 Norfolk Community Health and Care NHS Trust A Guide to Social Communication Difficulties and Autism 8 How you can help... Visual resources Visual Timetables These help children understand what is happening next and that the activity they are doing has an end. Visual timetables can be made using real objects, photos or symbols, depending on the child s level of ability. You may need to simplify them, so that the child is told what is happening for half the day, rather than the full day. Once an activity is finished, the child can be supported to take the symbol off the timetable and put it in the finished box or pocket. First and Then cards Choice boards These are particularly useful for children who struggle to settle to an activity. You may need to start with just two choices initially. During free time, choice boards can help focus a child who would struggle to make a decision otherwise. Timers These are a lovely visual way of showing a child that an activity has to end soon. Children who have favourite activities and struggle to leave them can more easily see when their time is up and that it s time to let someone else have a turn or move onto another activity. For children who struggle with moving from one activity to another, these cards can help them realise that what they are doing will end. First and then cards are helpful when children don t want to do an activity they can see that it will finish and what will happen next.

9 Norfolk Community Health and Care NHS Trust A Guide to Social Communication Difficulties and Autism 9 How you can help... Intensive interaction For children who are pre-verbal, or have very little intentional communication, intensive interaction can be useful. It is easy to set up - the only equipment needed is a sensitive person to interact with the child. The approach works by slowly developing enjoyable and relaxed interaction sequences between the interaction partner and the child. These interaction sequences are repeated frequently and gradually grow in duration and complexity. As this happens, the fundamentals of communication are gradually rehearsed and learnt in a free-flowing manner. The style of the adult is relaxed, non-directive and responsive. The adult basically allows the child to lead and direct, with the adult responding and joining in. The child sets the content and flow of the activity. The sessions are frequent, quite intense, but also fun-filled, playful and enjoyable. The adult and child should both be at ease, with enjoyment of the activity as the main motivation. A session could be highly dynamic, with a great deal of vocalisation, sometimes with fun-filled physical contacts. A session could also be peaceful, slow and quiet. The key points to remember are that the adult should: Create an atmosphere of equality, without controlling or leading Tune in and observe the child s behaviour Consistently respond to the child by joining in with or mirroring key behaviours Use pauses to allow the child to lead the session Give the child their full attention Respond to any vocalisations the child makes Please see the resources list for how to access further information about this approach.

10 Norfolk Community Health and Care NHS Trust A Guide to Social Communication Difficulties and Autism 10 Resources... I CAN: Afasic: Intensive interaction: The National Autistic Society Toddler Talk, Chatting with Children from I CAN: For further information or advice For further information, such as how to refer a child to our Speech and Language Therapy Service, contact your local office on You can receive help with queries about NHS services from NCH&C Patient Advice and Liaison Service (PALS) Tel: pals@nchc.nhs.uk If you would like this publication in large print, Braille, alternative format or in a different language, please contact us on and we will do our best to help. Produced by Norfolk Community Health and Care NHS Trust, September Review date, September Looking after you locally