Evidence -Base Practice Article Review
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Asystematicreviewofpragmaticlanguageinterventionforchildrenwithautismspectrumdisorder.pdf
RESEARCH ARTICLE
A systematic review of pragmatic language
interventions for children with autism
spectrum disorder
Lauren Parsons 1*, Reinie Cordier1, Natalie Munro1,2, Annette Joosten1, Renée Speyer3
1 School of Occupational Therapy and Social Work, Curtin University, Perth, Western Australia, Australia,
2 Faculty of Health Sciences, The University of Sydney, Sydney, New South Wales, Australia, 3 College of
Healthcare Sciences, James Cook University, Townsville, Queensland, Australia
Abstract
There is a need for evidence based interventions for children with autism spectrum disorder
(ASD) to limit the life-long, psychosocial impact of pragmatic language impairments. This
systematic review identified 22 studies reporting on 20 pragmatic language interventions for
children with ASD aged 0–18 years. The characteristics of each study, components of the
interventions, and the methodological quality of each study were reviewed. Meta-analysis
was conducted to assess the effectiveness of 15 interventions. Results revealed some
promising approaches, indicating that active inclusion of the child and parent in the interven-
tion was a significant mediator of intervention effect. Participant age, therapy setting or
modality were not significant mediators between the interventions and measures of prag-
matic language. The long-term effects of these interventions and the generalisation of learn-
ing to new contexts is largely unknown. Implications for clinical practice and directions for
future research are discussed.
Introduction
A core characteristic of autism spectrum disorder (ASD) is a deficiency in social communica-
tion and interaction. A wide range of verbal language abilities are reported in individuals with
ASD, but a striking feature about their language profile is a universal impairment in pragmatic
language [1]. This review will focus on interventions that target the pragmatic aspect of lan-
guage. Early definitions of pragmatic language refer to the use of language in context; encom-
passing the verbal, paralinguistic and non-verbal aspects of language [2]. Contemporary
definitions have expanded beyond just communicative functions to include behaviour that
includes social, emotional, and communicative aspects of language [3]. This expansion reflects
an understanding that pragmatic language, social skills and emotional understanding are
interconnected, and this definition of pragmatic language will be used for this review. While
this definition encompasses pragmatics en masse, one of the challenges for a systematic review
on pragmatic language interventions for children with ASD is identifying the skills of pragmat-
ics that are actually targeted. The following sections therefore provide a brief summary of
PLOS ONE | https://doi.org/10.1371/journal.pone.0172242 April 20, 2017 1 / 37
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OPEN ACCESS
Citation: Parsons L, Cordier R, Munro N, Joosten
A, Speyer R (2017) A systematic review of
pragmatic language interventions for children with
autism spectrum disorder. PLoS ONE 12(4):
e0172242. https://doi.org/10.1371/journal.
pone.0172242
Editor: Jacobus P. van Wouwe, TNO,
NETHERLANDS
Received: October 24, 2016
Accepted: February 1, 2017
Published: April 20, 2017
Copyright: © 2017 Parsons et al. This is an open access article distributed under the terms of the
Creative Commons Attribution License, which
permits unrestricted use, distribution, and
reproduction in any medium, provided the original
author and source are credited.
Data Availability Statement: All relevant data are
within the paper and its Supporting Information
files.
Funding: The authors received no specific funding
for this work.
Competing interests: The authors have declared
that no competing interests exist.
pragmatic language development, the skills identified as problematic in children with ASD
and a framework for classifying interventions.
Pragmatic language behaviours emerge during the prelinguisitic phase of language develop-
ment. Early language is typically characterised by a combination of gestures, vocalisations, and
simple phonetic forms [4]. While linguistically simple, these acts are social in nature and are
interpreted by adults as communicative in intent, leading to descriptions of children as “prag-
matically precocious” [4]. Further, joint attention acts as a scaffold for the development of
social communication [4]. Children with ASD display a lack of joint attention that begins in
infancy, and therefore display developmental differences in related communicative acts, such
as the use and comprehension of gestures, and attention to a social partner and a shared topic
(joint engagement) [5]. Further, approximately 30% of individuals with ASD develop only
minimal verbal communication [6], so interventions that target these early, preverbal stages of
pragmatic language are developmentally important for children with ASD as they can enhance
future language and social development [7].
During typical development, a range of communicative acts emerge and continue to
develop as structural language develops, conversational topic maintenance emerges in interac-
tions with adults, and the appropriateness of responses increases [1, 4]. The communicative,
social and emotional aspects of pragmatic language have recently been described in 27 observ-
able communicative behaviours, classified into five domains relevant for children aged 5–11
years [8]. The domains are: 1) Introduction and responsiveness (the ability to introduce com-
munication and be responsive to the communication of others); 2) Non-verbal communica-
tion (the use and understanding of gestures, facial expressions, body postures and proximity
between speakers); 3) Social-emotional attunement (interpreting the emotional reactions of
others and demonstrating appropriate responses); 4) Executive function (attending to interac-
tions and flexibility in planning communicative content); and 5) Negotiation (cooperating and
negotiating appropriately with communicative partners). For children with ASD who develop
verbal language, previously described pragmatic difficulties persist and further pragmatic lan-
guage deficits evolve, including fewer and often unskilled attempts at initiating communica-
tion, narrower ranges of communication acts, and difficulties producing novel language [9].
Documentation about the typical progression of pragmatic language into adolescence is
scarce. However, mastery of earlier emerging conversational skills such as cohesion, appropri-
ate referencing, and providing adequate responses is reported, along with an equal distribution
of conversational burden, and an ability to adapt speaking style to one’s conversational partner
or context [10]. Despite the limited knowledge on what is typical in adolescence, some differ-
ences in pragmatic language competence in individuals with ASD have been reported, such as
poor conversational topic management, the contribution of irrelevant information to conver-
sations, unusual prosody, reduced reciprocity and responses to partner cues, and inappropri-
ate eye-gaze [11].
In summary, deficits in pragmatic language affect individuals with ASD throughout child-
hood necessitating effective, evidence-based interventions that can minimise the isolating, and
long-term impacts of pragmatic language difficulties. Two studies have reported increased
feelings of loneliness and poorer friendship quality in children and adolescents with ASD
when compared to typically developing peers as a result of reduced pragmatic language skills
[12, 13]. Long-term outcomes have been studied in a sample of adults identified during child-
hood as having either a pragmatic language impairment (PLI) or ASD [14]. Participants with
ASD were found to have substantial pragmatic difficulties that persisted into adulthood, and
the quality of social relationships were poor for both adults with ASD and PLI. No participant
in the ASD group reported any close friendships or romantic relationships.
Pragmatic language interventions for children with ASD
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A recent review of 26 spoken language intervention studies for children with ASD found a
small effect on structural language competence [15], but to date there is no review of interven-
tions that target pragmatic language in children and adolescents with ASD. The purpose of
this study is to conduct a systematic review and meta-analysis of pragmatic language interven-
tions for children with ASD. The review will describe the studies reporting on pragmatic lan-
guage interventions for children with ASD and the characteristics of the included
interventions, and evaluate the methodological quality of the included studies. A meta-analysis
will be conducted to answer the following research questions: 1) do different settings (i.e.,
home, clinic, or school), person(s) of focus (i.e., child, parent, or both), or intervention modali-
ties (i.e., individual, group, or both) produce different intervention effects?; 2) are pragmatic
language interventions more effective than no treatment or usual treatment practices?; and 3)
do participant age, type of outcome measure, or the aforementioned intervention characteris-
tics mediate intervention effect?
Methods
The PRISMA statement guided the methodology and reporting of this systematic review and
the review was registered with the PROSPERO register of systematic reviews (registration
number CRD42015029161). A completed PRISMA checklist is provided in S1 Table.
Information sources
A comprehensive literature search was initially conducted using subject headings and free-text
strings across five electronic databases on April 8, 2015. An updated free-text search of the
same databases was conducted on May 14, 2016 to capture any new papers published since the
original search. The databases searched were: CINAHL, Embase, Eric, PsychINFO and
PubMed. A Google Scholar search was also conducted on November 26, 2015, and a search
within autism focused journals was conducted on November 30, 2015 in order to identify any
additional articles. The speechBITE website (www.speechbite.com), a database of intervention
studies in the field of speech pathology created and maintained by an advisory committee
based in the Discipline of Speech Pathology at The University of Sydney, was searched for
interventions pertaining to pragmatics/social communication for children in the ASD popula-
tion. Evidence-based Practice Briefs published on SpeechandLanguage.com (www.
speechandlanguage.com/ebp-briefs) were searched. SpeechandLanguage.com is a professional
development focused site for speech pathologists maintained by Pearson. Finally, reference
lists of included articles were searched to identify additional studies.
Search strategy
In searching electronic databases two search categories were combined: 1) fields in language
studies (pragmatics, social language, social communication, paralinguistics, nonverbal com-
munication, prosody, social behaviour, social skills, communication, communication disor-
ders, child language, verbal behaviour, language, language tests, language therapy, language
development disorders, speech therapy) and 2) disorder (autism, autism spectrum disorder,
autistic disorder, pervasive developmental-disorder not otherwise specified, Asperger syn-
drome, Rett syndrome, child disintegrative disorder). As no database contained a subject head-
ing related to pragmatic language, more general terms in the field of language and social skills
were included in an attempt to capture all literature on the subject; thus casting a wide net.
Limitations were applied for participant age (0–18 years), and English language. Free text
searches were also conducted in all databases for papers published between April 8, 2014 and
Pragmatic language interventions for children with ASD
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May 14, 2016. The full search strategy, including subject headings, free-text and limitations for
each database is provided in S2 Table.
Eligibility criteria
As pragmatic language difficulties present at a very young age in children with ASD and persist
into adulthood, it is necessary for therapists to provide pragmatic language interventions to
children throughout their development. This review will therefore assess the range of interven-
tions available to address pragmatic language difficulties through childhood and adolescence.
In order to classify pragmatic language skills for the purpose of this review, the five domains of
Introduction and Responsiveness, Non-verbal Communication, Social-emotional Attune-
ment, Executive Function and Negotiation are used as a framework [8]. While the pragmatic
language behaviours that these domains encompass are indented for children aged 5–11 years,
the pragmatic behaviours of early intentional communication observed in children younger
than five years are nonetheless subsumed within the domains (e.g., uses and responds to a vari-
ety of gestures, initiates verbal communication, responds to the communication or others).
This was deemed the most appropriate contemporary framework to utilise in the absence of a
pragmatic language classification system that adopts a developmental approach.
To be included in the review, articles were required to meet the following criteria: 1) partici-
pants were children (aged 0–18 years) with a primary diagnosis of ASD (including Asperger
syndrome, or PDD-NOS for children diagnosed prior to the Diagnostic and Statistical Manual
of Mental Disorders (DSM)—Fifth Edition), with or without an intellectual disability; 2) treat-
ment focused on preverbal pragmatic language behaviours or at least one of the behaviours
broadly encompassed by the pragmatic language domains of pragmatic language domains of
Introduction and Responsiveness, Non-verbal Communication, Social-emotional Attune-
ment, Executive Function and Negotiation; 3) studies included a control group with random
assignment to groups; 4) treatment outcomes measured at least one of the skills encompassed
by the definition of pragmatic language adopted for this review. Only papers published in
English in peer reviewed journals were considered for this review. Pharmacological interven-
tions were excluded. Outcome measurements of autism symptom severity were not considered
assessments of pragmatic language for the purpose of this review. These criteria were used in
order to identify all randomised controlled trials of pragmatic language interventions for chil-
dren with ASD.
Systematic review
Methodological quality. The Standard Quality Assessment criteria for evaluating primary
research papers from a variety of fields (Kmet checklist) was used to assess the methodological
quality of the included studies [16]. The 14-item checklist utilises a 3-point, ordinal scale
(0 = no, 1 = partial, 2 = yes), giving a systematic and quantifiable means for assessing the qual-
ity of studies of a variety of research designs [16]. Checklist items assess the sampling strategy,
participant characteristics described, sample size calculations, sample size collection, descrip-
tion and justification of analytic methods, result reporting, controls for confounding variables,
and whether conclusions drawn reflect results reported. An overall quality percentage score
can be calculated by dividing the total score rated by the maximum possible score, and studies
were then classified based on that score. The following convention was used for the classifica-
tion of methodological quality [17, 18]: a score of >80% was considered strong quality, a score
of 70–79% was considered good quality, 50–69% was considered fair quality and <50% was
considered to have poor methodological quality.
Pragmatic language interventions for children with ASD
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Data collection process. Comprehensive forms were developed in order to extract rele-
vant data from the included studies. Data on study characteristics were extracted for the fol-
lowing categories: participant diagnosis, control group, age range (mean and standard
deviation), study eligibility criteria, treatment condition, outcome measures and treatment
outcomes. Extraction of data pertaining to intervention components was guided by the TIDieR
Checklist, a 12-item checklist that guides the reporting of intervention studies so that proce-
dures can be replicated by other researchers and clinicians in the field [19]. Data were
extracted for skill(s) targeted, materials and procedures, interventionists, duration and setting/
mode of delivery, tailoring/modifications, methods of blinding and randomisation. Data relat-
ing to methodological quality were extracted in accordance with the Kmet checklist.
Data items, risk of bias and synthesis of results. All abstracts were reviewed by one
researcher for inclusion, and a second researcher reviewed a randomly selected 40% of the
abstracts to ensure accuracy in study selection for the review. The same assessors also rated the
extracted data pertaining to methodological quality of all included studies using the Kmet
checklist. Interrater reliability between the two independent assessors was established for both
the abstract selection and Kmet ratings of each included study. The likelihood of bias was
reduced in the extraction of data and in ratings of study quality for this review, as none of the
reviewers have any affiliations with any of the authors of the included studies. Data was synthe-
sised and summarised into a number of categories including study design, participant charac-
teristics, inclusion criteria, treatment components and outcomes, and methodological quality.
Treatment effectiveness was assessed using significance values and effect sizes of the main
pragmatic language outcome measure.
Meta-analysis
Subsampling was chosen as the predominant analytic technique for this review, as the small
number of included studies limited the viability of meta-regression using multiple covariates.
Data was extracted from the included studies to measure the overall effect of pragmatic lan-
guage interventions for children with ASD, and treatment effect as a function of the following
intervention characteristics: 1) setting (i.e., home, school or clinic); 2) focus of the intervention
(i.e., child, parent and child, parent only), and; 3) the mode of delivery (i.e., individual or
group). An analysis of the interventions based on the pragmatic language skills targeted was
considered; however, grouping interventions in this way would cause a comparison of a large
number of small groups, thus limiting the conclusions that could been drawn from the results.
Meta-regression was conducted to determine whether participant age, type of outcome
measure, or any of the three aforementioned intervention components mediated intervention
effect. The study sample size (17) allowed for multivariate analysis involving up to two covari-
ates without compromising power [20], so one multivariate model addressed the interaction
between participant age and mode of intervention delivery. This model was selected as partici-
pant age potentially confounded the results of the subgroup analysis pertaining to mode.
Lastly, between-groups analyses assessed the difference in post-intervention social communi-
cation competence of those who received a pragmatic language intervention and their compar-
ison controls who were groups by condition type (i.e., no treatment, treatment as usual, or an
alternative treatment).
To compare effect sizes, pre- and post- means, standard deviations, and sample sizes were
extracted. If the data required for meta-analysis calculations was not reported, attempts were
made to contact authors in order to request the desired data. In cases where more than one
paper reported on the same study sample, the paper reporting an outcome measure that evalu-
ated the greatest number of pragmatic language skills covered by the definition adopted for
Pragmatic language interventions for children with ASD
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this review was chosen for the analysis. Studies reporting on follow-up data only were also
excluded. When multiple outcome measures of social communication were reported for one
intervention, the measure that evaluated the greatest number of pragmatic language skills was
extracted for analysis. If a single outcome measure could not be chosen, then means for multi-
ple measures of pragmatic language were averaged and pooled standard deviations were calcu-
lated for the meta-analysis.
Extracted means, standard deviations, and sample sizes for pre- and post- measures were
entered into Comprehensive Meta-Analysis, Version 3.3.070. A random effects model was
used to generate effect sizes as the included studies are not likely to have the same true effect
due to the variability in the sampling, intervention characteristics, skills targeted, participant
characteristics and outcome measures utilised.
Heterogeneity was estimated via two methods. The Q statistic determines the spread of all effect sizes around the mean effect size. As Q can be poor at detecting heterogeneity in analyses with low power, I2 was also examined [21]. The I2 statistic estimates the ratio of true variance to total variance. For all sub-group analyses the Hedges g formula for standardised mean dif- ference (SMD) with a confidence interval of 95% was used to report effect sizes. Using Cohen’s
d convention for interpretation, an effect size of �0.2 reflects negligible difference, between � 0.2 and � 0.49 was considered as small; between � 0.5 and � 0.79 was considered
as moderate; and � 0.8 was considered as large [22].
Given that studies that report large and significant treatment effects are more likely to be
selected for publication, it is possible that some low-effect or non-significant interventions are
missing from the meta-analysis. The presence of publication bias was assessed using classic
fail-safe N. The test calculates the number of additional studies that, if added to the analysis,
would nullify the measured effect (N). If N is large it can be considered unlikely that there
would be so many unpublished low-effect studies and it can be assumed that the meta-analysis
is not compromised by publication bias.
Results
Study selection
A total of 2,909 papers were identified through the initial subject heading and free text searches
across the following databases: CINAHL, Embase, Eric, PsychINFO and PubMed. A further 29
records were identified via Google Scholar, autism specific journals, speechBITE, and Spee-
chandLanguage.com. These 2,938 studies were screened for duplicate titles and abstracts and
840 duplicated records were removed. The updated database search added a further 793
unique abstracts for screening. Two reviewers rated abstracts for inclusion. The first author
assessed all 2,891 eligible abstracts against the inclusion criteria, with a randomly selected 40%
of the studies assessed by a second rater for inter-rater reliability. The agreement between rat-
ers measured by Weighted Kappa was 0.84 (95%CI: 0.66–1.00). There were only three abstracts
in the random selection on which the raters did not agree, so all three records were included
for further full text screening.
After assessing abstracts on the criteria for inclusion a total of 36 studies were identified.
Full text records were accessed via Curtin University and the University of Sydney libraries to
further determine whether the studies met the criteria for inclusion in this review. Of these 36
studies, seven were not randomised controlled trials, five did not have an outcome measure-
ment that assessed pragmatic language, two did not include participants with ASD, and one
was not published in a peer reviewed journal (Fig 1). References for the 15 studies excluded
and reasons for exclusion are presented in Table 1. A total of 21 papers, reporting on 18 differ-
ent intervention studies were selected for inclusion based on the inclusion criteria (See Fig 1).
Pragmatic language interventions for children with ASD
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All of the included studies used a randomised controlled design, included participants aged
0–18 years with a diagnosis of ASD, and performed an intervention that aimed to improve any
of the pragmatic language skills incorporated by the definition of pragmatic language adopted
for this review.
Description of studies
Tables 2–5 include a detailed description of the included studies. Data points were collected
and synthesised as follows: Intervention studies for improving pragmatic language in children
with ASD (Table 2), intervention components (Table 3), pragmatic language skills targeted
(Table 4), and the methodological quality of included studies (Table 5).
Study participants. The 21 studies that met the eligibility criteria included 925 partici-
pants aged between 21 months and 14 years of age. Of the 21 included studies, 11 studies
Fig 1. Study flow diagram.
https://doi.org/10.1371/journal.pone.0172242.g001
Pragmatic language interventions for children with ASD
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included preschool aged children (younger than 5 years), and 10 studies included primary/ele-
mentary school aged children (aged between 5 and 12 years inclusive). None of the included
studies targeted children aged 13–18 years.
All intervention and control group participants had received a diagnosis of ASD in accor-
dance with the DSM-IV or DSM-5 prior to being included in all studies. No study included
control groups from different clinical populations or typically developing children. ASD diag-
nosis was confirmed in 20 studies by administering standardised assessments of ASD sympto-
mology to participants, and one study confirmed diagnosis via diagnostic documentation
from qualified community clinicians [38]. The absence of an intellectual disability or another
neurological or developmental disability was a criterion for inclusion for 12 studies. Of these
12 studies, nine assessed cognitive capacity for inclusion using a standardised assessment
appropriate for the age of the included participants, and the remaining three utilised parent
report as the children were too young to undertake formal IQ testing (i.e., under 6 years of
age). Three studies required that participants demonstrate age appropriate expressive or recep-
tive language prior to inclusion [38–40]. Treatment group sample sizes ranged from five to 59,
with nine of the papers reporting calculations of power to determine an appropriate sample
size. Further details on participant characteristics are summarised in Table 2.
Outcome measures. The method of outcome data collection varied across the 21 papers.
Behavioural observation was the most common method of pragmatic language skill measure-
ment, with 11 reports utilising this approach. Behavioural observations typically involved
recording the child interacting in a social context (e.g., playing with a parent, interacting in the
playground), and coding the footage for pragmatic language behaviours of interest. Parent
report measures were administered in six studies. These measures required parents to com-
plete a standardised questionnaire about their child’s social communication competence. One
study utilised both observational and parent report measures [47]. Standardised lab tasks
assessing emotion recognition were administered to study participants in five studies. Specific
assessments and methods for collection are described in Table 2.
Pragmatic language skills measured by these assessments varied greatly across studies. Of
the 11 papers that included behavioural observations, eight studies collected data pertaining to
initiations of joint attention, three measured joint engagement, three measured responsiveness
Table 1. Excluded studies with reasons for exclusion.
Study Reason for exclusion
Gattino, dos Santos Riesgo [23] No outcome measurement that assessed pragmatic language
Ichikawa, Takahashi [24] No outcome measurement that assessed pragmatic language
Kasari, Rotheram-Fuller [25] No outcome measurement that assessed pragmatic language
Lerner and Mikami [26] No outcome measurement that assessed pragmatic language
Wong and Kwan [27] No outcome measurement that assessed pragmatic language
Houghton, Schuchard [28] Not a randomised controlled trial
McFadden, Kamps [29] Not a randomised controlled trial
McMahon, Vismara [30] Not a randomised controlled trial
Oosterling, Visser [31] Not a randomised controlled trial
Radley, Ford [32] Not a randomised controlled trial
Shire, Goods [33] Not a randomised controlled trial
Wetherby, Guthrie [34] Not a randomised controlled trial
Adams, Lockton [35] Participants did not have a core diagnosis of ASD
Kamps, Thiemann-Bourque [36] Participants did not have a core diagnosis of ASD
Donaldson [37] Not published in a peer reviewed journal
https://doi.org/10.1371/journal.pone.0172242.t001
Pragmatic language interventions for children with ASD
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,
o b li g a to
ry re
s p o n s e s , a n d
c o n ti n g e n t
re s p o n s e s )
T re
a tm
e n t g ro
u p
m a d e
s ig
n ifi
c a n tl y
g re
a te
r
in c re
a s e
in u s e
o f o b li g a to
ry a n d
c o n ti n g e n t
re s p o n s e s . N
o s ig
n ifi
c a n t d if fe
re n c e
b e tw
e e n
g ro
u p s
in p ro
d u c ti o n
o r
re s p o n s e s
to
c o m
m e n ts
.
2 5 -m
in c h il d -p
a re
n t p la
y s e s s io
n c o d e d
fo r
c o m
m u n ic
a ti v e
a c ts
(c o m
m e n ti n g , la
b e ll in
g ,
re s p o n d in
g , d ir e c ti n g , s h a ri n g , o b ta
in in
g
in fo
rm a ti o n , re
je c ti n g
o r p ro
te s ti n g , s o c ia
l
c o n v e n ti o n s
a n d
ro u ti n e s , s p o n ta
n e o u s
s o c ia
l e x p re
s s io
n s )
P o s t-
h o c
a n a ly
s is
s h o w
e d
s ig
n ifi
c a n t ti m
e x
g ro
u p
in te
ra c ti o n s
fo r:
c o m
m e n ti n g , la
b e ll in
g ,
s h a ri n g , o b ta
in in
g in
fo rm
a ti o n , re
je c ti n g
o r
p ro
te s ti n g .
B u
il d
in g
B lo
c k s
p ro
g ra
m —
h o
m e
b a s e d
(H B
): F
u n c ti o n a l c o m
m u n ic
a ti o n
R o b e rt
s ,
W il li a m
s [4
4 ]
A u s tr
a li a
H B
: 2 7
3 .4
5 (r
a n g e
2 .2
– 4 .9
5 )
In c lu
s io
n : A
S D
d ia
g n o s is
; P
re -s
c h o o l a g e d
a t
s ta
rt o f p ro
g ra
m ; A
b le
to a c c e s s
c e n tr
e fo
r
tr e a tm
e n t
T h e
P ra
g m
a ti c s
P ro
fi le
S ta
ti s ti c a ll y
s ig
n ifi
c a n t c h a n g e s
p re
to p o s t
in te
rv e n ti o n
in a ll
g ro
u p s . N
o s ta
ti s ti c a ll y
s ig
n ifi
c a n t d if fe
re n c e s
in c h a n g e s
m a d e
b e tw
e e n -g
ro u p s .
B u
il d
in g
B lo
c k s
p ro
g ra
m —
c e n
tr e
b a s e d
(C B
): F
u n c ti o n a l c o m
m u n ic
a ti o n
C B
: 2 9
3 .5
9 (r
a n g e
2 .2
– 5 )
C o n tr
o l:
2 8
3 .6
4 (r
a n g e
2 .3
– 5 .0
)
S o
c ia
l E
m o
ti o
n a l N
e u
ro S
c ie
n c e
E n
d o
c ri
n o
lo g
y (S
E N
S E
) T
h e a te
r:
E n g a g e
in d ir e c te
d c o m
m u n ic
a ti o n ; U
s e
g e s tu
re s
a n d
n o n v e rb
a l c o m
m u n ic
a ti o n
in d ir e c te
d w
a y s ; E
m p a th
ic re
s p o n d in
g
C o rb
e tt , K
e y
[4 5 ] U
S A
T re
a tm
e n t:
1 7
1 1 .2
7 ±
2 .5
1 In
c lu
s io
n : A
S D
d ia
g n o s is
; W
A S
I s c o re �
7 0
S R
S —
S o c ia
l C
o m
m u n ic
a ti o n
S c a le
S ig
n ifi
c a n t d if fe
re n c e
m e a s u re
d b e tw
e e n
g ro
u p s
p o s t tr
e a tm
e n t a n d
a t tw
o m
o n th
fo ll o w
u p .
C o n tr
o l:
1 3
1 0 .7
4 ±
1 .8
9
S o
c ia
l S
k il
ls G
ro u
p In
te rv
e n
ti o
n —
H ig
h F
u n
c ti
o n
in g
A u
ti s m
(S .S
.
G R
IN -H
F A
): N
o n -v
e rb
a l
c o m
m u n ic
a ti o n ; L is
te n in
g s k il ls
to
e ff
e c ti v e ly
fa c il it a te
c o n v e rs
a ti o n
D e R
o s ie
r,
S w
ic k
[4 6 ] U
S A
T re
a tm
e n t:
2 7
1 0 .2 ±
1 .3
In c lu
s io
n : A
S D
d ia
g n o s is
; A
g e d
8 – 1 2
y e a rs
;
W IS
C -I
V v e rb
a l IQ
s c o re �
8 5 . E
x c lu
s io
n :
C B
C L
T -s
c o re >7
0
S R
S —
S o c ia
l C
o m
m u n ic
a ti o n
S c a le
S ig
n ifi
c a n t tr
e a tm
e n t e ff e c t.
C o n tr
o l:
2 8
9 .9 ±
1 .1
F in
d M
e A
p p
: A
tt e n d in
g to
p e o p le
;
F o ll o w
in g
s o c ia
l c u e s
F le
tc h e r-
W a ts
o n , P
e tr
o u
[4 7 ] S
c o tl a n d
T re
a tm
e n t:
2 7
4 .1
2 ±
0 .9
1 In
c lu
s io
n : D
ia g n o s is
o f A
S D
o r
o n
th e
w a it li s t
fo r d ia
g n o s is
; A
g e d <6
y e a rs
a t in
ta k e ; M
e t
A u ti s m
“c u t-
o ff ”
o n
s o c ia
l- c o m
m u n ic
a ti o n
a lg
o ri th
m o f A
D O
S ; A
b s e n c e
o f n e u ro
lo g ic
a l
d is
o rd
e r;
E n g li s h
s p e a k in
g p a re
n ts
B ri e f o b s e rv
a ti o n
o f s o c ia
l c o m
m u n ic
a ti o n
c h a n g e
(B O
S C
C )–
S o c ia
l C
o m
m u n ic
a ti o n
S c a le
N o t m
e a s u re
d im
m e d ia
te ly
fo ll o w
in g
in te
rv e n ti o n . N
o s ig
n ifi
c a n t d if fe
re n c e
b e tw
e e n
c h a n g e s
m a d e
b y
b o th
g ro
u p s
a t 6
m o n th
fo ll o w
u p .
C o n tr
o l:
2 7
4 .1
6 ±
1 .1
C S
B S
-D P
— S
o c ia
l C
o m
p o s it e
N o
s ta
ti s ti c a ll y
s ig
n ifi
c a n t d if fe
re n c e
fo u n d
in
c h a n g e
s c o re
s b e tw
e e n
g ro
u p s
b a s e li n e
to
p o s t,
o r
b a s e li n e
to 6
m o n th
fo ll o w
-u p .
T h
e ra
p e u
ti c
H o
rs e
R id
in g
: J o in
t
a tt
e n ti o n ; N
o n v e rb
a l c o m
m u n ic
a ti o n
G a b ri e ls
, P
a n
[4 8 ] U
S A
T re
a tm
e n t:
5 8
1 0 .5 ±
3 .2
In c lu
s io
n : A
g e d
6 – 1 6
y e a rs
; A
S D
d ia
g n o s is
;
S C
Q s c o re �
1 5 ; M
e t c li n ic
a l c u t-
o ff
fo r
A S
D o n
A D
O S
; Ir
ri ta
b il it y
a n d
S te
re o ty
p y
s u b s c a le
s o f
th e
A B
C -C
c o m
b in
e d
s c o re �
1 1 ; L e it e r-
R
n o n v e rb
a l IQ
s ta
n d a rd
s c o re �
4 0 . E
x c lu
s io
n :
P re
v io
u s ly
id e n ti fi e d
g e n e ti c
d is
o rd
e r
o f a
p h e n o ty
p e
s im
il a r
to A
S D
; H
is to
ry o f m
e d ic
a l
o r
b e h a v io
u ra
l is
s u e s ; H
is to
ry o f a n im
a l a b u s e
o r
p h o b ia
o f h o rs
e s ; >
2 h o u rs
o f e q u in
e
a s s is
te d
th e ra
p y
w it h in
th e
p a s t 6
m o n th
s ;
W e ig
h t e x c e e d in
g th
e ri d in
g c e n tr
e ’s
p o li c ie
s
S R
S —
S o c ia
l C
o m
m u n ic
a ti o n
S c a le
S ig
n ifi
c a n tl y
g re
a te
r im
p ro
v e m
e n t m
a d e
b y
tr e a tm
e n t g ro
u p
C o n tr
o l:
5 8
1 0 .0 ±
2 .7
(C o n ti n u e d
)
Pragmatic language interventions for children with ASD
PLOS ONE | https://doi.org/10.1371/journal.pone.0172242 April 20, 2017 9 / 37
T a b
le 2 .
(C o n ti n u e d
)
T re
a tm
e n
t/ T
a rg
e t
S k il ls
R e fe
re n
c e ,
L o
c a ti
o n
P a rt
ic ip
a n
t
g ro
u p
s (N
)
A g
e Y
e a rs
(M e a n ±
S D
)
In c lu
s io
n /E
x c lu
s io
n C
ri te
ri a
P ra
g m
a ti
c L
a n
g u
a g
e O
u tc
o m
e M
e a s u
re T
re a tm
e n
t O
u tc
o m
e
F a c e S
a y : R
e s p o n d in
g to
jo in
t a tt
e n ti o n
H o p k in
s ,
G o w
e r
[4 9 ]
U S
A
T re
a tm
e n t L F
A :
1 1
1 0 .3
1 ±
3 .3
1 N
o t s p e c ifi
e d
T w
o fi v e -m
in u te
o b s e rv
a ti o n s
o f th
e c h il d re
n
a t s c h o o l re
c e s s . In
te ra
c ti o n s
c o d e d
fo r
p o s it iv
e , n e g a ti v e
a n d
lo w
-l e v e l in
it ia
ti o n s
o f
s o c ia
l b e h a v io
u r a s
p e r H
a u c k , F
e in
[5 0 ]
S ig
n ifi
c a n t d if fe
re n c e
in to
ta l s c o re
, a n d
n e g a ti v e
in te
ra c ti o n s
s c o re
b e tw
e e n
L F
A
g ro
u p s
a n d
H F
A g ro
u p s
fo ll o w
in g
in te
rv e n ti o n .
T re
a tm
e n t:
H F
A : 1 3
1 0 .5
7 ±
3 .2
N o
s ig
n ifi
c a n t d if fe
re n c e
in P
o s it iv
e
In te
ra c ti o n s
o r
L o w
-l e v e l In
te ra
c ti o n s
s c o re
s
b e tw
e e n
L F
A g ro
u p s
a n d
H F
A g ro
u p s
fo ll o w
in g
in te
rv e n ti o n .
C o n tr
o l:
L F
A :
1 4
1 0 .0
5 ±
2 .3
0 E
m o ti o n
re c o g n it io
n o f p h o to
g ra
p h s
a n d
s c h e m
a ti c
d ra
w in
g s
S ig
n ifi
c a n t d if fe
re n c e
b e tw
e e n
c h a n g e
s c o re
s
in L F
A g ro
u p s
fo r
to ta
l a n d
p h o to
s o n ly
s c o re
s .
C o n tr
o l:
H F
A :
1 1
9 .8
5 ±
2 .8
7 S
ig n ifi
c a n t d if fe
re n c e
b e tw
e e n
c h a n g e
s c o re
s
in H
F A
g ro
u p s
fo r
a ll
s c o re
s (t
o ta
l, p h o to
s
o n ly
a n d
d ra
w in
g s
o n ly
).
M o
d ifi
e d
J A
S P
E R
In te
rv e n
ti o
n —
T e a c h
e r
d e li
v e re
d : In
it ia
ti o n
o f J o in
t
a tt
e n ti o n
(p o in
t, s h o w
g iv
e )
K a a le
, S
m it h
[5 1 ] N
o rw
a y
T re
a tm
e n t:
3 2
4 .0
6 ±
0 .6
9 In
c lu
s io
n : A
S D
d ia
g n o s is
; C
h ro
n o lo
g ic
a l a g e
2 4 – 6 0
m o n th
s ; A
tt e n d a n c e
in p re
s c h o o l.
E x c lu
s io
n : C
N S
d is
o rd
e rs
; N
o n -N
o rw
e g ia
n
s p e a k in
g p a re
n ts
F re
q u e n c y
o f J A
in it ia
ti o n
d u ri n g
E S
C S
N o
s ig
n ifi
c a n t d if fe
re n c e
b e tw
e e n
g ro
u p s
d if fe
re n c e
in c h a n g e s
m e a s u re
d .
C o n tr
o l:
2 7
4 .1
9 ±
0 .6
9 F
re q u e n c y
o f J A
in it ia
ti o n
d u ri n g
te a c h e r-
c h il d
p la
y
S ig
n ifi
c a n t b e tw
e e n
g ro
u p s
d if fe
re n c e
in
c h a n g e s
m e a s u re
d .
F re
q u e n c y
o f J A
in it ia
ti o n
d u ri n g
m o th
e r-
c h il d
p la
y
N o
s ig
n ifi
c a n t d if fe
re n c e
b e tw
e e n
g ro
u p s
d if fe
re n c e
in c h a n g e s
m e a s u re
d .
D u ra
ti o n
o f J E
d u ri n g
te a c h e r-
c h il d
p la
y N
o s ig
n ifi
c a n t d if fe
re n c e
b e tw
e e n
g ro
u p s
d if fe
re n c e
in c h a n g e s
m e a s u re
d .
D u ra
ti o n
o f J E
d u ri n g
m o th
e r-
c h il d
p la
y S
ig n ifi
c a n t b e tw
e e n
g ro
u p s
d if fe
re n c e
in
c h a n g e s
m e a s u re
d .
K a a le
,
F a g e rl a n d
[5 2 ]
N o rw
a y
S e e
K a a le
,
S m
it h
[5 1 ]
S e e
K a a le
,
S m
it h
[5 1 ]
S e e
K a a le
, S
m it h
[5 1 ]
F re
q u e n c y
o f J A
in it ia
ti o n
d u ri n g
E S
C S
N o
s ig
n ifi
c a n t b e tw
e e n
g ro
u p s
d if fe
re n c e
in
c h a n g e s
b e tw
e e n
b a s e li n e
a n d
1 2
m o n th
fo ll o w
-u p .
F re
q u e n c y
o f J A
in it ia
ti o n
d u ri n g
te a c h e r-
c h il d
p la
y
S ig
n ifi
c a n t b e tw
e e n
g ro
u p s
d if fe
re n c e
in
c h a n g e s
fr o m
b a s e li n e
to 1 2
m o n th
fo ll o w
u p .
F re
q u e n c y
o f J A
in it ia
ti o n
d u ri n g
m o th
e r-
c h il d
p la
y
N o
s ig
n ifi
c a n t b e tw
e e n
g ro
u p s
d if fe
re n c e
in
c h a n g e s
b e tw
e e n
b a s e li n e
a n d
1 2
m o n th
fo ll o w
-u p .
D u ra
ti o n
o f J E
d u ri n g
te a c h e r-
c h il d
p la
y N
o s ig
n ifi
c a n t b e tw
e e n
g ro
u p s
d if fe
re n c e
in
c h a n g e s
b e tw
e e n
b a s e li n e
a n d
1 2
m o n th
fo ll o w
-u p .
D u ra
ti o n
o f J E
d u ri n g
m o th
e r-
c h il d
p la
y S
ig n ifi
c a n t b e tw
e e n
g ro
u p s
d if fe
re n c e
in
c h a n g e s
fr o m
b a s e li n e
to 1 2
m o n th
fo ll o w
u p .
J A
S P
E R
In te
rv e n
ti o
n :
In it ia
ti o n s
o f
jo in
t a tt
e n ti o n
(p o in
t, s h o w
, g iv
e );
R e s p o n s e
to jo
in t a tt e n ti o n
K a s a ri ,
F re
e m
a n
[5 3 ]
U S
A
T re
a tm
e n t:
2 0
3 .6 ±
0 .5
9 N
o t s p e c ifi
e d
In it ia
ti o n
o f J o in
t A
tt e n ti o n
(s h o w
in g ,
c o o rd
in a te
d jo
in t lo
o k s , p o in
ti n g , g iv
in g )
d u ri n g
E S
C S
T re
a tm
e n t a n d
S y m
b o li c
p la
y g ro
u p s
s h o w
e d
g re
a te
r im
p ro
v e m
e n t in
s h o w
in g
th a n
c o n tr
o l
g ro
u p . N
o s ig
n ifi
c a n t d if fe
re n c e
in s h o w
in g
b e tw
e e n
tr e a tm
e n t a n d
s y m
b o li c
p la
y g ro
u p s .
A ll
g ro
u p s
s h o w
e d
s ig
n ifi
c a n t im
p ro
v e m
e n t in
c o o rd
in a te
d jo
in t lo
o k s . N
o s ig
n ifi
c a n t
d if fe
re n c e s
n o te
d in
p o in
ti n g
o r
g iv
in g .
S y m
b o li c
p la
y :
2 1
3 .5 ±
0 .5
8
C o n tr
o l:
1 7
3 .5 ±
0 .4
1
1 5 -m
in u te
c a re
g iv
e r-
c h il d
in te
ra c ti o n
c o d e d
fo r jo
in t a tt e n ti o n
s k il ls
: c h il d ’s
fr e q u e n c y
o f
jo in
t a tt e n ti o n
s k il ls
(e .g
., c o o rd
in a te
d lo
o k s ,
p o in
ti n g , a n d
s h o w
in g );
ti m
e s p e n t jo
in tl y
e n g a g e d
a n d
in te
ra c ti v e
a ro
u n d
o b je
c ts
;
w h o
in it ia
te d
jo in
t e n g a g e m
e n t (p
a re
n t o r
c h il d )
T re
a tm
e n t a n d
S y m
b o li c
p la
y g ro
u p s
s h o w
e d
s ig
n ifi
c a n tl y
g re
a te
r g a in
s th
a n
th e
c o n tr
o l
g ro
u p
in c o o rd
in a te
d jo
in t lo
o k s . N
o s ig
n ifi
c a n t
d if fe
re n c e
in c o o rd
in a te
d jo
in t lo
o k s
b e tw
e e n
tr e a tm
e n t a n d
S y m
b o li c
p la
y g ro
u p s . A
ll
g ro
u p s
s h o w
e d
s ig
n ifi
c a n t im
p ro
v e m
e n t in
p o in
ti n g . S
ig n ifi
c a n t in
te ra
c ti o n
e ff
e c ts
fo u n d
fo r
p o in
ti n g
a n d
s h o w
in g
(p <0
.0 5 ).
T re
a tm
e n t
g ro
u p
s h o w
e d
s ig
n ifi
c a n tl y
g re
a te
r g a in
s th
a n
th e
c o n tr
o l g ro
u p
in c h il d
in it ia
te d
jo in
t
a tt e n ti o n . N
o d if fe
re n c e s
w e re
fo u n d
in
m o th
e r in
it ia
te d
jo in
t e n g a g e m
e n t.
L a w
to n
a n d
K a s a ri
[5 4 ] U
S A
S e e
K a s a ri ,
F re
e m
a n
[5 3 ]
S e e
K a s a ri ,
F re
e m
a n
[5 3 ]
S e e
K a s a ri , F
re e m
a n
[5 3 ]
S h a re
d p o s it iv
e a ff
e c t d u ri n g
jo in
t a tt
e n ti o n
N o
s ig
n ifi
c a n t d if fe
re n c e
b e tw
e e n
tr e a tm
e n t
a n d
S y m
b o li c
p la
y g ro
u p s
a t p o s t,
6 -m
o n th
fo ll o w
-u p
o r
1 2 -m
o n th
fo ll o w
-u p .
S h a re
d p o s it iv
e a ff
e c t w
it h
u tt
e ra
n c e s
d u ri n g
jo in
t a tt e n ti o n
N o
s ig
n ifi
c a n t d if fe
re n c e
b e tw
e e n
tr e a tm
e n t
a n d
S y m
b o li c
p la
y g ro
u p s
a t p o s t,
6 -m
o n th
fo ll o w
-u p
o r
1 2 -m
o n th
fo ll o w
-u p . (C
o n ti n u e d
)
Pragmatic language interventions for children with ASD
PLOS ONE | https://doi.org/10.1371/journal.pone.0172242 April 20, 2017 10 / 37
T a b
le 2 .
(C o n ti n u e d
)
T re
a tm
e n
t/ T
a rg
e t
S k il ls
R e fe
re n
c e ,
L o
c a ti
o n
P a rt
ic ip
a n
t
g ro
u p
s (N
)
A g
e Y
e a rs
(M e a n ±
S D
)
In c lu
s io
n /E
x c lu
s io
n C
ri te
ri a
P ra
g m
a ti
c L
a n
g u
a g
e O
u tc
o m
e M
e a s u
re T
re a tm
e n
t O
u tc
o m
e
M o
d ifi
e d
J A
S P
E R
In te
rv e n
ti o
n —
P a re
n t-
c h
il d
d y a d
fo c u
s e d
: In
it ia
ti n g
jo in
t e n g a g e m
e n t;
In it ia
ti n g
c o m
m u n ic
a ti o n
K a s a ri , G
u ls
ru d
[5 5 ] U
S A
T re
a tm
e n t:
1 9
C o n tr
o l:
1 9
2 .5
3 ±
0 .0
8
2 .6
1 ±
0 .0
7
In c lu
s io
n : A
g e d <3
6 m
o n th
s ; M
e e ts
A S
D
d ia
g n o s ti c
c ri te
ri a ; N
o a d d it io
n a l s y n d ro
m e s
1 5
m in
u te
c a re
g iv
e r-
c h il d
in te
ra c ti o n
c o d e d
fo r jo
in t a tt e n ti o n
(i n it ia
ti o n s
a n d
re s p o n s e s )
S ig
n ifi
c a n tl y
g re
a te
r g a in
s in
re s p o n s iv
e n e s s
to jo
in t a tt e n ti o n
fo r
th e
tr e a tm
e n t g ro
u p
(p <0
.0 5 ).
N o
s ig
n ifi
c a n t d if fe
re n c e s
m e a s u re
d
in in
it ia
ti o n s
o f jo
in t a tt
e n ti o n .
1 5
m in
u te
c a re
g iv
e r-
c h il d
in te
ra c ti o n
c o d e d
fo r e n g a g e m
e n t s ta
te s
(u n e n g a g e d /o
th e r
e n g a g e m
e n t,
o b je
c t e n g a g e m
e n t,
jo in
t
e n g a g e m
e n t)
T re
a tm
e n t g ro
u p
m a d e
s ig
n ifi
c a n t re
d u c ti o n s
in ti m
e s p e n t in
o b je
c t e n g a g e m
e n t c o m
p a re
d
to th
e c o n tr
o ls
(p <0
.0 1 ).
T re
a tm
e n t g ro
u p
m a d e
s ig
n ifi
c a n t in
c re
a s e s
in ti m
e s p e n t
jo in
tl y
e n g a g e d
c o m
p a re
d to
c o n tr
o ls
(p <0
.0 5 ).
N o
s ig
n ifi
c a n t d if fe
re n c e
b e tw
e e n
g ro
u p s
in u n e n g a g e d /o
th e r e n g a g e m
e n t
s ta
te s .
J A
S P
E R
— C
a re
g iv
e r
E d
u c a ti
o n
M o
d u
le :
J o in
t e n g a g e m
e n t w
it h
c a re
g iv
e r
K a s a ri , L a w
to n
[5 6 ] U
S A
T re
a tm
e n t:
4 8
a t e x it , 4 4
a t
fo ll o w
-u p
3 .5 ±
.8 3
In c lu
s io
n : A
S D
d ia
g n o s is
; “L
o w
-r e s o u rc
e d
fa m
il y ”;
A g e d
b e tw
e e n
2 a n d
5 y e a rs
; M
u ll e n
m e n ta
l a g e >1
2 m
o n th
s .
E S
C S
— In
it ia
ti o n
o f jo
in t a tt e n ti o n
s k il ls
B o th
g ro
u p s
s h o w
e d
s ig
n ifi
c a n t
im p ro
v e m
e n ts
im m
e d ia
te ly
fo ll o w
in g
in te
rv e n ti o n
p e ri o d
(p <0
.0 0 1 ).
G a in
s fo
r C
M M
g ro
u p
s ig
n ifi
c a n tl y
g re
a te
r th
a n
C E
M g ro
u p
fo ll o w
in g
in te
rv e n ti o n
p e ri o d
(p =
0 .0
5 ).
E ff e c t
o f tr
e a tm
e n t m
a in
ta in
e d
fo r
b o th
g ro
u p s
a t 1 2
w e e k
fo ll o w
-u p
(p =
0 .0
5 ).
C o n tr
o l:
5 9
a t
e x it , 5 1
a t
fo ll o w
-u p
3 .5
7 ±
.8 5
1 0
m in
u te
c a re
g iv
e r-
c h il d
in te
ra c ti o n
c o d e d
fo r ti m
e s p e n t jo
in tl y
e n g a g e d
B o th
g ro
u p s
s h o w
e d
s ig
n ifi
c a n t
im p ro
v e m
e n ts
im m
e d ia
te ly
fo ll o w
in g
in te
rv e n ti o n
p e ri o d
(p <0
.0 0 1 ).
G a in
s fo
r C
M M
g ro
u p
s ig
n ifi
c a n tl y
g re
a te
r th
a n
C E
M g ro
u p
fo ll o w
in g
in te
rv e n ti o n
p e ri o d
(p <0
.0 0 3 ).
T re
a tm
e n t e ff e c t m
a in
ta in
e d
fo r
C M
M g ro
u p
a t 1 2 -w
e e k
fo ll o w
-u p
(p =
0 .0
2 ),
b u t n o t th
e
C E
M g ro
u p .
Im p
ro v is
a ti
o n
a l m
u s ic
th e ra
p y :
J o in
t
a tt
e n ti o n
b e h a v io
u rs
(e y e -c
o n ta
c t,
tu rn
ta k in
g )
K im
, W
ig ra
m
[5 7 ] K
o re
a
G ro
u p
o n e : 5
G ro
u p
tw o : 5
A ll
p a rt
ic ip
a n ts
:
4 .2
7 ±
1 .0
In c lu
s io
n : A
S D
d ia
g n o s is
E S
C S
S ig
n ifi
c a n t ti m
e x
g ro
u p
in te
ra c ti o n , w
it h
g re
a te
r g a in
s m
a d e
p o s t m
u s ic
th e ra
p y
c o m
p a re
d to
p o s t p la
y s e s s io
n s .
S u
m m
e rM
A X
+ M
in d
R e a d
in g
: S
o c ia
l-
c o m
m u n ic
a ti o n ; F
a c e -e
m o ti o n
re c o g n it io
n
L o p a ta
,
T h o m
e e r
[3 9 ]
U S
A
T re
a tm
e n t:
1 8
C o n tr
o l:
1 8
8 .8
3 ±
1 .4
7
8 .8
3 ±
1 .5
0
In c lu
s io
n : A
S D
d ia
g n o s is
; W
IS C
-I V
s h o rt
fo rm
IQ >7
0 ; W
IS C
-I V
V C
I o r
P R
I �
8 0 ; E
x p re
s s iv
e
o r
re c e p ti v e
la n g u a g e
o n
th e
C A
S L �
8 0
C a m
b ri d g e
M in
d re
a d in
g F
a c e -V
o ic
e B
a tt e ry
fo r C
h il d re
n (C
A M
-C )
S ig
n ifi
c a n t ti m
e x
tr e a tm
e n t c o n d it io
n e ff e c t
fa v o u ri n g
S u m
m e rM
A X
+ M
in d
R e a d in
g
g ro
u p
fo r
F a c e s
s c o re
o n ly
.
E m
o ti o n
R e c o g n it io
n D
is p la
y S
u rv
e y
(E R
D S
)
S ta
ti s ti c a ll y
s ig
n ifi
c a n t c h a n g e s
m e a s u re
d in
a ll
g ro
u p s . N
o s ta
ti s ti c a ll y
s ig
n ifi
c a n t
d if fe
re n c e s
in c h a n g e s
m a d e
b e tw
e e n -
g ro
u p s .
S o c ia
l E
m o ti o n a l E
v a lu
a ti o n
S ta
ti s ti c a ll y
s ig
n ifi
c a n t c h a n g e s
in R
e c e p ti v e
s c o re
s m
e a s u re
d in
a ll
g ro
u p s . N
o s ta
ti s ti c a ll y
s ig
n ifi
c a n t d if fe
re n c e s
in c h a n g e s
m a d e
b e tw
e e n -g
ro u p s .
S k il
ls tr
e a m
in g
: F
a c e -e
m o ti o n
re c o g n it io
n
L o p a ta
,
T h o m
e e r
[3 8 ]
U S
A
T re
a tm
e n t:
1 8
C o n tr
o l:
1 8
9 .3
9 ±
1 .7
2
9 .5
6 ±
1 .5
4
In c lu
s io
n : H
F A
S D
d ia
g n o s is
; W
IS C
-I V
s h o rt
fo rm
IQ >7
0 ; W
IS C
-I V
V C
I o r
P R
I �
8 0 ;
E x p re
s s iv
e o r
re c e p ti v e
la n g u a g e
o n
th e
C A
S L �
8 0
D A
N V
A 2
A N
C O
V A
re s u lt s
b e c a m
e n o n -s
ig n ifi
c a n t a ft e r
a p p li c a ti o n
o f B
o n fe
rr o n i c o rr
e c ti o n .
E m
o ti
o n
R e c o
g n
it io
n T
ra in
in g
:
E m
o ti o n
re c o g n it io
n th
ro u g h
fa c ia
l
e x p re
s s io
n
R y a n
a n d
C h a rr
a g a in
[5 8 ]
Ir e la
n d
T re
a tm
e n t:
2 0
C o n tr
o l:
1 0
9 .2
5 ±
1 .8
3
1 0 .5
8 ±
2 .0
8
In c lu
s io
n : N
o t s p e c ifi
e d . E
x c lu
s io
n : E
R T
s c o re
<8 0 %
; D
if fi c u lt y
w it h
c o m
p re
h e n s io
n o f
e m
o ti o n
la b e ls
E R
T Im
p ro
v e m
e n ts
m a d e
b y
th e
tr e a tm
e n t g ro
u p
w e re
s ig
n ifi
c a n tl y
la rg
e r th
a n
th o s e
o f th
e
c o n tr
o ls
. G
a in
s w
e re
m a in
ta in
e d
a t 3
m o n th
fo ll o w
-u p
fo r
2 5
p a rt
ic ip
a n ts
m e a s u re
d .
S e a v e r-
N E
T T
: N
o n v e rb
a l
c o m
m u n ic
a ti o n ; E
m o ti o n
re c o g n it io
n
S o o ry
a , S
ip e r
[5 9 ] U
S A
T re
a tm
e n t:
3 5
C o n tr
o l:
3 4
1 0 .0
5 ±
1 .2
7
9 .8
7 ±
1 .3
2
In c lu
s io
n : A
S D
d ia
g n o s is
; A
g e d
8 – 1 1
y e a rs
;
V e rb
a l IQ
s c o re >7
0 . E
x c lu
s io
n :
C o m
m e n c e m
e n t o f p s y c h ia
tr ic
m e d ic
a ti o n
3 0
d a y s
p ri o r to
s c re
e n in
g ; K
n o w
n g ro
s s
s tr
u c tu
ra l
a b n o rm
a li ti e s
o f th
e b ra
in ; A
c ti v e
s e iz
u re
d is
o rd
e r;
A g g re
s s io
n to
w a rd
s o th
e rs
S o c ia
l b e h a v io
u r c o m
p o s it e
c o m
p ri s e d
o f
th e
fo ll o w
in g : S
R S
, C
C C
-2 , a n d
G ri ffi
th
E m
p a th
y M
e a s u re
S ta
ti s ti c a ll y
s ig
n ifi
c a n t im
p ro
v e m
e n ts
fo ll o w
in g
in te
rv e n ti o n
c o m
p a re
d to
th e
c o n tr
o l
g ro
u p . N
o s ig
n ifi
c a n t in
im p ro
v e m
e n ts
m e a s u re
d b e tw
e e n
g ro
u p s
a t 1 2 -w
e e k
fo ll o w
-
u p .
(C o n ti n u e d
)
Pragmatic language interventions for children with ASD
PLOS ONE | https://doi.org/10.1371/journal.pone.0172242 April 20, 2017 11 / 37
T a b
le 2 .
(C o n ti n u e d
)
T re
a tm
e n
t/ T
a rg
e t
S k il ls
R e fe
re n
c e ,
L o
c a ti
o n
P a rt
ic ip
a n
t
g ro
u p
s (N
)
A g
e Y
e a rs
(M e a n ±
S D
)
In c lu
s io
n /E
x c lu
s io
n C
ri te
ri a
P ra
g m
a ti
c L
a n
g u
a g
e O
u tc
o m
e M
e a s u
re T
re a tm
e n
t O
u tc
o m
e
M in
d R
e a d
in g
[6 0 ]:
F a c ia
l e x p re
s s io
n
d e c o d in
g ; P
ro s o d y
d e c o d in
g
T h o m
e e r,
S m
it h
[4 0 ] U
S A
T re
a tm
e n t:
2 2
C o n tr
o l:
2 1
8 .5
7 ±
1 .1
6
8 .8
6 ±
1 .3
9
In c lu
s io
n : A
S D
d ia
g n o s is
; W
IS C
-I V
s h o rt
fo rm
IQ >7
0 ; W
IS C
-I V
V C
I o r
P R
I �
8 0 ; C
A S
L s h o rt
fo rm
e x p re
s s iv
e o r
re c e p ti v e
s c o re �
8 0
C a m
b ri d g e
M in
d re
a d in
g F
a c e -V
o ic
e B
a tt e ry
fo r C
h il d re
n (C
A M
-C )
In te
rv e n ti o n
g ro
u p
h a d
s ig
n ifi
c a n tl y
h ig
h e r
F a c e
a n d
V o ic
e s c o re
s th
a n
c o n tr
o ls
a t p o s t-
te s t a n d
5 -w
e e k
fo ll o w
-u p .
E m
o ti o n
R e c o g n it io
n D
is p la
y S
u rv
e y
(E R
D S
)
In te
rv e n ti o n
g ro
u p
h a d
s ig
n ifi
c a n tl y
h ig
h e r
E x p re
s s iv
e s c o re
s th
a n
c o n tr
o ls
a t p o s t-
te s t,
a n d
s ig
n ifi
c a n tl y
h ig
h e r E
x p re
s s iv
e a n d
R e c e p ti v e
s c o re
s a t 5 -w
e e k
fo ll o w
-u p .
S R
S In
te rv
e n ti o n
g ro
u p
h a d
s ig
n ifi
c a n tl y
lo w
e r
s c o re
s (i .e
. fe
w e r s y m
p to
m s ) th
a n
c o n tr
o ls
a t
5 -w
e e k
fo ll o w
-u p
b u t n o t p o s t-
te s t.
N o te
s : R
C T
= R
a n d o m
is e d
C o n tr
o ll e d
T ri a l,
A S
D =
A u ti s m
S p e c tr
u m
D is
o rd
e r,
W IS
C -I
II =
W e c h s le
r In
te ll ig
e n c e
S c a le
fo r
C h il d re
n (T
h ir d
E d it io
n ),
m C
B R
S =
M o d ifi
e d
C h il d
B e h a v io
r
R a ti n g
S c a le
, P
L S
= P
re s c h o o l L a n g u a g e
S c a le
IV , C
A S
L =
C o m
p re
h e n s iv
e A
s s e s s m
e n t o f S
p o k e n
L a n g u a g e , M
L U
m =
M e a n
L e n g th
o f U
tt e ra
n c e
in m
o rp
h e m
e s , W
A S
I =
, S
R S
= ,
A B
A S
= , N
E P
S Y
= A
D e v e lo
p m
e n ta
l N
E u ro
P S
Y c h o lo
g ic
a l A
s s e s s m
e n t,
M F
I =
M e m
o ry
fo r F
a c e s
Im m
e d ia
te , M
F D
= M
e m
o ry
fo r
F a c e s
D e la
y e d , T
O M
= T
h e o ry
o f M
in d ,
W IS
C -I
V =
W e c h s le
r In
te ll ig
e n c e
S c a le
fo r
C h il d re
n (F
o u rt
h E
d it io
n ),
S R
S =
S o c ia
l R
e s p o n s iv
e n e s s
S c a le
, E
S C
S =
E a rl y
S o c ia
l C
o m
m u n ic
a ti o n
S c a le
s , A
D O
S =
A u ti s m
D ia
g n o s ti c
O b s e rv
a ti o n
S c h e d u le
, C
S B
S -D
P =
C o m
m u n ic
a ti o n
a n d
S y m
b o li c
B e h a v io
r S
c a le
s —
D e v e lo
p m
e n ta
l P
ro fi le
, S
C Q
= S
o c ia
l C
o m
m u n ic
a ti o n
Q u e s ti o n n a ir e , A
B C
-C =
A b e rr
a n t
B e h a v io
r C
h e c k li s t—
C o m
m u n it y , D
A N
V A
-2 =
D ia
g n o s ti c
A n a ly
s is
o f N
o n v e rb
a l A
c c u ra
c y
(S e c o n d
E d it io
n ),
E R
T =
E m
o ti o n
R e c o g n it io
n T
e s t,
C C
C -2
= C
h il d re
n ’s
C o m
m u n ic
a ti o n
C h e c k li s t (S
e c o n d
E d it io
n ),
S C
E R
T S
= S
o c ia
l C
o m
m u n ic
a ti o n , E
m o ti o n a l R
e g u la
ti o n , T
ra n s a c ti o n a l S
u p p o rt
s , M
S E
L =
M u ll e n
S c a le
o f E
a rl y
L e a rn
in g
h tt
p s :/ /d
o i.o
rg /1
0 .1
3 7 1 /j o u rn
a l. p o n e .0
1 7 2 2 4 2 .t 0 0 2
Pragmatic language interventions for children with ASD
PLOS ONE | https://doi.org/10.1371/journal.pone.0172242 April 20, 2017 12 / 37
T a b
le 3 .
P ra
g m
a ti
c la
n g
u a g
e in
te rv
e n
ti o
n c h
a ra
c te
ri s ti
c s .
In te
rv e n
ti o
n /P
ra g
m a ti
c
L a n
g u
a g
e S
k il ls
T a rg
e te
d
P ro
c e d
u re
In te
rv e n
ti o
n is
ts D
u ra
ti o
n a n
d S
e tt
in g
/M o
d e
o f
d e li v e ry
T a il o
ri n
g /M
o d
ifi c a ti
o n
s
T J D
P [4
1 ]
P a re
n ts
tr a in
e d
in u s e
o f T
J D
P (c
o m
p u te
r
g a m
e fa
c il it a ti n g
p ra
c ti c e
in d e c o d in
g
e m
o ti o n s
fr o m
n o n -v
e rb
a l c u e s , a n d
s e le
c ti n g
a p p ro
p ri a te
re a c ti o n s ).
P a re
n t fa
c il it a te
s
c h il d ’s
u s e
o f T
J D
P . C
h il d re
n p a rt
ic ip
a te
in
g ro
u p
a c ti v it ie
s to
g e n e ra
li s e
T J D
P c o n te
n t
a n d
le a rn
a d d it io
n a l s o c ia
l a n d
p ro
b le
m -
s o lv
in g
s k il ls
. P
a re
n ts
a tt e n d
c o n c u rr
e n t
tr a in
in g
in s k il ls
th a t c h il d re
n a re
le a rn
in g .
D e te
c ti o n
o f e m
o ti o n s
v ia
n o n -v
e rb
a l c u e s ,
p ra
c ti c e
o f re
la x a ti o n
te c h n iq
u e s , ‘p
la y
d a te
s ’
w it h
p e e rs
a n d
c o m
p le
ti o n
o f ‘S
e c re
t A
g e n t
J o u rn
a l’
c o m
p le
te d
a t h o m
e . T
o k e n
e c o n o m
y
u s e d
in s e s s io
n to
re w
a rd
a p p ro
p ri a te
b e h a v io
u r
a n d
c o m
p le
ti o n
o f h o m
e p ra
c ti c e .
T h e ra
p is
t: P
o s tg
ra d u a te
c li n ic
a l
p s y c h o lo
g y
a n d
c o u n s e ll in
g
s tu
d e n ts
, a n d
th e
c h ie
f
in v e s ti g a to
r; P
a re
n t
1 4
h o u rs
+ h o m
e p ra
c ti c e : 1
x 2 -h
o u r
c li n ic
s e s s io
n /w
e e k
fo r
7 w
e e k s . C
li n ic
: c o m
p u te
r
p ro
g ra
m , g ro
u p
th e ra
p y
(3 c h il d re
n a n d
2
th e ra
p is
ts ),
p a re
n t tr
a in
in g ; H
o m
e : h o m
e
p ra
c ti c e
N o n e
d e s c ri b e d .
E m
o ti o n
re c o g n it io
n
th ro
u g h
g e s tu
re ,
p o s tu
re , p ro
s o d y
In it ia
ti n g
a n d
m a in
ta in
in g
a c o n v e rs
a ti o n
M E
H R
I T
re a tm
e n
t [4
2 ,
4 3 ]
N o
d e s c ri p ti o n
o f in
te rv
e n ti o n
m a te
ri a ls
o r
te c h n iq
u e s
p ro
v id
e d . T
h e ra
p is
ts c o a c h e d
fa m
il ie
s o n
h o w
b e s t to
fa c il it a te
in te
ra c ti o n
a n d
c o m
m u n ic
a ti o n
w it h
th e ir
c h il d . F
ir s t h o u r
s p e n t w
it h
o n e
th e ra
p is
t, th
e n
1 5 – 2 0
m in
u te
b re
a k
fo r c h il d
w h il e
th e ra
p is
t c o n s u lt e d
w it h
p a re
n t re
g a rd
in g
th e
th e ra
p y . F
in a l h o u r
s p e n t
w it h
a s e c o n d
th e ra
p is
t. C
a re
g iv
e r
s p e n d s
3
h o u rs
p e r
d a y
in te
ra c ti n g
w it h
c h il d
a w
a y
fr o m
c li n ic
, a n d
m e t w
it h
th e ra
p is
t to
d is
c u s s
p ro
g re
s s
a n d
re v ie
w v id
e o ta
p e s
c h il d -
c a re
g iv
e r
p la
y s e s s io
n s
e v e ry
8 w
e e k s .
T h e ra
p is
ts : s p e e c h
p a th
o lo
g is
ts
a n d
o c c u p a ti o n a l th
e ra
p is
ts
1 0 4
h o u rs
in c li n ic
; 1 0 9 5
h o u rs
a t h o m
e : 1
x
2 -h
o u r
c li n ic
s e s s io
n /w
e e k
fo r 1 2
m o n th
s ; 3
h o m
e p ra
c ti c e
h o u rs
/d a y . C
li n ic
: o n e -o
n -o
n e
th e ra
p y ; H
o m
e : p a re
n t in
te ra
c ti o n
w it h
c h il d
a t h o m
e
E a c h
c h il d
a s s e s s e d
b y
th e ra
p is
t a n d
s tr
a te
g ie
s a p p ro
p ri a te
fo r th
e in
d iv
id u a l c h il d
a n d
fa m
il y
id e n ti fi e d
to a d d re
s s
s tr
e n g th
s a n d
c h a ll e n g e s . In
te rv
e n ti o n
id e n ti fi e s
5
d e v e lo
p m
e n ta
l c a p a c it ie
s a n d
th e ra
p is
ts
a tt e m
p t to
e n s u re
c h il d re
n a re
fu n c ti o n in
g
a d e q u a te
ly a t lo
w e r
c a p a c it ie
s b e fo
re
ta rg
e ti n g
la te
r c a p a c it ie
s .
E n g a g e
in c o n v e rs
a ti o n s
o r
p ro
to -c
o n v e rs
a ti o n
s
U s e
id e a s
a n d
la n g u a g e
fu n c ti o n a ll y
B u
il d
in g
B lo
c k s
p ro
g ra
m —
c e n
tr e
b a s e d
[4 4 ]
T h e ra
p is
ts fa
c il it a te
d m
a n u a li s e d
in te
rv e n ti o n
w it h
c h il d re
n . S
e s s io
n p ro
c e d u re
s o r
fo c u s
s k il ls
n o t d e s c ri b e d . T
h e ra
p e u ti c
te c h n iq
u e s
in c lu
d e d
d ir e c t in
te rv
e n ti o n
a n d
le s s
d ir e c te
d
ro u ti n e s . P
a re
n t m
e e ti n g s
o p e ra
te d
c o n c u rr
e n tl y , a ll o w
in g
p a re
n ts
to m
e e t w
it h
p ro
fe s s io
n a ls
a n d
o th
e r
p a re
n ts
, a n d
to fo
rm a
s u p p o rt
n e tw
o rk
. T
o p ic
s in
c lu
d e d
p o s it iv
e
b e h a v io
u r
s u p p o rt
, c o m
m u n ic
a ti o n , s e lf -h
e lp
is s u e s , s c h o o l o p ti o n s , s p e c ia
li s t s e rv
ic e s , a n d
s e n s o ry
is s u e s .
T h e ra
p is
ts : te
a c h e rs
, s p e e c h
p a th
o lo
g is
ts , o c c u p a ti o n a l
th e ra
p is
ts , p s y c h o lo
g is
ts
8 0
h o u rs
fo r
c h il d ; 1 2 0
h o u rs
fo r
p a re
n t:
1 x
2 -h
o u r
c li n ic
s e s s io
n /w
e e k
fo r 4 0
w e e k s ; 1
x
3 -h
o u r
p a re
n t s e s s io
n s /w
e e k
fo r
4 0
w e e k s .
C li n ic
: G
ro u p
th e ra
p y
(4 – 6
c h il d re
n )
a n d
p a re
n t tr
a in
in g
T h e ra
p is
ts w
o rk
e d
w it h
c h il d re
n to
a d d re
s s
in d iv
id u a l n e e d s . P
a re
n t tr
a in
in g
to p ic
s w
h ic
h
w e re
p ri o ri ti s e d
a c c o rd
in g
to in
d iv
id u a l
in te
re s ts
a n d
n e e d s .
F u n c ti o n a l
c o m
m u n ic
a ti o
n
B u
il d
in g
B lo
c k s
p ro
g ra
m —
h o
m e
b a s e d
[4 4 ]
T h e ra
p is
ts v is
it e d
fa m
il y
h o m
e to
im p le
m e n t
in te
rv e n ti o n
w it h
th e
c h il d , a n d
w o rk
w it h
p a re
n t(
s )
to d e v e lo
p s k il ls
in w
o rk
in g
w it h
th e ir
c h il d . F
o c u s in
g o n
p la
y a n d
n a tu
ra l ro
u ti n e s ,
th e ra
p is
t m
o d e l s k il ls
, g iv
e c o n s tr
u c ti v e
fe e d b a c k , a n d
d is
c u s s
is s u e s
im m
e d ia
te to
th e
n e e d s
o f th
e fa
m il y . T
h e ra
p is
t v is
it s
to th
e p re
-
s c h o o l/ d a y -c
a re
to o b s e rv
e th
e c h il d
a n d
p ro
v id
e s tr
a te
g ie
s to
s ta
ff to
s u p p o rt
s k il l
g e n e ra
li s a ti o n
.
T h e ra
p is
ts : te
a c h e rs
, s p e e c h
p a th
o lo
g is
ts , o c c u p a ti o n a l
th e ra
p is
ts , p s y c h o lo
g is
ts
4 0
h o u rs
: 1
x 2 -h
o u r
h o m
e v is
it /f o rt
n ig
h t fo
r
2 0
fo rt
n ig
h ts
. H
o m
e : o n e -o
n -o
n e
th e ra
p y
P ro
g ra
m s
in d iv
id u a li s e d
fo ll o w
in g
c o n s u lt a ti o n s
w it h
p a re
n ts
a n d
o th
e r
p ro
fe s s io
n a ls
in v o lv
e d
in th
e c h il d ’s
p ro
g ra
m .
F u n c ti o n a l
c o m
m u n ic
a ti o
n
(C o n ti n u e d
)
Pragmatic language interventions for children with ASD
PLOS ONE | https://doi.org/10.1371/journal.pone.0172242 April 20, 2017 13 / 37
T a b
le 3 .
(C o n ti n u e d
)
In te
rv e n
ti o
n /P
ra g
m a ti
c
L a n
g u
a g
e S
k il ls
T a rg
e te
d
P ro
c e d
u re
In te
rv e n
ti o
n is
ts D
u ra
ti o
n a n
d S
e tt
in g
/M o
d e
o f
d e li v e ry
T a il o
ri n
g /M
o d
ifi c a ti
o n
s
S E
N S
E T
h e a te
r [4
5 ]
T h e ra
p is
ts a n d
p e e r
a c to
rs a tt e n d e d
2 d a y s
o f
tr a in
in g
in in
te rv
e n ti o n . S
E N
S E
T h e a tr
e
p ro
g ra
m is
m a n u a li s e d . S
e s s io
n s
in it ia
ll y
c o m
p ri s e d
o f th
e a tr
ic a l g a m
e s
a n d
ro le
-
p la
y in
g e x e rc
is e s . A
4 5 -m
in u te
p la
y w
a s
in tr
o d u c e d
in s e s s io
n 3 , a n d
p a rt
ic ip
a n ts
re h e a rs
e d
th e ir
ro le
s w
it h
th e ir
p e e rs
(l e a rn
in g
li n e s , s o n g s
a n d
c h o re
o g ra
p h y , c h a ra
c te
r
d e v e lo
p m
e n t)
fo r
th e
re m
a in
in g
7 w
e e k s .
V id
e o
fo o ta
g e
o f ta
rg e t b e h a v io
u rs
, ro
le -p
la y s
a n d
s o n g s
a c te
d o u t b y
p e e rs
v ie
w e d
b y
p a rt
ic ip
a n ts
a s
h o m
e w
o rk
. T
w o
p u b li c
p e rf
o rm
a n c e s
o f th
e p la
y g iv
e n
a t th
e e n d
o f
in te
rv e n ti o n
p e ri o d .
P e e r:
T y p ic
a ll y
d e v e lo
p in
g (T
D )
c h il d
o f s a m
e g e n d e r
a n d
s im
il a r
a g e
to p a rt
ic ip
a n t.
T h e ra
p is
t:
Q u a li fi c a ti o n s
n o t s p e c ifi
e d
4 0
h o u rs
in c li n ic
; 1 7 .5
h o u rs
a t h o m
e : 1
x
4 -h
o u r
c li n ic
s e s s io
n s /w
e e k
fo r
1 0
w e e k s ; 1
x
1 5 -m
in u te
h o m
e p ra
c ti c e
s e s s io
n s /d
a y
fo r
1 0
w e e k s . C
li n ic
: g ro
u p
th e ra
p y
(1 7
c h il d re
n w
it h
A S
D , 2 3
T D
p e e rs
); H
o m
e : h o m
e p ra
c ti c e
R o le
s in
th e
p la
y w
e re
a s s ig
n e d
b a s e d
o n
in d iv
id u a l fa
c to
rs s u c h
a s
a g e , v e rb
a l a b il it y ,
in te
re s ts
, a n d
ta le
n ts
. E
n g a g e
in d ir e c te
d
c o m
m u n ic
a ti o
n
U s e
g e s tu
re s
a n d
n o n v e rb
a l
c o m
m u n ic
a ti o
n in
d ir e c te
d w
a y s
E m
p a th
ic re
s p o n d in
g
S .S
.G R
IN -H
F A
[4 6 ]
T h e ra
p is
ts fa
c il it a te
d th
e ra
p y
s e s s io
n s
w it h
p a rt
ic ip
a n ts
u s in
g a
c o m
b in
a ti o n
o f d id
a c ti c
in s tr
u c ti o n
a n d
a c ti v e
p ra
c ti c e
(e .g
. ro
le -p
la y ,
h a n d s -o
n a c ti v it ie
s ).
S e s s io
n c o n te
n t d iv
id e d
in to
3 m
o d u le
s (5
s e s s io
n s
p e r
m o d u le
)
c o v e ri n g
c o m
m u n ic
a ti o n , w
o rk
in g
w it h
o th
e rs
a n d
fr ie
n d s h ip
s k il ls
. P
a re
n ts
a tt e n d e d
s e s s io
n s
1 , 5 , 1 0
a n d
1 5 , fa
c il it a te
d h o m
e
p ra
c ti c e , a n d
s u p p o rt
e d
th e
p a rt
ic ip
a n t in
c o m
m u n it y
b a s e d
a c ti v it ie
s .
T h e ra
p is
t: T
ra in
e d
in S
.S .
G R
IN -H
F A
b y
p ro
g ra
m
d e v e lo
p e rs
. Q
u a li fi c a ti o n s
n o t
s p e c ifi
e d . P
a re
n t
1 5
h o u rs
+ h o m
e p ra
c ti c e : 1
x 6 0 -m
in u te
c li n ic
s e s s io
n /w
e e k
fo r
1 5
w e e k s ; T
im e
fo r
h o m
e
a n d
c o m
m u n it y
p ra
c ti c e
n o t s p e c ifi
e d . C
li n ic
:
G ro
u p
th e ra
p y
(2 th
e ra
p is
ts , 2 7
c h il d re
n );
H o m
e : C
o m
m u n it y
b a s e d
p ra
c ti c e
N o n e
d e s c ri b e d .
N o n -v
e rb
a l
c o m
m u n ic
a ti o
n
L is
te n in
g s k il ls
to
e ff e c ti v e ly
fa c il it a te
c o n v e rs
a ti o n
F in
d M
e A
p p
[4 7 ]
P a re
n ts
p ro
v id
e d
w it h
iP a d
a n d
w ri tt e n
in s tr
u c ti o n s
d e a li n g
w it h
w o rk
in g
th e
iP a d
a n d
b a s ic
tr o u b le
s h o o ti n g . C
h il d re
n u s e d
iP a d
a p p
a t h o m
e u n d e r
th e
g u id
a n c e
o f th
e ir
p a re
n ts
.
A c ti v it ie
s c o m
p ri s e d
tw o
p a rt
s : P
a rt
1 ) c h il d
id e n ti fi e s
th e
p e rs
o n
o n
th e
s c re
e n ; P
a rt
2 )
c h il d
id e n ti fi e s
th e
o b je
c t th
a t th
e c h a ra
c te
r o n
th e
s c re
e n
is a tt e n d in
g to
b y
fo ll o w
in g
th e
c h a ra
c te
r’ s
e y e
g a z e
a n d
p o in
ti n g .
P a re
n t
3 0 – 4 0
h o u rs
: 1
x 5
m in
u te
iP a d
s e s s io
n /d
a y
fo r
6 m
o n th
s o r;
3 – 4
x 1 0
m in
u te
iP a d
s e s s io
n s / w
e e k
fo r
6 m
o n th
s . H
o m
e : iP
a d
A p p
L e v e ls
in th
e a p p
in c re
a s e d
in c o m
p le
x it y
a s
c h il d re
n p ro
g re
s s e d : P
a rt
1 )
m o re
d is
tr a c to
rs
o n
s c re
e n , s o m
e th
a t m
o v e ; P
a rt
2 )
c h a ra
c te
r
m o v e d
to lo
o k in
g o n ly
A tt e n d in
g to
p e o p le
F o ll o w
in g
s o c ia
l c u e s
T h
e ra
p e u
ti c
h o
rs e
ri d
in g
[4 8 ]
L e s s o n s
c o m
p ri s e d
tw o
p a rt
s : 1 )
th e ra
p e u ti c
ri d in
g s k il ls
; 2 )
h o rs
e m
a n s h ip
s k il ls
. A
c o n s is
te n t le
s s o n
ro u ti n e
fo ll o w
e d : p u t o n
ri d in
g h e lm
e t,
w a it
o n
b e n c h , m
o u n t h o rs
e ,
ri d in
g a c ti v it ie
s , d is
m o u n t h o rs
e , g ro
o m
h o rs
e ,
a n d
p u t a w
a y
e q u ip
m e n t.
T h e ra
p is
t
C e rt
ifi e d
th e ra
p e u ti c
ri d in
g
in s tr
u c to
r
7 .5
h o u rs
: 1 0
x 4 5
m in
u te
s e s s io
n s / w
e e k
fo r
1 0
w e e k s . C
li n ic
: T
h e ra
p e u ti c
h o rs
e ri d in
g
g ro
u p s
(2 – 4
c h il d re
n a n d
1 v o lu
n te
e r
p e r
c h il d )
N o n e
d e s c ri b e d .
J o in
t a tt e n ti o n
N o n v e rb
a l
c o m
m u n ic
a ti o
n
F a c e S
a y
[4 9 ]
T h e ra
p is
ts tr
a in
e d
c h il d re
n in
th e
u s e
o f
c o m
p u te
r h a rd
w a re
a n d
F a c e S
a y
c o m
p u te
r
p ro
g ra
m fo
r 2
s e s s io
n s , th
e n
fa c il it a te
d
c h il d re
n ’s
u s e
o f th
e p ro
g ra
m . T
h re
e g a m
e s
fr o m
F a c e S
a y
p ro
g ra
m u s e d : 1 ) A
m a z in
g
G a z in
g : to
u c h
o b je
c t o n
th e
s c re
e n
th a t a n
a v a ta
r is
lo o k in
g a t;
2 )
B a n d
A id
C li n ic
: s e le
c t
th e
“b a n d
a id
” th
a t w
o u ld
fi t o v e r
th e
d is
to rt
e d
p a rt
o f a n
a v a ta
r’ s
fa c e
to m
a k e
it w
h o le
; 3 )
F o ll o w
th e
L e a d e r:
id e n ti fy
w h e th
e r
tw o
fa c ia
l
e x p re
s s io
n s
a re
th e
s a m
e o r
d if fe
re n t.
T h e ra
p is
t: In
v e s ti g a to
rs ;
q u a li fi c a ti o n s
n o t s p e c ifi
e d
2 – 5
h o u rs
: 2
x 1 0 – 2 5
m in
u te
s e s s io
n s /w
e e k
fo r
6 w
e e k s ; S
c h o o l:
C o m
p u te
r p ro
g ra
m
L e v e ls
in g a m
e s
in c re
a s e d
in c o m
p le
x it y
a s
c h il d re
n p ro
g re
s s e d : m
o re
d is
tr a c to
rs o n
s c re
e n , c h il d
is a s k e d
to m
a n ip
u la
te fa
c ia
l
e x p re
s s io
n s
to m
a tc
h a
ta rg
e t.
R e s p o n d in
g to
jo in
t
a tt e n ti o n
(C o n ti n u e d
)
Pragmatic language interventions for children with ASD
PLOS ONE | https://doi.org/10.1371/journal.pone.0172242 April 20, 2017 14 / 37
T a b
le 3 .
(C o n ti n u e d
)
In te
rv e n
ti o
n /P
ra g
m a ti
c
L a n
g u
a g
e S
k il ls
T a rg
e te
d
P ro
c e d
u re
In te
rv e n
ti o
n is
ts D
u ra
ti o
n a n
d S
e tt
in g
/M o
d e
o f
d e li v e ry
T a il o
ri n
g /M
o d
ifi c a ti
o n
s
J A
In te
rv e n
ti o
n
(J A
S P
E R
) [5
3 , 5 4 ]
T h e ra
p is
ts w
e re
tr a in
e d
in m
a n u a li s e d
in te
rv e n ti o n
te c h n iq
u e s
p ri o r
to
c o m
m e n c e m
e n t.
S e s s io
n s
b e g a n
w it h
5 – 8
m in
u te
s o f d is
c re
te tr
ia l tr
a in
in g
to p ri m
e fo
r
ta rg
e t tr
e a tm
e n t g o a l a t a
ta b le
. T
h e ra
p is
t th
e n
u s e d
p ro
m p ti n g
a n d
re in
fo rc
e m
e n t in
n a tu
ra ll y
o c c u rr
in g
o p p o rt
u n it ie
s to
s h a p e
ta rg
e te
d s k il l
d u ri n g
s e m
i- s tr
u c tu
re d
fl o o r
s e s s io
n .
T h e ra
p is
t: e d u c a ti o n a l
p s y c h o lo
g y
s tu
d e n ts
1 2 .5
– 1 5
h o u rs
: 1
x 3 0 -m
in u te
c li n ic
s e s s io
n /
d a y
fo r
5 – 6
w e e k s . C
li n ic
: O
n e -o
n -o
n e
th e ra
p y
In d iv
id u a l c h il d
g o a ls
d e te
rm in
e d
b y
o u tc
o m
e s
o f E
S C
S , S
tr u c tu
re d
P la
y
A s s e s s m
e n t a n d
p a re
n t-
c h il d
in te
ra c ti o n .
M a s te
ry o f g o a ls
re a c h e d
w h e n
c h il d
d e m
o n s tr
a te
d th
e g o a l in
3 d if fe
re n t w
a y s
a t
le a s t 3
ti m
e s
a t th
e ta
b le
a n d
o n
th e
fl o o r.
In it ia
ti o n s
o f jo
in t
a tt e n ti o n
(p o in
t, s h o w
,
g iv
e )
R e s p o n s e
to jo
in t
a tt e n ti o n
M o
d ifi
e d
J A
S P
E R
In te
rv e n
ti o
n —
P a re
n t-
c h
il d
d y a d
fo c u
s e d
[5 5 ]
T h e ra
p is
ts fa
c il it a te
d in
te rv
e n ti o n
s e s s io
n s
w it h
p a re
n t-
c h il d
d y a d s
u s in
g p la
y ro
u ti n e s .
S e s s io
n s tr
u c tu
re : P
a rt
1 )
3 0
m in
s o f d ir e c t
in s tr
u c ti o n , m
o d e ll in
g , g u id
e d
p ra
c ti c e , a n d
fe e d b a c k
b y
th e ra
p is
t; P
a rt
2 )
1 0
m in
s o f
c a re
g iv
e r
p ra
c ti c in
g te
c h n iq
u e s
le a rn
t.
H a n d o u ts
fo r
c a re
g iv
e rs
s u m
m a ri z in
g
in te
rv e n ti o n
o b je
c ti v e s .
T h e ra
p is
t: e d u c a ti o n a l
p s y c h o lo
g y
s tu
d e n ts
1 8
h o u rs
: 3
x 4 5 -m
in u te
c li n ic
s e s s io
n s /w
e e k
fo r
8 w
e e k s . C
li n ic
: O
n e -o
n -o
n e
th e ra
p y
B e g in
n in
g p o in
t a n d
m o d u le
s in
d iv
id u a li s e d
a n d
d e te
rm in
e d
b y
in te
ra c ti o n
in in
it ia
l p a re
n t-
c h il d
s e s s io
n .
In it ia
ti n g
jo in
t
e n g a g e m
e n t
In it ia
ti n g
c o m
m u n ic
a ti o n
M o
d ifi
e d
J A
S P
E R
In te
rv e n
ti o
n —
T e a c h
e r
d e li v e re
d [5
1 , 5 2 ]
A m
o d ifi
c a ti o n
o f p re
v io
u s ly
m a n u a li s e d
tr e a tm
e n t (s
e e
J A
S P
E R
[5 3 ])
. T
h e ra
p is
ts
a tt e n d e d
w o rk
s h o p
a n d
5 re
h e a rs
a l s e m
in a rs
to le
a rn
in te
rv e n ti o n
te c h n iq
u e s . T
h e ra
p is
ts
th e n
tr a in
e d
te a c h e rs
in in
te rv
e n ti o n
te c h n iq
u e s . T
e a c h e rs
fa c il it a te
d s e s s io
n s
w it h
p a rt
ic ip
a n ts
a n d
th e ra
p is
ts p ro
v id
e d
w e e k ly
s u p e rv
is io
n to
te a c h e rs
. S
e s s io
n s
s tr
u c tu
re :
P a rt
1 )
5 m
in s
a d u lt -l e a d
p ri m
in g
fo r th
e
ta rg
e te
d J A
-s k il l,
v ia
to y
p re
s e n ta
ti o n ,
p ro
m p ti n g , e x a g g e ra
ti o n
o f s h a re
d in
te re
s t;
P a rt
2 )
1 5
m in
s c h il d -l e a d
fl o o r
p la
y fo
c u s in
g
o n
g e n e ra
li s a ti o n
b y
fo ll o w
in g
th e
c h il d ’s
le a d ,
c re
a ti n g
p la
y ro
u ti n e s , ta
lk in
g a b o u t w
h a t th
e
c h il d
w a s
d o in
g , p ro
m p ts
a n d
re s p o n s e s
to J A
-
s k il ls
.
T e a c h e r;
T h e ra
p is
t: C
h il d
a n d
A d o le
s c e n t M
e n ta
l H
e a lt h
C li n ic
c o u n s e ll o rs
(n o
q u a li fi c a ti o n s
d e s c ri b e d )
2 7
h o u rs
: 2
x 2 0
m in
u te
s e s s io
n s /d
a y
fo r
8
w e e k s . S
c h o o l:
O n e -o
n -o
n e
th e ra
p y
N o n e
d e s c ri b e d .
In it ia
ti o n
o f J o in
t
a tt e n ti o n
(p o in
t, s h o w
g iv
e )
J A
S P
E R
— C
a re
g iv
e r
M e d
ia te
d M
o d
e l [5
6 ]
T h e ra
p is
ts fo
ll o w
e d
m a n u a li s e d
in te
rv e n ti o n
a im
in g
to e s ta
b li s h
d id
a c ti c
e n g a g e m
e n t
b e tw
e e n
c h il d
a n d
c a re
g iv
e r
d u ri n g
th re
e
h o m
e ro
u ti n e s
(p la
y a n d
tw o
o th
e r
e v e ry
d a y
a c ti v it ie
s ).
T h e ra
p is
ts c o a c h e d
p a re
n ts
in
s e tt in
g u p
th e
le a rn
in g
e n v ir o n m
e n t,
m o d e ll in
g
a n d
p ro
m p ti n g
fo r jo
in t a tt e n ti o n , e x p a n d in
g
p la
y a n d
u s in
g d e v e lo
p m
e n ta
ll y
a p p ro
p ri a te
la n g u a g e . A
n e w
s tr
a te
g y
in tr
o d u c e d
e a c h
w e e k . H
a n d o u ts
p ro
v id
e d
to p a re
n ts
e a c h
w e e k .
T h e ra
p is
t: Q
u a li fi c a ti o n s
n o t
s p e c ifi
e d
2 4
h o u rs
: 2
x 1 -h
o u r
h o m
e s e s s io
n s /w
e e k
fo r
1 2
w e e k s . H
o m
e : O
n e -o
n -o
n e
th e ra
p y
N o n e
d e s c ri b e d .
J o in
t e n g a g e m
e n t w
it h
c a re
g iv
e r
J A
S P
E R
— C
a re
g iv
e r
E d
u c a ti
o n
M o
d e l [5
6 ]
P a re
n ts
a tt e n d e d
tr a in
in g
in m
a n u a li s e d
in te
rv e n ti o n . M
a te
ri a l c o v e re
d s im
il a r
to
C a re
g iv
e r
M e d ia
te d
M o d e l (s
e e
K a s a ri , 2 0 1 4
a b o v e )
w it h
a fo
c u s
o n
b e h a v io
u r
m a n a g e m
e n
t, d e v e lo
p in
g ro
u ti n e s
a n d
te a c h in
g c o m
m u n ic
a ti o n . W
e e k ly
h a n d o u ts
p ro
v id
e d
to p a re
n ts
.
T h e ra
p is
t: Q
u a li fi c a ti o n s
n o t
s p e c ifi
e d
2 4
h o u rs
: 1
x 2
h o u rs
s e s s io
n /w
e e k
fo r
1 2
w e e k s . C
li n ic
: P
a re
n t g ro
u p
tr a in
in g
N o n e
d e s c ri b e d .
J o in
t e n g a g e m
e n t w
it h
c a re
g iv
e r
(C o n ti n u e d
)
Pragmatic language interventions for children with ASD
PLOS ONE | https://doi.org/10.1371/journal.pone.0172242 April 20, 2017 15 / 37
T a b
le 3 .
(C o n ti n u e d
)
In te
rv e n
ti o
n /P
ra g
m a ti
c
L a n
g u
a g
e S
k il ls
T a rg
e te
d
P ro
c e d
u re
In te
rv e n
ti o
n is
ts D
u ra
ti o
n a n
d S
e tt
in g
/M o
d e
o f
d e li v e ry
T a il o
ri n
g /M
o d
ifi c a ti
o n
s
Im p
ro v is
a ti
o n
a l m
u s ic
th e ra
p y
[5 7 ]
S e m
i- fl e x ib
le tr
e a tm
e n t m
a n u a l d e v e lo
p e d .
In s tr
u m
e n ts
a v a il a b le
in c lu
d e d
p ia
n o ,
c y m
b a ls
, d ru
m s , x y lo
p h o n e , h a rp
, b e ll s
a n d
s h a k e rs
, h o rn
s a n d
w h is
tl e s . S
e s s io
n
s tr
u c tu
re : P
a rt
1 )
1 5
m in
s u n d ir e c te
d c h il d -l e d
a c ti v it y
w it h
th e ra
p is
t s u p p o rt
in g
a n d
e la
b o ra
ti n g
o n
c h il d ’s
p la
y ; P
a rt
2 ) 1 5
m in
s
d ir e c te
d a c ti v it y
w it h
th e ra
p is
t m
o d e ll in
g tu
rn -
ta k in
g a c ti v it ie
s w
it h in
c h il d ’s
fo c u s
a n d
in te
re s t.
T h e ra
p is
t: m
u s ic
th e ra
p is
ts , p la
y
th e ra
p is
ts , m
u s ic
th e ra
p y
s tu
d e n ts
6 h o u rs
: 1
x 3 0
m in
u te
s e s s io
n s /w
e e k
fo r 1 2
w e e k s . C
li n ic
: O
n e -o
n -o
n e
th e ra
p y
N o n e
d e s c ri b e d .
J o in
t a tt e n ti o n
b e h a v io
u rs
(e y e -c
o n ta
c t,
tu rn
ta k in
g )
S u
m m
e rM
A X
+ M
in d
R e a d
in g
(M R
)
c o
m p
u te
r p
ro g
ra m
[3 9 ]
S e e
S k il ls
tr e a m
in g
fo r
d e s c ri p ti o n
o f s e s s io
n
s tr
u c tu
re a n d
p a re
n t c o m
p o n e n t.
M R
w a s
im p le
m e n te
d in
a d d it io
n to
S k il ls
tr e a m
in g
3
s e s s io
n s
p e r
w e e k , a n d
re p la
c e d
th e
e m
o ti o n
re c o g n it io
n in
s tr
u c ti o n
ty p ic
a ll y
im p le
m e n te
d in
S k il ls
tr e a m
in g .
T h e ra
p is
t: G
ra d u a te
a n d
u n d e rg
ra d u a te
s tu
d e n ts
(d is
c ip
li n e
n o t s p e c ifi
e d )
1 4 5
h o u rs
fo r c h il d ; 7 .5
h o u rs
fo r
p a re
n t:
5 x
7 0
m in
u te
tr e a tm
e n t c y c le
s , 5
d a y s
p e r
w e e k ,
fo r
5 w
e e k s ; 1
x 9 0
m in
u te
p a re
n t tr
a in
in g
s e s s io
n s / w
e e k
fo r
5 w
e e k s . C
li n ic
: G
ro u p
th e ra
p y
(6 c h il d re
n a n d
3 th
e ra
p is
ts )
S e e
S k il ls
tr e a m
in g
a n d
M R
S o c ia
l- c o m
m u n ic
a ti o n
F a c e -e
m o ti o n
re c o g n it io
n
S k il ls
tr e a m
in g
[3 8 ]
M a n u a li s e d
in te
rv e n ti o n . S
e s s io
n s tr
u c tu
re :
P a rt
1 )
2 0
m in
s in
s tr
u c ti o n
in ta
rg e t s k il l;
2 )
5 0
m in
s th
e ra
p e u ti c
a c ti v it y . T
o c o n c lu
d e , e a c h
c h il d
d is
c u s s e d
th e
s o c ia
l s k il ls
th e y
u s e d
to
c o m
p le
te th
e a c ti v it y . A
c ti v it ie
s p ro
v id
e d
p ra
c ti c e
in a n d
re in
fo rc
e d
id e n ti fy
in g
a n d
in te
rp re
ti n g
id io
m s , m
u lt ip
le m
e a n in
g s
o f
c o m
m o n
la n g u a g e , id
e n ti fy
in g
fa c ia
l fe
a tu
re s ,
p o s it io
n s
a n d
p h y s io
lo g ic
a l re
a c ti o n s
th a t
c h a ra
c te
ri s e
d if fe
re n t e m
o ti o n s . S
k il ls
ta rg
e te
d
v ia
d ir e c t in
s tr
u c ti o n , m
o d e ll in
g , ro
le -p
la y in
g ,
fe e d b a c k , a n d
tr a n s fe
r o f le
a rn
in g . A
c o n c u rr
e n t p a re
n t tr
a in
in g
g ro
u p
fo c u s e d
o n
in c re
a s in
g u n d e rs
ta n d in
g o f a u ti s m
a n d
th e
in te
rv e n ti o n
te c h n iq
u e s .
T h e ra
p is
t: e d u c a ti o n
a n d
p s y c h o lo
g y
s tu
d e n ts
1 4 5
h o u rs
fo r c h il d ; 7 .5
h o u rs
fo r
p a re
n t:
5 x
7 0
m in
u te
tr e a tm
e n t c y c le
s , 5
d a y s
p e r
w e e k ,
fo r
5 w
e e k s ; 1
x 9 0
m in
u te
p a re
n t tr
a in
in g
s e s s io
n s / w
e e k
fo r
5 w
e e k s . C
li n ic
: G
ro u p
th e ra
p y
(6 c h il d re
n a n d
3 th
e ra
p is
ts )
a n d
p a re
n t tr
a in
in g .
S o c ia
l s k il ls
w e re
ta u g h t in
a p ro
g re
s s io
n fr
o m
b a s ic
to m
o re
c o m
p le
x . T
h e
s a m
e s k il ls
w e re
ta u g h t to
a ll
p a rt
ic ip
a n ts
; h o w
e v e r,
s k il ls
w e re
ta il o re
d to
p a rt
ic ip
a n t a g e
s o
th a t ta
rg e t s k il ls
re fl e c te
d o f s o c ia
l s it u a ti o n s /d
e m
a n d s
e n c o u n te
re d
b y
c h il d re
n o f v a ri o u s
a g e s .
P ro
g re
s s io
n o f fa
c e -e
m o ti o n
re c o g n it io
n
a c ti v it ie
s : 1 )
id e n ti fi c a ti o n
o f fa
c ia
l
e x p re
s s io
n s
in p ic
tu re
s ; 2 )
e x a m
in a ti o n
o f
o th
e r
c h il d re
n ’s
e x p re
s s io
n s
d u ri n g
a c ti v it ie
s ;
3 )
id e n ti fi c a ti o n
o f p h y s io
lo g ic
a l re
a c ti o n s
a s s o c ia
te d
w it h
d if fe
re n t fa
c ia
l e x p re
s s io
n s .
In d iv
id u a li s e d
d a il y
c o n tr
a c t o f 2 – 3
ta rg
e ts
n o t
c o v e re
d in
th e
c u rr
ic u lu
m .
F a c e -e
m o ti o n
re c o g n it io
n
E m
o ti
o n
re c o
g n
it io
n
tr a in
in g
[5 8 ]
T h e ra
p is
ts fa
c il it a te
d in
te rv
e n ti o n
s e s s io
n s .
S e s s io
n s
c o m
p ri s e d
o f d ir e c t in
s tr
u c ti o n
o n
c o m
p o n e n ts
o f s ix
ta rg
e t fa
c ia
l e x p re
s s io
n s ,
a n d
p ra
c ti c e
o p p o rt
u n it ie
s (e
.g . ro
le p la
y ,
d ra
w in
g , m
a tc
h in
g g a m
e s ).
W o rk
b o o k s
c o m
p le
te d
a s
h o m
e w
o rk
fo ll o w
in g
s e s s io
n s
1 – 3 . P
a re
n ts
e n c o u ra
g e d
to a s s is
t w
it h
h o m
e w
o rk
a n d
a tt e n d
in fo
rm a ti o n
e v e n in
g o n
th e ra
p e u ti c
te c h n iq
u e s .
T h e ra
p is
t: Q
u a li fi c a ti o n s
n o t
s p e c ifi
e d
4 h o u rs
: 1
x 1 -h
o u r
c li n ic
s e s s io
n s /w
e e k
fo r
4
w e e k s . C
li n ic
: o n e -o
n -o
n e
th e ra
p y ; H
o m
e :
h o m
e p ra
c ti c e
N o n e
d e s c ri b e d .
E m
o ti o n
re c o g n it io
n
th ro
u g h
fa c ia
l e x p re
s s io
n
S e a v e r-
N E
T T
[5 9 ]
T re
a tm
e n t fa
c il it a te
d m
a n u a li s e d
in te
rv e n ti o n .
S e s s io
n s tr
u c tu
re : P
a rt
1 )
1 5
m in
s fr
e e -p
la y /
s n a c k
ti m
e ; P
a rt
2 )
6 0
m in
s in
s tr
u c ti o n ; p a rt
3 )
1 5
m in
w ra
p -u
p ti m
e . In
s tr
u c ti o n
fo ll o w
e d
a
m o d u la
r c o g n it iv
e b e h a v io
u ra
l in
te rv
e n ti o n -
b a s e d
c u rr
ic u lu
m v ia
d id
a c ti c
in s tr
u c ti o n ,
re in
fo rc
e m
e n t a c ti v it ie
s , v is
u a l s u p p o rt
s , s k il ls
p ra
c ti c e
a n d
a to
k e n
e c o n o m
y fo
r
re in
fo rc
e m
e n t.
P a re
n t tr
a in
in g
ra n
c o n c u rr
e n tl y
w it h
g ro
u p
th e ra
p y
s e s s io
n s ,
c o v e ri n g
tr e a tm
e n t ra
ti o n a l,
h o m
e w
o rk
re v ie
w
a n d
d is
c u s s io
n .
T h e ra
p is
t: C
li n ic
a l p s y c h o lo
g is
t
a n d
th e ra
p y
a s s is
ta n ts
1 8
h o u rs
fo r
c h il d ; 6
h o u rs
fo r
p a re
n t:
1 x
9 0 -m
in u te
c li n ic
s e s s io
n /w
e e k
fo r 1 2
w e e k s ; 1
x 3 0 -m
in u te
p a re
n t s e s s io
n s /w
e e k
fo r 1 2
w e e k s . C
li n ic
: g ro
u p
th e ra
p y
(4 – 6
c h il d re
n ,
2 – 3
in te
rv e n ti o n is
ts ) a n d
p a re
n t tr
a in
in g
C o n s id
e ra
ti o n
fo r
in d iv
id u a li s a ti o n
d e s c ri b e d
in re
fe re
n c e
to m
a n u a l c o n te
n t,
b u t
p ro
c e d u re
s n o t s p e c ifi
e d .
N o n v e rb
a l
c o m
m u n ic
a ti o
n
E m
o ti o n
re c o g n it io
n
(C o n ti n u e d
)
Pragmatic language interventions for children with ASD
PLOS ONE | https://doi.org/10.1371/journal.pone.0172242 April 20, 2017 16 / 37
T a b
le 3 .
(C o n ti n u e d
)
In te
rv e n
ti o
n /P
ra g
m a ti
c
L a n
g u
a g
e S
k il ls
T a rg
e te
d
P ro
c e d
u re
In te
rv e n
ti o
n is
ts D
u ra
ti o
n a n
d S
e tt
in g
/M o
d e
o f
d e li v e ry
T a il o
ri n
g /M
o d
ifi c a ti
o n
s
M in
d R
e a d
in g
(M R
)
c o
m p
u te
r p
ro g
ra m
[4 0 ]
T h e ra
p is
ts a tt e n d e d
8 h o u rs
o f tr
a in
in g
in
in te
rv e n ti o n
p ro
to c o l,
a n d
w e re
re q u ir e d
to
p a s s
e x a m
. S
e s s io
n s tr
u c tu
re : 1 )
M R
tr a in
in g :
a u d io
-v is
u a l s ti m
u li
o f v o ic
e s
a n d
fa c e s
te a c h
c h il d re
n to
re c o g n is
e 4 1 2
s im
p le
a n d
c o m
p le
x
e m
o ti o n s
th ro
u g h
o b s e rv
a ti o n
o f e m
o ti o n
e x p re
s s io
n s , s tr
u c tu
re d
le s s o n s , q u iz
z e s ,
“g a m
e s ”
fo r
a d d it io
n a l p ra
c ti c e , a n d
re w
a rd
s ;
2 )
in v iv
o re
h e a rs
a l tr
ia ls
p re
s e n te
d a t 5
in te
rv a ls
d u ri n g
s e s s io
n s
p ro
v id
e a d d it io
n a l
p ra
c ti c e
a t d e c o d in
g a n d
e n c o d in
g ta
rg e t
e x p re
s s io
n s
o n o -o
n -o
n e
w it h
a th
e ra
p is
t; 3 )
a
“p o in
ts ”
s y s te
m to
re w
a rd
e d
b e h a v io
u r
a n d
d e c o d in
g /e
n c o
d in
g s k il ls
.
T h e ra
p is
t: e d u c a ti o n
a n d
p s y c h o lo
g y
s tu
d e n ts
3 6
h o u rs
: 2
x 9 0 -m
in u te
c li n ic
s e s s io
n s /w
e e k
fo r
1 2
w e e k s . C
li n ic
: c o m
p u te
r p ro
g ra
m , o n e -
o n -o
n e
in v iv
o re
h e a rs
a l tr
ia ls
.
N o n e
d e s c ri b e d .
F a c ia
l e x p re
s s io
n
d e c o d in
g
P ro
s o d y
d e c o d in
g
h tt
p s :/ /d
o i. o rg
/1 0 .1
3 7 1 /j o u rn
a l. p o n e .0
1 7 2 2 4 2 .t 0 0 3
Pragmatic language interventions for children with ASD
PLOS ONE | https://doi.org/10.1371/journal.pone.0172242 April 20, 2017 17 / 37
to another’s communicative attempts, one measured verbal initiations, one measured fre-
quency of requests, and one coded communicative acts. The five studies that administered
assessments directly to participants all measured emotion recognition via non-verbal cues
such as facial expression, posture, gesture or prosody. All parent report surveys measured
capacity for reciprocal social communication.
Results reported. Pre-post data were reported in 20 papers, with Kaale, Fagerland [52]
reporting on the 12-month follow-up data from the study originally reported by Kaale, Smith
[51]. Follow-up data were presented in nine papers, with time frames ranging from 5-weeks to
12-months post cessation of intervention. Lawton and Kasari [54] reported on results collected
from the same sample following the same course of intervention as Kasari, Freeman [53], but
using an alternative outcome measure at four time points: pre, post, 6-month follow-up and
12-month follow-up. Casenhiser, Shanker [42] and Casenhiser, Binns [43] also reported results
from the same intervention study, with the latter presenting a re-analysis of the video data col-
lected for an alternative purpose. The treatment outcome(s) for each study is presented in
Table 3.
Interventions. A detailed description of each intervention is provided in Table 3. Twenty
different intervention programs were reported across the 21 studies, although four were vari-
ous modifications of the Joint Attention, Symbolic Play and Engagement Regulation [JASPER]
Table 4. Pragmatic language skills targeted by included interventions.
Intervention Pragmatic language skills
Preverbal
pragmatic
language
Introduction and
responsiveness
Nonverbal
comm.
Social Emotional
attunement
Executive
Function
Negotiation
TJDP [41] ♦ ♦ MEHRI Treatment [42, 43] ♦ ♦ ♦ SENSE Theater [45] ♦ ♦ ♦ S.S.GRIN-HFA [46] ♦ ♦ ♦ FindMe App [47] ♦ ♦ Therapeutic Horse-riding [48] ♦ ♦ FaceSay [49] ♦ ♦ JA Intervention (JASPER) [53, 54] ♦ ♦ ♦ Modified JASPER Intervention—
Parent-child dyad focused [55]
♦ ♦ ♦
Modified JASPER Intervention—
Teacher delivered [51, 52]
♦ ♦ ♦
JASPER—Caregiver Mediated
Model [56]
♦ ♦
JASPER—Caregiver Education
Model [56]
♦ ♦
Improvisational music therapy [57] ♦ ♦ ♦ SummerMAX + MR [39] ♦ Skillstreaming [38] ♦ Building Blocks program—center
based [44]
♦
Building Blocks program—home
based [44]
♦
Emotion recognition training [58] ♦ Seaver-NETT [59] ♦ Mind Reading (MR) computer
program [40]
♦
https://doi.org/10.1371/journal.pone.0172242.t004
Pragmatic language interventions for children with ASD
PLOS ONE | https://doi.org/10.1371/journal.pone.0172242 April 20, 2017 18 / 37
T a b
le 5 .
M e th
o d
o lo
g ic
a l q
u a li ty
o f in
c lu
d e d
s tu
d ie
s .
S tu
d y
T re
a tm
e n
t C
o n
tr o
l R
a n
d o
m is
a ti
o n
B li n
d in
g M
e th
o d
o lo
g ic
a l
Q u
a li ty
B e a u m
o n t a n d
S o fr
o n o ff
[4 1 ]
T J D
P :
C h il d
fo c u s e d , c o m
p u te
r b a s e d
a c ti v it ie
s w
it h
s m
a ll
g ro
u p
th e ra
p y
W a it -l is
te d
c o n tr
o l
R a n d o m
is a ti o n
re p o rt
e d
b u t p ro
c e d u re
n o t
d e s c ri b e d .
N o
b li n d in
g o f p a rt
ic ip
a n ts
o r
in v e s ti g a to
rs
re p o rt
e d .
G o o d
q u a li ty
: 7 5 %
C a s e n h is
e r,
S h a n k e r
[4 2 ]
M E
H R
I T
re a tm
e n
t: P
a re
n t a n d
c h il d
fo c u s e d , s o c ia
l- in
te ra
c ti o n
b a s e d
th e ra
p y
C o m
m u n it y
tr e a tm
e n t
c o n tr
o l
R a n d o m
is a ti o n
s tr
a ti fi e d
b y
a g e , la
n g u a g e
a n d
c o g n it io
n le
v e l a t e n tr
y . R
a n d o m
n u m
b e r
g e n e ra
to r
u s e d
to a s s ig
n p a rt
ic ip
a n ts
to g ro
u p s
fo ll o w
in g
s c re
e n in
g .
N o
b li n d in
g o f p a rt
ic ip
a n ts
o r
th e ra
p is
ts re
p o rt
e d .
C o d in
g o f in
te ra
c ti o n s
c o m
p le
te d
b y
in d e p e n d e n t c o d e rs
w h o
w e re
b li n d
to
in te
rv e n ti o n
g ro
u p . B
li n d in
g to
te s ti n g
ti m
e n o t
re p o rt
e d .
G o o d
q u a li ty
: 7 5 %
C a s e n h is
e r,
B in
n s
[4 3 ]
M E
H R
I T
re a tm
e n
t: P
a re
n t a n d
c h il d
fo c u s e d , s o c ia
l- in
te ra
c ti o n
b a s e d
th e ra
p y
C o m
m u n it y
tr e a tm
e n t
c o n tr
o l
R a n d o m
is a ti o n
s tr
a ti fi e d
b y
a g e , la
n g u a g e
a n d
c o g n it io
n le
v e l a t e n tr
y . R
a n d o m
n u m
b e r
g e n e ra
to r
u s e d
to a s s ig
n p a rt
ic ip
a n ts
to g ro
u p s
fo ll o w
in g
s c re
e n in
g .
N o
b li n d in
g o f p a rt
ic ip
a n ts
o r
th e ra
p is
ts re
p o rt
e d .
C o d in
g o f c o m
m u n ic
a ti o n
a c ts
c o m
p le
te d
b y
in d e p e n d e n t c o d e rs
, w
it h
v id
e o s
n u m
b e re
d to
d is
g u is
e g ro
u p
a s s ig
n m
e n t a n d
te s ti n g
ti m
e .
A d e q u a te
q u a li ty
:
6 4 %
C o rb
e tt , K
e y
[4 5 ]
S E
N S
E T
h e a te
r: C
h il d
fo c u s e d , th
e a tr
e
b a s e d
g ro
u p
th e ra
p y
W a it -l is
te d
c o n tr
o l
R a n d o m
is a ti o n
re p o rt
e d
b u t p ro
c e d u re
n o t
d e s c ri b e d .
N o
b li n d in
g o f p a rt
ic ip
a n ts
o r
in v e s ti g a to
rs
re p o rt
e d .
A d e q u a te
q u a li ty
:
6 1 %
D e R
o s ie
r,
S w
ic k
[4 6 ]
S .S
.G R
IN -H
F A
: C
h il d
fo c u s e d ,
c o g n it iv
e b e h a v io
u ra
l a n d
s o c ia
l
le a rn
in g
b a s e d
g ro
u p
th e ra
p y
a d a p te
d
to fo
c u s
o n
s o c ia
l c h a ll e n g e s
p e rt
in e n t
in A
S D
C h il d
fo c u s e d ,
c o g n it iv
e b e h a v io
u ra
l
a n d
s o c ia
l le
a rn
in g
b a s e d
g ro
u p
th e ra
p y
R a n d o m
is a ti o n
re p o rt
e d
b u t p ro
c e d u re
n o t
d e s c ri b e d .
N o
b li n d in
g o f p a rt
ic ip
a n ts
o r
in v e s ti g a to
rs
re p o rt
e d .
A d e q u a te
q u a li ty
:
5 7 %
F le
tc h e r-
W a ts
o n ,
P e tr
o u
[4 7 ]
F in
d M
e A
p p
: C
h il d
fo c u s e d
iP a d
a p p
T re
a tm
e n t a s
u s u a l
c o n tr
o l
R a n d o m
is a ti o n
s tr
a ti fi e d
b y
A D
O S
s o c ia
l
c o m
m u n ic
a ti o n
s c o re
. B
lo c k
ra n d o m
is a ti o n
w it h
v a ry
in g
a n d
ra n d o m
ly o rd
e re
d b lo
c k
s iz
e
p ro
d u c e d
b y
in d e p e n d e n t re
s e a rc
h e r.
B a s e li n e
a s s e s s m
e n ts
a d m
in is
te re
d a n d
s c o re
d
b y
fi rs
t a u th
o r
p ri o r
to g ro
u p
a ll o c a ti o n .
P a rt
ic ip
a n ts
a n d
in v e s ti g a to
rs n o t b li n d e d
to
g ro
u p
a ll o c a ti o n . P
o s t-
a s s e s s m
e n ts
w e re
p a re
n t
re p o rt
m e a s u re
s a n d
th e re
fo re
n o t b li n d e d .
C o d in
g o f v id
e o s
fo r fo
ll o w
-u p
a s s e s s m
e n t
c o m
p le
te d
b y
in d e p e n d e n t ra
te r,
b li n d
to g ro
u p
a ll o c a ti o n .
A d e q u a te
q u a li ty
:
6 8 %
G a b ri e ls
, P
a n
[4 8 ]
T h
e ra
p e u
ti c
H o
rs e -r
id in
g :
C h il d
fo c u s e d , th
e ra
p e u ti c
h o rs
e ri d in
g
in te
rv e n ti o n
B a rn
a c ti v it ie
s S
tr a ti fi e d
b y
n o n v e rb
a l IQ
b y
p ro
je c t’ s
s ta
ti s ti c ia
n u s in
g s iz
e 4
b lo
c k
ra n d o m
is a ti o n .
R a ti n g s
o f s o c ia
l c o m
m u n ic
a ti o n
c o m
p le
te d
b y
c a re
g iv
e r
a n d
th e re
fo re
u n b li n d e d . B
li n d in
g o f
th e ra
p is
ts a n d
p a rt
ic ip
a n ts
n o t re
p o rt
e d .
A d e q u a te
q u a li ty
:
6 4 %
H o p k in
s ,
G o w
e r
[4 9 ]
F a c e S
a y :
C h il d
fo c u s e d , c o m
p u te
r
b a s e d
in te
rv e n ti o n
C o m
p u te
r b a s e d
d ra
w in
g p ro
g ra
m
R a n d o m
is a ti o n
re p o rt
e d
b u t p ro
c e d u re
n o t
d e s c ri b e d .
N o
b li n d in
g o f p a rt
ic ip
a n ts
o r
in v e s ti g a to
rs
re p o rt
e d
fo r p ra
g m
a ti c
la n g u a g e
o u tc
o m
e
m e a s u re
s .
P o o r
q u a li ty
: 4 6 %
K a a le
, S
m it h
[5 1 ]
M o
d ifi
e d
J A
S P
E R
In te
rv e n
ti o
n —
T e a c h
e r
d e li v e re
d :
T e a c h e r
d e li v e re
d ,
c h il d
fo c u s e d , jo
in t a tt e n ti o n
in te
rv e n ti o n
O rd
in a ry
p re
-s c h o o l
p ro
g ra
m
R a n d o m
is a ti o n
c o n d u c te
d b y
th e
fi rs
t a u th
o r
fo ll o w
in g
b a s e li n e
a s s e s s m
e n t.
T h e
li s t,
g e n e ra
te d
b y
a n
in d e p e n d e n t s ta
ti s ti c ia
n ,
c o n ta
in e d
ra n d o m
b lo
c k s
o f fo
u r
fo r e a c h
s tu
d y
s it e
a n d
w a s
n o t s tr
a ti fi e d . T
h e
li s t w
a s
g e n e ra
te d
s o
a s
to e n s u re
e q u a l d is
tr ib
u ti o n
o f
p a rt
ic ip
a n ts
to b o th
th e
in te
rv e n ti o n
a n d
c o n tr
o l
g ro
u p
a t e a c h
re c ru
it m
e n t s it e .
P a rt
ic ip
a n ts
a n d
in v e s ti g a to
rs b li n d
to tr
e a tm
e n t
g ro
u p
a t b a s e li n e
a s s e s s m
e n t.
V id
e o
c o d in
g fo
r
s o c ia
l c o m
m u n ic
a ti o
n o u tc
o m
e s
c o m
p le
te d
b y
re s e a rc
h a s s is
ta n ts
b li n d e d
to s tu
d y
p u rp
o s e ,
g ro
u p
a ll o c a ti o n
a n d
te s ti n g
ti m
e .
G o o d
q u a li ty
: 7 9 %
K a a le
,
F a g e rl a n d
[5 2 ]
M o
d ifi
e d
J A
S P
E R
In te
rv e n
ti o
n —
T e a c h
e r
d e li v e re
d :
T e a c h e r
d e li v e re
d ,
c h il d
fo c u s e d , jo
in t a tt e n ti o n
in te
rv e n ti o n
O rd
in a ry
p re
-s c h o o l
p ro
g ra
m
R a n d o m
is a ti o n
re p o rt
e d
b u t p ro
c e d u re
n o t
d e s c ri b e d .
B li n d in
g o f p a rt
ic ip
a n ts
a n d
th e ra
p is
ts n o t
re p o rt
e d . V
id e o
c o d in
g fo
r s o c ia
l c o m
m u n ic
a ti o n
o u tc
o m
e s
c o m
p le
te d
b y
re s e a rc
h a s s is
ta n ts
b li n d e d
to s tu
d y
p u rp
o s e , g ro
u p
a ll o c a ti o n
a n d
te s ti n g
ti m
e . A
ll o th
e r
a s s e s s m
e n ts
a d m
in is
te re
d
b y
in d e p e n d e n t re
s e a rc
h e rs
, b li n d
to g ro
u p
a ll o c a ti o n .
G o o d
q u a li ty
: 7 9 %
(C o n ti n u e d
)
Pragmatic language interventions for children with ASD
PLOS ONE | https://doi.org/10.1371/journal.pone.0172242 April 20, 2017 19 / 37
T a b
le 5 .
(C o n ti n u e d
)
S tu
d y
T re
a tm
e n
t C
o n
tr o
l R
a n
d o
m is
a ti
o n
B li n
d in
g M
e th
o d
o lo
g ic
a l
Q u
a li ty
K a s a ri ,
F re
e m
a n
[5 3 ]
J A
In te
rv e n
ti o
n (J
A S
P E
R ):
T h e ra
p is
t
d e li v e re
d , c h il d
fo c u s e d , jo
in t a tt e n ti o n
in te
rv e n ti o n
T re
a tm
e n t a s
u s u a l
c o n tr
o l
R a n d o m
is a ti o n
o f p a rt
ic ip
a n ts
to g ro
u p s
re p o rt
e d
b u t p ro
c e d u re
n o t d e s c ri b e d .
R a n d o m
is a ti o n
o f th
e ra
p is
ts to
tr e a tm
e n t
p ro
c e d u re
a n d
c h il d
re p o rt
e d
b u t p ro
c e d u re
n o t
d e s c ri b e d .
B li n d in
g o f p a rt
ic ip
a n ts
a n d
th e ra
p is
ts n o t
re p o rt
e d . S
ta ff
in th
e in
te rv
e n ti o n
s e tt in
g w
e re
in d e p e n d e n t o f th
e re
s e a rc
h s ta
ff a n d
b li n d
to th
e
s tu
d y
h y p o th
e s e s . V
id e o
c o d in
g fo
r s o c ia
l
c o m
m u n ic
a ti o n
o u tc
o m
e s
c o m
p le
te d
b y
in d e p e n d e n t c o d e rs
b li n d e d
to g ro
u p
a ll o c a ti o n .
S c re
e n in
g a s s e s s m
e n ts
a d m
in is
te re
d b y
in d e p e n d e n t re
s e a rc
h e rs
, b li n d
to s tu
d y
p u rp
o s e
a n d
h y p o th
e s e s .
A d e q u a te
q u a li ty
:
6 1 %
L a w
to n
a n d
K a s a ri
[5 4 ]
J A
In te
rv e n
ti o
n (J
A S
P E
R ):
T h e ra
p is
t
d e li v e re
d , c h il d
fo c u s e d , jo
in t a tt e n ti o n
in te
rv e n ti o n
T re
a tm
e n t a s
u s u a l
c o n tr
o l
R a n d o m
is a ti o n
o f p a rt
ic ip
a n ts
to g ro
u p s
re p o rt
e d
b u t p ro
c e d u re
n o t d e s c ri b e d .
B li n d in
g o f p a rt
ic ip
a n ts
, th
e ra
p is
ts a n d
v id
e o
c o d e rs
n o t re
p o rt
e d . S
c re
e n in
g a s s e s s m
e n ts
a d m
in is
te re
d b y
in d e p e n d e n t re
s e a rc
h e rs
, b li n d
to g ro
u p
a ll o c a ti o n .
A d e q u a te
q u a li ty
:
5 7 %
K a s a ri ,
G u ls
ru d
[5 5 ]
M o
d ifi
e d
J A
S P
E R
In te
rv e n
ti o
n —
P a re
n t-
c h
il d
d y a d
fo c u
s e d
: T
h e ra
p is
t
d e li v e re
d , p a re
n t fo
c u s e d , jo
in t
a tt e n ti o n
in te
rv e n ti o n
W a it -l is
te d
c o n tr
o l
R a n d o m
n u m
b e rs
m e th
o d
u s e d
to ra
n d o m
is e
p a rt
ic ip
a n ts
to c o n d it io
n .
B li n d in
g o f p a rt
ic ip
a n ts
a n d
th e ra
p is
ts n o t
re p o rt
e d . V
id e o
c o d in
g fo
r s o c ia
l c o m
m u n ic
a ti o n
o u tc
o m
e s
c o m
p le
te d
b y
in d e p e n d e n t c o d e rs
b li n d e d
to g ro
u p
a ll o c a ti o n
a n d
te s ti n g
ti m
e .
G o o d
q u a li ty
: 7 1 %
K a s a ri , L a w
to n
[5 6 ]
J A
S P
E R
— C
a re
g iv
e r
E d
u c a ti
o n
M o
d e l:
C a re
g iv
e r
g ro
u p
tr a in
in g , jo
in t
a tt e n ti o n
in te
rv e n ti o n
T re
a tm
e n t a s
u s u a l
R a n d o m
is a ti o n
o f p a rt
ic ip
a n ts
to g ro
u p s
c o n d u c te
d b y
in d e p e n d e n t d a ta
c e n tr
e , b u t
p ro
c e d u re
n o t d e s c ri b e d .
B li n d in
g o f p a rt
ic ip
a n ts
a n d
th e ra
p is
ts n o t
re p o rt
e d . A
s s e s s m
e n ts
a d m
in is
te re
d a t a ll
ti m
e
p o in
ts b y
e x a m
in e rs
b li n d
to tr
e a tm
e n t c o n d it io
n
a n d
s tu
d y
h y p o th
e s e s . A
n a ly
s is
c o n d u c te
d b y
in d e p e n d e n t d a ta
c e n tr
e . V
id e o
c o d in
g fo
r s o c ia
l
c o m
m u n ic
a ti o n
o u tc
o m
e s
c o m
p le
te d
b y
in d e p e n d e n t c o d e rs
b li n d e d
to g ro
u p
a ll o c a ti o n .
A d e q u a te
q u a li ty
:
6 8 %
K im
, W
ig ra
m
[5 7 ]
Im p
ro v is
a ti
o n
a l m
u s ic
th e ra
p y :
T h e ra
p is
t d e li v e re
d , c h il d
fo c u s e d ,
im p ro
v is
a ti o n a l m
u s ic
th e ra
p y
P la
y s e s s io
n s
R a n d o m
is a ti o n
o f p a rt
ic ip
a n ts
to g ro
u p s
re p o rt
e d
b u t p ro
c e d u re
n o t d e s c ri b e d .
B li n d in
g o f p a rt
ic ip
a n ts
a n d
th e ra
p is
ts n o t
re p o rt
e d . V
id e o
c o d in
g fo
r s o c ia
l c o m
m u n ic
a ti o n
o u tc
o m
e s
c o m
p le
te d
b y
in d e p e n d e n t c o d e rs
b li n d e d
to tr
e a tm
e n t c o n d it io
n .
P o o r
q u a li ty
: 3 6 %
L o p a ta
,
T h o m
e e r
[3 8 ]
S k il ls
tr e a m
in g
: T
h e ra
p is
t d e li v e re
d ,
c h il d
fo c u s e d , s o c ia
l s k il ls
g ro
u p
th e ra
p y
W a it -l is
te d
c o n tr
o l
R a n d o m
is a ti o n
s tr
a ti fi e d
o n
a g e , g e n d e r
a n d
e th
n ic
it y . O
n e
re s e a rc
h e r
ra n d o m
ly a s s ig
n e d
n u m
b e rs
to p a rt
ic ip
a n ts
, a n d
a s e c o n d
re s e a rc
h e r
u s e d
a ta
b le
o f ra
n d o m
n u m
b e rs
to
a s s ig
n n u m
e ri c a ll y
id e n ti fi e d
c h il d re
n
N o
b li n d in
g o f p a rt
ic ip
a n ts
, th
e ra
p is
t o r
te s te
rs
re p o rt
e d .
G o o d
q u a li ty
: 7 5 %
L o p a ta
,
T h o m
e e r
[3 9 ]
S u
m m
e rM
A X
+ M
R :
T h e ra
p is
t a n d
c o m
p u te
r d e li v e re
d , c h il d
fo c u s e d ,
g ro
u p
th e ra
p y
T h e ra
p is
t d e li v e re
d ,
c h il d
fo c u s e d , g ro
u p
th e ra
p y
R a n d o m
is a ti o n
o f p a rt
ic ip
a n ts
to g ro
u p s
c o n d u c te
d u s in
g a n
o n li n e
ra n d o m
n u m
b e r
g e n e ra
to r
R e s e a rc
h e rs
a n d
p a rt
ic ip
a n ts
u n a w
a re
o f
tr e a tm
e n t a ll o c a ti o n
a t b a s e li n e
a s s e s s m
e n t.
P o s t-
a s s e s s m
e n ts
c o n d u c te
d b y
re s e a rc
h e rs
b li n d
to s tu
d y
h y p o th
e s is
. B
in d in
g o f th
e ra
p is
ts
n o t re
p o rt
e d .
S tr
o n g
q u a li ty
:
8 2 %
R o b e rt
s ,
W il li a m
s [4
4 ]
B u
il d
in g
B lo
c k s
p ro
g ra
m —
h o
m e
b a s e d
: th
e ra
p is
t d e li v e re
d , c h il d
a n d
p a re
n t fo
c u s e d , h o m
e b a s e d
th e ra
p y .
W a it -l is
te d
c o n tr
o l
R a n d o m
is a ti o n
c o m
p le
te d
u s in
g c o m
p u te
r
g e n e ra
te d
ra n d o m
n u m
b e r
ta b le
s .
N o
b li n d in
g o f p a rt
ic ip
a n ts
, th
e ra
p is
t o r
te s te
rs
re p o rt
e d .
A d e q u a te
q u a li ty
:
6 8 %
B u
il d
in g
B lo
c k s
p ro
g ra
m —
c e n
te r
b a s e d
: T
h e ra
p is
t d e li v e re
d p la
y g ro
u p
a n d
p a re
n t tr
a in
in g .
R y a n
a n d
C h a rr
a g a in
[5 8 ]
E m
o ti
o n
re c o
g n
it io
n tr
a in
in g
:
T h e ra
p is
t d e li v e re
d , c h il d
fo c u s e d ,
e m
o ti o n
re c o g n it io
n th
e ra
p y .
W a it -l is
te d
c o n tr
o l
R a n d o m
is a ti o n
o f p a rt
ic ip
a n ts
to g ro
u p s
re p o rt
e d
b u t p ro
c e d u re
n o t d e s c ri b e d .
B li n d in
g o f p a rt
ic ip
a n ts
a n d
th e ra
p is
ts n o t
re p o rt
e d . P
o s t-
m e a s u re
s a d m
in is
te re
d b y
p s y c h o lo
g is
t w
h o
w a s
b li n d e d
to p re
-s c o re
s . N
o t
re p o rt
e d
w h e th
e r
te s te
r w
a s
b li n d
to tr
e a tm
e n t
a ll o c a ti o n s
a s
w e ll .
A d e q u a te
q u a li ty
:
5 7 %
S o o ry
a , S
ip e r
[5 9 ]
S e a v e r-
N E
T T
: T
h e ra
p is
t d e li v e re
d ,
c h il d
fo c u s e d , g ro
u p
in te
rv e n ti o n
w it h
c o n c u rr
e n t p a re
n t tr
a in
in g .
F a c il it a te
d p la
y
s e s s io
n s
P a rt
ic ip
a n ts
ra n d o m
is e d
b y
c o m
p u te
r g e n e ra
te d
ra n d o m
is a ti o n
in b lo
c k s
o f 1 0 – 1 2
o v e r
7
re c ru
it m
e n t p h a s e s
R a ti n g s
o f s o c ia
l c o m
m u n ic
a ti o n
c o m
p le
te d
b y
c a re
g iv
e r
a n d
th e re
fo re
u n b li n d e d . B
li n d in
g o f
th e ra
p is
ts a n d
p a rt
ic ip
a n ts
n o t re
p o rt
e d .
G o o d
q u a li ty
: 7 5 %
(C o n ti n u e d
)
Pragmatic language interventions for children with ASD
PLOS ONE | https://doi.org/10.1371/journal.pone.0172242 April 20, 2017 20 / 37
T a b
le 5 .
(C o n ti n u e d
)
S tu
d y
T re
a tm
e n
t C
o n
tr o
l R
a n
d o
m is
a ti
o n
B li n
d in
g M
e th
o d
o lo
g ic
a l
Q u
a li ty
T h o m
e e r,
S m
it h
[4 0 ]
M in
d R
e a d
in g
(M R
) c o
m p
u te
r
p ro
g ra
m :
C h il d
fo c u s e d , c o m
p u te
r
b a s e d
in te
rv e n ti o n
w it h
in v iv
o
re h e a rs
a l tr
ia ls
.
W a it -l is
te d
c o n tr
o l
P a rt
ic ip
a n ts
ra n d o m
is e d
to g ro
u p s
u s in
g o n li n e
n u m
b e r
g e n e ra
to r.
B li n d in
g o f p a rt
ic ip
a n ts
a n d
th e ra
p is
ts n o t
re p o rt
e d . N
o d e s c ri p ti o n
p ro
v id
e d
a s
to w
h o
a d m
in is
te re
d p ri m
a ry
m e a s u re
m e n ts
o f s o c ia
l
c o m
m u n ic
a ti o n , a n d
n o
re p o rt
o f te
s te
r b li n d in
g .
S e c o n d a ry
m e a s u re
m e n t o f s o c ia
l
c o m
m u n ic
a ti o n
w a s
c o m
p le
te d
b y
p a re
n ts
v ia
q u e s ti o n n a ir e , a n d
p a re
n ts
c o u ld
n o t b e
b li n d e d
to tr
e a tm
e n t c o n d it io
n .
G o o d
q u a li ty
: 6 8 %
h tt
p s :/ /d
o i. o rg
/1 0 .1
3 7 1 /j o u rn
a l. p o n e .0
1 7 2 2 4 2 .t 0 0 5
Pragmatic language interventions for children with ASD
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intervention initially reported by Kasari, Freeman [53]. Originally a clinic based, therapist
facilitated, individual, child-focused intervention for joint attention skills, JASPER approach
was first modified to include a focus on the parent-child dyad [55]. It was later trialed as a
teacher delivered, school-based intervention [51, 52]. Most recently JASPER was implemented
via two models of parent delivered intervention: 1) Caregiver Mediated Model (CMM); and 2)
Caregiver Education Model (CEM) [56]. Education of the parent was the focus of these
approaches, with CMM being delivered by the therapist to both the child and parent in a one-
on-one setting at home, and CEM delivered in a group setting with parents only. Additionally,
Lopata, Thomeer [39] studied a treatment protocol which combines the intervention
approaches reported on by Lopata, Thomeer [38] and Thomeer, Smith [40].
The mode of delivery and focus subject of the interventions varied across the studies. Prag-
matic language skills were targeted in a group setting in nine intervention protocols. Of those
nine approaches, five were child directed interventions, one focused on educating parents
[56], and three focused on both the children and parents. An individual approach to interven-
tion was taken in 11 studies, of which seven were child focused. The remaining four individual
interventions focused on the child and the parent through direct intervention of the therapist
with the child, along with training parents in therapeutic techniques to support their child. A
combination of group and individual activities were employed in two interventions and both
of these focused on the children only [41, 59].
Clinics were the setting for 15 of the interventions, and five of these also included out of ses-
sion practice either at home or in the community. All clinic based interventions were facili-
tated by a therapist trained in the particular intervention program, with one also utilising the
parent as an interventionist while completing computer based activities [41], and one includ-
ing the use of typically developing peers in the group intervention [45]. Three interventions
were implemented in the child’s home and these were all facilitated by a trained therapist. The
child’s school was the setting for two interventions, with one being a therapist facilitated com-
puter based intervention [49] and the other being facilitated by teachers who were trained in
the intervention procedures by therapists [51, 52].
Interventions varied in frequency (i.e., the number of times the intervention is provided per
day or per week) and total intervention duration (i.e., the time period over which the interven-
tion is presented). The shortest intervention was the Emotion Recognition Intervention [58]
which was conducted over four weeks; totalling four hours of intervention. The longest inter-
vention was the MEHRI treatment [42, 43] implemented over 12 months, totalling 104 clinic
hours and 1,092 home-based hours. Eight of the interventions had a total duration of 10–15
weeks, with the most frequently occurring duration being 12 weeks. Eight interventions were
implemented in fewer than 10 weeks, and four interventions lasted 26 weeks or more. The
intervention with the lowest intensity was the improvisational music therapy [57], which
required 30 minutes of intervention per week. The most intense intervention was Skillstreatm-
ing and SummerMAX + Mind Reading which involved five daily 70-minute treatment
“cycles”, five days per week for five weeks, equating to 29 intervention hours per week [39].
The most common session frequency was weekly, with 11 interventions running weekly ses-
sions with the interventionist. Only two studies reported an expected frequency for home-
practice between sessions, and both interventions required daily practice. Five interventions
ran on at least a daily basis, with a modified JASPER intervention occurring twice daily [51,
52] and Skillstreatming and SummerMAX + Mind occurring five times daily [38]. The least
frequently occurring intervention sessions occurred in the Building Blocks program—home
based [44], with the clinician visiting the participant’s home every other week; no specific prac-
tice between sessions were described.
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A synthesis of the pragmatic language skills targeted by each intervention is provided in
Table 4. The most frequently targeted skill was nonverbal communication with 14 interven-
tions focusing on the use and interpretation of gesture, facial expressions and/or tone of voice.
Introduction and responsiveness was the target of 10 interventions, 10 interventions also tar-
geted preverbal social communication behaviours, and 4 interventions targeted social emo-
tional attunement. No one intervention reported targeting all pragmatic language skills
adopted for this review, and no intervention targeted the skills of executive function or
negotiation.
Control groups. All participants included in control groups had a diagnosis of ASD.
Seven studies assigned control participants to waitlisted control groups who served as a no-
treatment comparison during the intervention phase of the project then went on the receive
the intervention at a later stage. Control participants in five studies attended clinic sessions at
the same frequency as the intervention group, but participated in activities that were hypothe-
sised not to treat the targeted skill set (e.g., computer based drawing activity, facilitated play
with toys). Control groups in nine studies were assigned to a treatment as usual group where
the “usual treatment” reflected typical intervention practice in the setting in which the study
was set (e.g., typical preschool program, an alternative social skills program with differing
intervention practices [46, 51]).
Methodological quality. A description of the methodological quality and Kmet ratings of
the included studies is provided in Table 5. One study, reporting on the effectiveness of Sum-
merMAX + Mind Reading [39], was rated as having strong methodological quality using the
Kmet checklist. Good methodological quality was measured in 8 of the papers. One of these
reported on results of The Junior Detective Program [41], one reported on the MEHRI treat-
ment [42], three reported on different adaptations of JASPER [51, 52, 55], one reported on
Skillstreaming [38], one reported on the Seaver-NETT program [59], and one reported on the
Mind Reading computer program [40]. Adequate methodological quality was rated in 9
papers, and the remaining 2 were rated as having poor methodological quality.
Risk of bias in studies. All studies reported randomisation of participants to groups, and
10 detailed the procedures for random allocation in detail. The remaining 11 studies did not
report on the generation of the allocation of participants to groups and so the risk of bias in
these studies is unclear. All included studies were at risk of bias due to challenges in blinding
of participants, their families and those involved in administering the interventions; an
acknowledged difficulty in designing clinical intervention research [61]. However, blinding of
outcome measurements was reported in eight studies that utilised observational measures of
pragmatic language [42, 43, 51–53, 55–57]. In these studies, video recorded observations were
coded and rated by independent researchers unaware of the participants’ group allocation or
time in the study when the observations were collected. Raters in three of the studies were also
blind to the purpose of the study [51–53]. Two further studies reported observational measures
of pragmatic language, but it is not clear whether observers were blinded [49, 54]. The risk of
bias in the outcome measurements of all other studies is either evident or unknown. The
researchers either administered assessments directly to the child, or collected information via
parent survey and are at risk of bias due to unclear reports of blinding for child directed assess-
ments, and an inability to blind parent-rated outcome measurements.
Sample size calculations were reported and an appropriate sample size was used in 9 stud-
ies, leaving the risk of bias unclear in the remaining 12 studies. A potential invested interest
bias was apparent in a number of studies, with authors having conducted previous research on
the same topic, or being involved in the development of the intervention protocol being inves-
tigated [38–41, 53–56].
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The fail-safe N calculated during meta-analysis was 108, meaning as many nil effect studies
would need to have been conducted and not published in order to negate the observed effect
of the included studies. Such a large N-value indicates a low risk of publication bias.
Effects of interventions: Meta-analysis results
Fifteen of the 21 studies were included in the meta-analysis. Three studies [40, 46, 57] could
not be included in the analysis as the data required for calculations were not reported. The
authors were contacted to collect the required data needed for the meta-analysis, but none of
the authors responded to the requests. A further two studies were excluded [42, 53], as they
reported on the same sample as two other studies [43, 54], but used outcome measures that
evaluated a narrower range of pragmatic language skills. One final study was excluded as it
reported on 12-month follow up data only [52]. Seven studies measured social communication
using more than one instrument. A single outcome measure was extracted for inclusion in the
analysis from four of these studies, as the measure chosen was likely to reflect a more compre-
hensive suite of pragmatic language skill than the others reported [39, 54–56]. The remaining
three articles reported two or more similar measurements of a single pragmatic language con-
struct [41, 43, 51], so the mean scores were averaged and pooled standard deviations were cal-
culated for each study for use in the analysis. There were 17 participant samples across the 15
included studies, as two studies contained two intervention groups [44, 47].
Overall treatment effects were calculated for pragmatic language interventions on pre-post
outcome measures. Sub-group analysis was conducted to compare the effect as a function of
three intervention characteristics: 1) setting (i.e., clinic, home, school), intervention focus (i.e.,
child focused, parent focused, or both), and mode of delivery (i.e., group interventions, one-
on-one interventions or both). Further analysis was conducted to detect whether participant
age, outcome measure type, intervention setting, focus or mode of delivery mediated interven-
tion effect. Between groups analysis was also conducted to compare post-intervention scores
with control groups, grouped by control condition type. Three control condition types were
included: 1) waitlisted control groups where participants served as an untreated comparison
group who eventually went on to receive the intervention; 2) treatment as usual control groups
where participants received interventions typically prescribed in the clinic or school in which
the intervention was set; and 3) alternative treatment controls where participants attended the
clinical setting but participated in an activity that reflected the intervention approach without
the activity that was thought to be the agent of change.
Overall effect of pragmatic language interventions. Effect sizes ranged from 0.162 to
1.288 in the pre-post intervention within groups analysis, as shown in Fig 2. Of the 17 inter-
vention groups sampled, 24% produced a large effect, 29% proceed a medium effect, and 29%
produced a small effect. An effect size < 0.2 was measured in 18% of the intervention groups.
A small but significant post-intervention between-groups total effect size was found, favouring
pragmatic language interventions for children with ASD (z(17) = 2.889, p = 0.004, Hedge’s g = 0.274, 95%CI = 0.088–0.460). The overall intervention effect was moderate (z(17) = 6.642, p < 0.001, Hedge’s g = 0.500, 95%CI = 0.352–0.647). The between-study heterogeneity was not significant (Q(16) = 19.413, p = 0.248), and 17.570% of true variability (I2) could be explained by individual study characteristics. Following the subgroup analysis of intervention character-
istics meta-regression analysis was performed to further explain variability in the results.
Effect size as a function of intervention characteristics. Figs 3 to 5 indicate the effect
sizes of pragmatic language interventions grouped by setting, focus and mode of delivery
respectively. Interventions set in the clinic demonstrated a significant, moderate effect size (z
(12) = 5.758, p < 0.001, Hedge’s g = 0.535, 95%CI = 0.353–0.718), which was the largest effect
Pragmatic language interventions for children with ASD
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size calculated as a function of setting. Interventions set in the school were approaching signifi-
cance, with a small effect (z(3) = 1.925, p = 0.054, Hedge’s g = 0.408, 95%CI = -0.007–0.824), and interventions set in the home did not have a significant effect on improving pragmatic lan-
guage skills when compared to the other settings (z(2) = 1.846, p = 0.065). However, these results should be interpreted with caution as only two studies were set in the home and just
one at school compared to 12 in the clinic setting group. Approaches that integrated a care-
giver into the program via education and/or coaching in intervention techniques demon-
strated a significant, moderate-large effect (z(4) = 5.265, p < 0.001, Hedge’s g = 0.760, 95% CI = 0.477–1.043), while the intervention that focused on parent education only had no signifi-
cant impact on the pragmatic language skills of children with ASD (z(1) = 0.341, p = 0.733). The majority of studies focused on administering the intervention directly to the children with
ASD, and these interventions demonstrated a significant, moderate effect (z(12) = 5.842, p < 0.001, Hedge’s g = 0.482, 95%CI = 0.320–0.644). Again, caution is required in interpreting these results as there is only one study in the parent focused group, and 12 and 4 in the child
focused and combined child and parent focused groups respectively. Whether interventions
Fig 2. Within intervention group pre-post meta-analysis. Notes: Hedge’s g interpreted as per Cohen’s d conventions: �0.2 = negligible
difference, 0.2–0.49 = small, 0.5–0.79 = moderate, � 0.8 = large.
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Pragmatic language interventions for children with ASD
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were administered to a group, the individual or both, effects were significant and moderate in
size. Group interventions produced the largest effect of the three modalities (z(5) = 3.811, p < 0.001, Hedge’s g = 0.553, 95%CI = 0.269–0.838).
Factors mediating intervention effect. No differences were detected in outcomes as a
result of participant age or method of pragmatic language measurement (i.e., parent report,
observation, or lab task). The analysis of intervention characteristics indicated that interven-
tion setting and mode were not significant mediators of intervention effect. However, inter-
vention focus (e.g. child, parent or child and parent) was found to be a significant mediator of
pragmatic language outcomes (F(2) = 4.17, p = 0.0381), accounting for all of the between- study variance in the model (R2 = 100%). Lastly, as there was a concordance between increased age and receiving intervention in a group, participant age was examined in relation to mode.
This did not produce a significant result, indicating age did not mediate the effect of mode of
delivery (i.e., individual, group, or both).
Effect of pragmatic language interventions compared with comparison groups. As
shown in Fig 6, pragmatic language interventions for children with ASD showed a moderate,
significant effect when compared to the waitlisted control group (z(7) = 2.780, p = 0.005, Hedge’s g = 0.5.18, 95%CI = 0.153–0.883). Customised pragmatic language interventions did not have a significant effect when compared to an alternative treatment (z(5) = 1.560, p = 0.119) or treatment as usual (z(5) = 0.222, p = 0.824). Effect size of intervention compared to waitlisted controls was similar to that of the overall pre-post results for all interventions.
Fig 3. Within intervention group pre- post- meta-analysis, grouped by setting. Notes: Hedge’s g interpreted as per Cohen’s d
conventions: �0.2 = negligible difference, 0.2–0.49 = small, 0.5–0.79 = moderate, � 0.8 = large. Clinic: participants attended the
interventionists premises; Home: clinicians visited participant’s home OR parents administered intervention at home; School: intervention
was carried out at the participants’ school outside of the normal curriculum.
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Discussion
This study aimed to review and analyse the evidence-base for interventions to improve prag-
matic language skills in children with ASD. Using procedures as outlined by the PRISMA
statement [62], a systematic review and meta-analysis of RCT studies were conducted.
Participants in all 21 included papers were of pre-school or elementary/primary school age.
Associations between early intervention for children with ASD and reduced symptom severity
in the long term are widely accepted. Similarly, gestural non-verbal joint attention has been
shown to be predictive of later language acquisition in children with ASD [5]. As such, provid-
ing effective interventions for early developing pragmatic language skills to verbal and mini-
mally verbal pre-school aged children is likely to have a crucial impact on future social and
linguistic development. The two interventions producing a large effect on pragmatic language
for the 0–5 year age group were clinic-based approaches that focused on developing functional
language use [42–44]. Other interventions for this age group targeted giving and responding
to non-verbal communication acts to engage in joint attention with a social partner, produced
negligible to moderate effect sizes, indicating a need for further development and investigation
of these interventions.
Interventions for children aged 6–12 years broadly targeted children without any comorbid
language or neurodevelopmental disorders. A similar gap is highlighted in the boarder lan-
guage and communication intervention literature for minimally verbal children with ASD in
Fig 4. Within intervention group pre- post- intervention meta-analysis, grouped by therapy focus. Notes: Hedge’s g interpreted as
per Cohen’s d conventions: �0.2 = negligible difference, 0.2–0.49 = small, 0.5–0.79 = moderate, � 0.8 = large. Child: interventions were
administered to the participants only either in groups or individually; Child and parents: parent training and//or education were integrated into
intervention sessions either concurrently with the child/ren or in separate sessions; Parent: sessions only involved parent education.
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this age group [6]. Studies of older children, like those included in this review, focus on verbal
children and it is suggested that adapting interventions designed for younger children with
ASD could provide potential intervention approaches for older, minimally verbal children
with ASD [6]. Given the large effect of interventions such as Building Blocks in targeting prag-
matic language in under five year olds [44], adaptations of these approaches may be a viable
option for further investigation for minimally verbal older children with ASD. Randomised
controlled trials assessing pragmatic language outcomes following the introduction of an alter-
native support for the production of language (e.g., Picture Exchange Communication System
(PECS), or the use of speech production applications/devices), of which this review found
none, could also provide future evidence for interventions appropriate to this population.
This review did not find any evidence for any effective pragmatic language interventions
for adolescents with ASD, highlighting a gap in the continuity of effective interventions for
individuals with ASD as their social environment evolves and becomes more complex. A more
multifaceted set of pragmatic language skills is required as children continue to develop from
early childhood into adolescence and adulthood. Pragmatic language interventions that recog-
nise the increasing complexity of social interactions would aid in the reduction of the long-
term psychosocial impacts that these deficits can have on the development of quality relation-
ships [14], which in turn can reduce social exclusion and promote resilience [63].
Intervention was provided in a group setting in 13 of the studies. At an aggregate level, the
group interventions were significantly more effective than individually focused interventions,
Fig 5. Within intervention group pre- post- treatment meta-analysis, grouped by mode. Notes: Hedge’s g interpreted as per Cohen’s d
conventions: �0.2 = negligible difference, 0.2–0.49 = small, 0.5–0.79 = moderate, � 0.8 = large. Individual: interventions were administered
in a one-on-one setting; Group: interventions were administered to participants in small groups; Both: sessions were comprised of individual
and group aspects.
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but by a small magnitude. Interestingly, a majority (80%) of the group-based interventions
were also focused on the older age cohort (6–12 years), potentially mediating the sub-group
analysis by mode. However, the results of the meta-regression indicate that interventions deliv-
ered at different ages resulted in similar outcomes. The notion that group interventions have a
greater impact than individual approaches is reflected in the results of one included study that
found a group intervention produced a large effect size, compared to the moderate effect pro-
duced by same intervention, but implemented in a one-on-one setting [44]. This highlights the
need for further investigation as to the ideal setting for pragmatic language interventions and
the factors that mediate change. Individual interventions could potentially be enhanced
through the inclusion of techniques used in the group interventions, but a knowledge gap is
evident in the included studies as to the factors that may have mediated the changes measured
in each intervention. Data from much larger participant samples than those included in this
review would need to be collected in order to reliably analyse mediating and moderating fac-
tors. However, if the mediating and moderating factors that positively influence intervention
outcomes were known then those factors that had largest influence on change could be incor-
porated into individual interventions in order to enhance their effectiveness.
Notably, groups were comprised exclusively of peers with ASD in all interventions, with the
exception of SENSE Theater which included typically developing peers [45]. This is contrasted
by a systematic review of peer-mediated interventions for children with ASD, in which a
majority of studies (34 of the 42) included peers without a disability [64]. There is emerging lit-
erature suggesting that the use of typically developing peers in group interventions increases
Fig 6. Between intervention groups post-score meta-analysis, grouped by control group type. Notes: Hedge’s g interpreted as per
Cohen’s d conventions: �0.2 = negligible difference, 0.2–0.49 = small, 0.5–0.79 = moderate, � 0.8 = large. Alternative treatment: control
groups attended an activity that reflected aspects of the intervention without the components thought to be crucial in improving pragmatic
language; Treatment as usual: control groups received the intervention or education program typically administered in the intervention
setting; Waitlisted control: control groups served as an untreated comparison.
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the social interactions of children and adolescents with ASD, and aid in skill maintenance and
generalisation in the long term [65]. It is possible then, that the inclusion of typically develop-
ing peers has the potential to further increase the effectiveness of the group interventions
included in this review; clearly this is an avenue worth exploring.
Skill generalisation is a continuing problem for social interaction interventions for children
with ASD [66]. Decontextualised learning has been identified as a barrier to generalisation in
other social skill interventions for children with ASD and recommendations such as home-
based practice, parent involvement in therapy, and practice with a variety of people and set-
tings have been made to aid generalisation [67–69]. A majority of included pragmatic language
interventions (71%) included in this review were set in the clinic and approximately half of the
interventions (11) included strategies for generalisation, such as the involvement of parents in
interventions and the inclusion of out-of-session practice. The clinic was found to be the most
effective setting when compared to home or school, and even though strategies to enhance
skill generalisation were included in most of the clinic-based interventions, little is known
about whether these strategies were effective. Outcome measurement often assessed pragmatic
language in the context in which the intervention was administered or via a decontextualised
assessment instrument, so conclusions cannot be drawn as to the generalisability of skills fol-
lowing these interventions. This highlights the need for researchers to consider including
assessments in their investigations that capture behavioural observations of pragmatic lan-
guage skills in varying contexts. Additionally, clinic-based interventions can be inaccessible to
some families because of financial or logistical limitations, and there can be a limited availabil-
ity of therapists in some locations, particularly in rural settings. These factors highlight the
need for further development and research to enhance the effectiveness of school based inter-
ventions, or programs that increase the effectiveness of parents as interventionists in the
home.
This review found that the person(s) of treatment focus was the only variable identified as
being a significant mediating factor in the meta-regression. Interventions that focused on
treating the child as well as coaching parents in intervention techniques produced the greatest
effect, with some of these interventions occurring in the home, and others occurring in the
clinic. These results are mirrored in a recent review of spoken language interventions for chil-
dren with ASD. The review found approaches that included both the clinician and parent in
the delivery of therapy produced a significant, moderate effect in comparison to approaches
delivered by the clinician or parent only [15]. Results from both reviews are in contrast to the
findings of a review of parent-mediated interventions for children with ASD. Specifically, the
review of parent-mediated interventions found mixed results as to the effectiveness of such
approaches in improving language and social communication in young children with ASD
[70]. However, the importance of including parents in interventions for children with ASD is
also recognised in the same review due to a caregiver’s capacity to provide intervention early,
and across a variety of environments and people.
Interestingly, one intervention included in this systematic review, investigated the effective-
ness of parent training seminars without the child being present [56]. That study produced a
negligible effect in comparison to other interventions that were delivered directly to the child
or child-parent dyad (see Fig 4). If parents are to implement interventions in the home to
enhance treatment efficacy, then generic training seminars may not be the ideal approach. Cli-
nicians should also observe the parent-child interaction in order to customise training to the
family, and provide parents with specific feedback on progress. The rationale provided by the
authors for studying a caregiver-training only intervention was to provide assistance to low resourced families who might not otherwise be able to access intervention services. Given the negligible effect of this delivery model, further investigation of caregiver-training approaches
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is needed. Establishing the appropriate balance between the clinician and parent components
of interventions could increase effectiveness and accessibility to services. Clearly, there is a
need for further research in the area of parent-mediated interventions for improving prag-
matic language in order for stronger conclusions to be drawn.
Pragmatic language encompasses a complex skill set; the execution of which needs to be
constantly adjusted in dynamic social environments. As such, assessing pragmatic language is
challenging for clinicians and researchers alike. In assessing pragmatic language outcomes, 10
studies included in this review utilised parent report rating scales or lab-based assessments
administered to the child. The results of the meta-analysis indicate that a larger effect size is
likely to be detected when pragmatic language is measured through these types of measures
when compared to observational measures. The potential introduction of bias through the use
of parent questionnaires has already been discussed in this paper due to the inability to blind
caregivers to treatment conditions. Additionally, the structured nature of standardised lab-
based assessments fails to capture the complex dynamics of the social context and is often not
the ideal assessment medium for children with ASD. Eleven included studies utilised observa-
tional ratings of pragmatic language skills. While these produced only a small effect size in
comparison to other types of outcome measures, the ecological validity of these outcomes mea-
sures is recognised and perhaps provide a truer indication of the effect of the interventions
studied. However, if researchers and clinicians are to use observational measures of pragmatic
language, further investigation of the psychometric properties of available instruments is
required. While the inter-rater reliability of observational measures is commonly reported in
the included studies, other psychometric properties such as, internal consistency, validity and
responsiveness, of the measures is mostly unknown.
A majority of the interventions reviewed (14 out of 20) targeted non-verbal communica-
tion, a hallmark impairment of ASD [71]. Skills were usually targeted in isolation with just
seven interventions targeting a combination of pragmatic language skills. With the expanding
definition of pragmatic language comes a need for interventions to target a wider skill set,
especially in the over 5-year age group. No one intervention included in this review targeted
all of pragmatic language skills, and additionally, none of the studies targeted the skills of exec-
utive function or negotiation. Targeting skills in isolation neglects the dynamic and complex
nature of social interactions. It is possible that interventions that target one skill show a large
effect, but are not as clinically beneficial as more holistic approaches that obtain smaller effects.
More research is required into the effectiveness of interventions that target a more comprehen-
sive skill set for pragmatic language.
Only one study differentiated groups by the presence or absence of an intellectual disability
[49]. The intervention group with participants who did not have an intellectual disability dem-
onstrated a large treatment effect. This is contrasted against the moderate effect measured in
the intervention group of children with ASD with an intellectual disability who received the
same intervention. This could mean that children without an intellectual disability gain more
from pragmatic language interventions; however, due caution needs to be exercised here and
more research is required comparing the cognitive profiles of children with ASD and the
impact this has on intervention effectiveness. These findings also emphasise the heterogeneity
in autism profiles and the need to consider factors that might mediate an intervention’s effect
in order to make interventions as beneficial as possible.
The longitudinal benefits of the included interventions are mostly unknown. Follow-up
data were reported in nine papers with times ranging from 5-weeks to 12-months post-inter-
vention. Given that individuals with ASD experience pragmatic language impairments into
adulthood [14], there is a need for researchers to track the benefits of interventions overex-
tended time frames to evaluate their effectiveness in improving long-term social functioning.
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Finally, results of the meta-analysis showed that treatment effects were greatest when com-
parison groups received no treatment (i.e., waitlisted controls), and the effect of tailored prag-
matic language interventions was negligible in comparison to the treatment as usual control
conditions. Again, these results are mirrored the findings of a review of spoken language inter-
ventions for children with ASD; targeted interventions were no more effective in improving
spoken language than comprehensive ASD interventions [15]. Intervention approaches for
improving pragmatic language, trialled with children with ASD show some promise; however,
factors that might mediate greater change and the generalisation of skills need further investi-
gation. In summary, we need a greater understanding of: a) how cognitive and language pro-
files influence treatment effects; b) the most effective intervention setting and intervention
agents to achieve large effects; and c) the inclusion of more strategies to enhance skill
generalisation.
Limitations
Great care was taken during the process of this review in order to minimise the introduction
of bias. A comprehensive search was conducted including relevant databases alongside a num-
ber of professional and academic information sources. Abstract screening for study selection
and ratings of methodological quality were conducted by two independent researchers with
acceptable levels of interrater reliability. Despite its methodological rigour, this review is sub-
ject to a number of limitations. Quasi-experimental design studies and single case experimen-
tal designs were excluded from the review. The choice to include randomised study designs
only when evaluating interventions for children with ASD could confound results given the
potential for high levels of heterogeneity in participant samples. The included studies are also
at risk of bias due to limitations in methodological design or reporting. The potential for
within-group heterogeneity in samples of children with ASD, coupled with incomplete control
for confounding variables and inadequate blinding, somewhat limits the conclusions that can
be generalised to the broader population of children with ASD. With the exception of partici-
pant age, this study was also unable to address whether other participant characteristics (e.g.,
expressive or receptive language ability, autism symptom severity, cognitive ability) impacted
on the effect of the included interventions. This was due to inadequate reporting of participant
demographic and diagnostic variables.
Conclusions
The consequences of the social communication impairments in children with ASD are far
reaching and life-long, and tailored pragmatic language interventions have the potential to
reduce these impacts for children with ASD. This review of pragmatic language interventions
for children with ASD found a number of promising approaches. Findings of this meta-analy-
sis suggest that the person(s) of focus is a significant mediator of intervention effect, but the
age of participants is not, suggesting that regardless of age, the child with ASD and their parent
must be actively included in an intervention in order to maximise benefits. Further, group
interventions appear to be more effective than those delivered one-on-one, and the inclusion
of typically developing peers may have the potential to increase the effectiveness of group
interventions. At this point, the generalisation of pragmatic language skills outside of the clini-
cal context and longitudinal effects of pragmatic language interventions for children with ASD
are largely unknown. There is a need for more studies that investigate: the most effective dos-
age of these intervention approaches; intervention effectiveness when confounding variables
such as language competence or intellectual ability are controlled for; and the development of
interventions targeting pragmatic language skills in adolescents with ASD. The bias introduced
Pragmatic language interventions for children with ASD
PLOS ONE | https://doi.org/10.1371/journal.pone.0172242 April 20, 2017 32 / 37
into a number of studies via the use of parent rated measures of pragmatic language highlights
the need for further development in the area of pragmatic language measurement. Instruments
that capture the complex nature of the social interactions are required so that researchers and
clinicians can obtain unbiased measurements of pragmatic language competence to assess
change following intervention as well as skill generalisation.
Supporting information
S1 Table. PRISMA checklist.
(DOCX)
S2 Table. Search terms.
(DOCX)
Acknowledgments
The authors would like to thank Belinda Cuomo for her assistance with abstract screening and
ratings of methodological quality.
Author Contributions
Conceptualization: LP RC NM AJ.
Data curation: LP.
Formal analysis: LP RC.
Investigation: LP RC NM RS.
Methodology: LP RC NM AJ.
Supervision: RC NM AJ.
Writing – original draft: LP.
Writing – review & editing: LP RC NM AJ RS.
References 1. Paul R, Norbury C. Language disorders from infancy through adolescence: Listening, speaking, read-
ing, writing, and communicating. St. Louis, MO: Elsevier Health Sciences; 2012.
2. Prutting C, Kirchner. A clinical apraisal of the pragmatic aspects of language. J Speech Hear Disord.
1987; 52:105–19. PMID: 3573742
3. Adams C, Baxendale B, Lloyd J, Aldred C. Pragmatic language impairment: Case studies of social and
pragmatic language therapy. Child Lang Teach Ther. 2005; 21(3):227–50.
4. Snow CE, Pan BA, Imbens-Bailey A, Herman J. Learning how to say what one means: A longitudinal
study of children’s speech act use. Social Development. 1996; 5(1):56–84.
5. Mundy P, Sigman M, Kasari C. A longitudinal study of joint attention and langauge development in autis-
tic children. J Autism Dev Disord. 1990; 20(1):115–28. PMID: 2324051
6. Tager-Flusberg H, Kasari C. Minimally verbal school-aged children with autism spectrum disorder: the
neglected end of the spectrum. Autism Res. 2013; 6(6):468–78. https://doi.org/10.1002/aur.1329
PMID: 24124067
7. Bono MA, Daley T, Sigman M. Relations among joint attention, amount of intervention and language
gain in autism. J Autism Dev Disord. 2004; 34(5):495–505. PMID: 15628604
8. Cordier R, Munro N, Wilkes-Gillan S, Speyer R, Pearce WM. Reliability and validity of the Pragmatics
Observational Measure (POM): A new observational measure of pragmatic language for children. Res
Dev Disabil. 2014; 35(7):1588–98. https://doi.org/10.1016/j.ridd.2014.03.050 PMID: 24769431
Pragmatic language interventions for children with ASD
PLOS ONE | https://doi.org/10.1371/journal.pone.0172242 April 20, 2017 33 / 37
9. Aldred C, Green J, Adams C. A new social communication intervention for children with autism: Pilot
randomised controlled treatment study suggesting effectiveness. Journal of Child Psychology and Psy-
chiatry. 2004; 45(8):1420–30. https://doi.org/10.1111/j.1469-7610.2004.00848.x PMID: 15482502
10. Ciccia AH, Turkstra LS. Cohesion, communication burden, and response adequacy in adolescent con-
versations. Advances in Speech Language Pathology. 2002; 4(1):1–8.
11. Paul R, Orlovski SM, Marcinko HC, Volkmar F. Conversational behaviors in youth with high-functioning
ASD and Asperger syndrome. J Autism Dev Disord. 2009; 39(1):115–25. https://doi.org/10.1007/
s10803-008-0607-1 PMID: 18607708
12. Bauminger N, Kasari C. Loneliness and friendship in high-functioning children with autism. Child Dev.
2000:447–56. PMID: 10834476
13. Locke J, Ishijima EH, Kasari C, London N. Loneliness, friendship quality and the social networks of ado-
lescents with high-functioning autism in an inclusive school setting. Journal of Research in Special Edu-
cational Needs. 2010; 10(2):74–81.
14. Whitehouse AJ, Watt HJ, Line EA, Bishop DV. Adult psychosocial outcomes of children with specific
language impairment, pragmatic language impairment and autism. Int J Lang Commun Disord. 2009;
44(4):511–28. https://doi.org/10.1080/13682820802708098 PMID: 19340628
15. Hampton L, Kaiser A. Intervention effects on spoken-language outcomes for children with autism: a sys-
tematic review and meta-analysis. J Intellect Disabil Res. 2016; 60(5):444–63. https://doi.org/10.1111/
jir.12283 PMID: 27120988
16. Kmet LM, Lee RC, Cook LS. Standard quality assessment criteria for evaluating primary research
papers from a variety of fields. Alberta, Canada: Alberta Heritage Foundation for Medical Research;
2004.
17. Lee L, Packer TL, Tang SH, Girdler S. Self-management education programs for age-related macular
degeneration: A systematic review. Australas J Ageing. 2008; 27(4):170–6. https://doi.org/10.1111/j.
1741-6612.2008.00298.x PMID: 19032617
18. Millard T, Elliott J, Girdler S. Self-management education programs for people living with HIV/AIDS: a
systematic review. AIDS Patient Care STDS. 2013; 27(2):103–13. https://doi.org/10.1089/apc.2012.
0294 PMID: 23298279
19. Hoffmann TC, Glasziou PP, Boutron I, Milne R, Perera R, Moher D, et al. Better reporting of interven-
tions: template for intervention description and replication (TIDieR) checklist and guide. Br Med J. 2014;
348:g1687.
20. Hedges LV, Pigott TD. The power of statistical tests for moderators in meta-analysis. Psychol Methods.
2004; 9(4):426. https://doi.org/10.1037/1082-989X.9.4.426 PMID: 15598097
21. Higgins JP, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses. BMJ.
2003; 327(7414):557–60. https://doi.org/10.1136/bmj.327.7414.557 PMID: 12958120
22. Cohen J. Statistical power analysis for the behavioral sciences. 2nd ed. Hillsdale, NJ: Earlbaum;
1988.
23. Gattino GS, dos Santos Riesgo R, Longo D, Loguercio Leite JC, Faccini LS. Effects of relational music
therapy on communication of children with autism: A randomized controlled study. Nordic Journal of
Music Therapy. 2011; 20(2):142–54.
24. Ichikawa K, Takahashi Y, Ando M, Anme T, Ishizaki T, Yamaguchi H, et al. TEACCH-based group
social skills training for children with high-functioning autism: A pilot randomized controlled trial. Biopsy-
chosoc Med. 2013; 7(1):14. https://doi.org/10.1186/1751-0759-7-14 PMID: 24083413
25. Kasari C, Rotheram-Fuller E, Locke J, Gulsrud A. Making the connection: Randomized controlled trial
of social skills at school for children with autism spectrum disorders. Journal of Child Psychology and
Psychiatry. 2012; 53(4):431–9. https://doi.org/10.1111/j.1469-7610.2011.02493.x PMID: 22118062
26. Lerner MD, Mikami AY. A preliminary randomized controlled trial of two social skills interventions for
youth with high-functioning autism spectrum disorders. Focus Autism Other Dev Disabl. 2012; 27(3):
147–57.
27. Wong VC, Kwan QK. Randomized controlled trial for early intervention for autism: A pilot study of the
Autism 1-2-3 Project. J Autism Dev Disord. 2010; 40(6):677–88. https://doi.org/10.1007/s10803-009-
0916-z PMID: 20020319
28. Houghton K, Schuchard J, Lewis C, Thompson CK. Promoting child-initiated social-communication in
children with autism: Son-Rise Program intervention effects. J Commun Disord. 2013; 46(5–6):
495–506. Language: English. Entry Date: 20140110. Revision Date: 20140620. Publication Type: jour-
nal article. https://doi.org/10.1016/j.jcomdis.2013.09.004 PMID: 24209427
29. McFadden B, Kamps D, Heitzman-Powell L. Social communication effects of peer-mediated recess
intervention for children with autism. Res Autism Spectr Disord. 2014; 8(12):1699–712. https://doi.org/
10.1016/j.rasd.2014.08.015 PMID: 26312064
Pragmatic language interventions for children with ASD
PLOS ONE | https://doi.org/10.1371/journal.pone.0172242 April 20, 2017 34 / 37
30. McMahon CM, Vismara LA, Solomon M. Measuring changes in social behavior during a social skills
intervention for higher-functioning children and adolescents with autism spectrum disorder. J Autism
Dev Disord. 2013; 43(8):1843–56. https://doi.org/10.1007/s10803-012-1733-3 PMID: 23239098
31. Oosterling I, Visser J, Swinkels S, Rommelse N, Donders R, Woudenberg T, et al. Randomized con-
trolled trial of the focus parent training for toddlers with autism: 1-year outcome. J Autism Dev Disord.
2010; 40(12):1447–58. https://doi.org/10.1007/s10803-010-1004-0 PMID: 20440639
32. Radley KC, Ford WB, Battaglia AA, McHugh MB. The effects of a social skills training package on social
engagement of children with autism spectrum disorders in a generalized recess setting. Focus Autism
Other Dev Disabl. 2014; 29(4):216–29.
33. Shire SY, Goods K, Shih W, Distefano C, Kaiser A, Wright C, et al. Parents’ adoption of social communi-
cation intervention strategies: Families including children with autism spectrum disorder who are mini-
mally verbal. J Autism Dev Disord. 2014; 45(6):1712–24.
34. Wetherby AM, Guthrie W, Woods J, Schatschneider C, Holland RD, Morgan L, et al. Parent-imple-
mented social intervention for toddlers with autism: An RCT. Pediatrics. 2014; 134(6):1084–93. Lan-
guage: English. Entry Date: 20141219. Revision Date: 20141226. Publication Type: journal article.
https://doi.org/10.1542/peds.2014-0757 PMID: 25367544
35. Adams C, Lockton E, Freed J, Gaile J, Earl G, McBean K, et al. The Social Communication Intervention
Project: A randomized controlled trial of the effectiveness of speech and language therapy for school-
age children who have pragmatic and social communication problems with or without autism spectrum
disorder. Int J Lang Commun Disord. 2012; 47(3):233–44. https://doi.org/10.1111/j.1460-6984.2011.
00146.x PMID: 22512510
36. Kamps D, Thiemann-Bourque K, Heitzman-Powell L, Schwartz I, Rosenberg N, Mason R, et al. A com-
prehensive peer network intervention to improve social communication of children with autism spectrum
disorders: A randomized trial in kindergarten and first grade. J Autism Dev Disord. 2014; 45(6):
1809–24.
37. Donaldson AL. Siblings of children with ASD: Promoting social communication. Perspectives on Lan-
guage Learning and Education. 2015; 22(1):31–8.
38. Lopata C, Thomeer ML, Volker MA, Toomey JA, Nida RE, Lee GK, et al. RCT of a manualized social
treatment for high-functioning autism spectrum disorders. J Autism Dev Disord. 2010; 40(11):
1297–310. https://doi.org/10.1007/s10803-010-0989-8 PMID: 20232240
39. Lopata C, Thomeer ML, Rodgers JD, Donnelly JP, McDonald CA. RCT of mind reading as a component
of a psychosocial treatment for high-functioning children with ASD. Res Autism Spectr Disord. 2016;
21:25–36.
40. Thomeer ML, Smith RA, Lopata C, Volker MA, Lipinski AM, Rodgers JD, et al. Randomized controlled
trial of Mind Reading and in vivo rehearsal for high-functioning children with ASD. J Autism Dev Disord.
2015; 45(7):2115–27. https://doi.org/10.1007/s10803-015-2374-0 PMID: 25643864
41. Beaumont R, Sofronoff K. A multi-component social skills intervention for children with Asperger syn-
drome: The Junior Detective Training Program. Journal of Child Psychology and Psychiatry. 2008;
49(7):743–53. https://doi.org/10.1111/j.1469-7610.2008.01920.x PMID: 18503531
42. Casenhiser DM, Shanker SG, Stieben J. Learning through interaction in children with autism: Prelimi-
nary data from asocial-communication-based intervention. Autism. 2013; 17(2):220–41. https://doi.org/
10.1177/1362361311422052 PMID: 21949005
43. Casenhiser DM, Binns A, McGill F, Morderer O, Shanker SG. Measuring and supporting language func-
tion for children with autism: Evidence from a randomized control trial of a social-interaction-based ther-
apy. J Autism Dev Disord. 2015; 45(3):846–57. https://doi.org/10.1007/s10803-014-2242-3 PMID:
25234481
44. Roberts J, Williams K, Carter M, Evans D, Parmenter T, Silove N, et al. A randomised controlled trial of
two early intervention programs for young children with autism: Centre-based with parent program and
home-based. Res Autism Spectr Disord. 2011; 5(4):1553–66.
45. Corbett BA, Key AP, Qualls L, Fecteau S, Newsom C, Coke C, et al. Improvement in social competence
using a randomized trial of a theatre intervention for children with autism spectrum disorder. J Autism
Dev Disord. 2015:1–15.
46. DeRosier ME, Swick DC, Davis NO, McMillen JS, Matthews R. The efficacy of a social skills group inter-
vention for improving social behaviors in children with high functioning autism spectrum disorders. J
Autism Dev Disord. 2011; 41(8):1033–43. https://doi.org/10.1007/s10803-010-1128-2 PMID: 21042870
47. Fletcher-Watson S, Petrou A, Scott-Barrett J, Dicks P, Graham C, O’Hare A, et al. A trial of an iPad
intervention targeting social communication skills in children with autism. Autism. 2015.
48. Gabriels RL, Pan Z, Dechant B, Agnew JA, Brim N, Mesibov G. Randomized controlled trial of therapeu-
tic horseback riding in children and adolescents with autism spectrum disorder. J Am Acad Child Ado-
lesc Psychiatry. 2015; 54(7):541–9. https://doi.org/10.1016/j.jaac.2015.04.007 PMID: 26088658
Pragmatic language interventions for children with ASD
PLOS ONE | https://doi.org/10.1371/journal.pone.0172242 April 20, 2017 35 / 37
49. Hopkins IM, Gower MW, Perez TA, Smith DS, Amthor FR, Wimsatt F, et al. Avatar assistant: Improving
social skills in students with an ASD through a computer-based intervention. J Autism Dev Disord.
2011; 41(11):1543–55. https://doi.org/10.1007/s10803-011-1179-z PMID: 21287255
50. Hauck M, Fein D, Waterhouse L, Feinstein C. Social initiations by autistic children to adults and other
children. J Autism Dev Disord. 1995; 25(6):579–95. PMID: 8720028
51. Kaale A, Smith L, Sponheim E. A randomized controlled trial of preschool-based joint attention interven-
tion for children with autism. J Child Psychol Psychiatry. 2012; 53(1):97–105. https://doi.org/10.1111/j.
1469-7610.2011.02450.x PMID: 21883204
52. Kaale A, Fagerland MW, Martinsen EW, Smith L. Preschool-based social communication treatment for
children with autism: 12-month follow-up of a randomized trial. J Am Acad Child Adolesc Psychiatry.
2014; 53(2):188–98. https://doi.org/10.1016/j.jaac.2013.09.019 PMID: 24472253
53. Kasari C, Freeman S, Paparella T. Joint attention and symbolic play in young children with autism: A
randomized controlled intervention study. Journal of Child Psychology and Psychiatry. 2006; 47(6):
611–20. https://doi.org/10.1111/j.1469-7610.2005.01567.x PMID: 16712638
54. Lawton K, Kasari C. Brief report: Longitudinal improvements in the quality of joint attention in preschool
children with autism. J Autism Dev Disord. 2012; 42(2):307–12. https://doi.org/10.1007/s10803-011-
1231-z PMID: 22187107
55. Kasari C, Gulsrud AC, Wong C, Kwon S, Locke J. Randomized controlled caregiver mediated joint
engagement intervention for toddlers with autism. J Autism Dev Disord. 2010; 40(9):1045–56. https://
doi.org/10.1007/s10803-010-0955-5 PMID: 20145986
56. Kasari C, Lawton K, Shih W, Barker TV, Landa R, Lord C, et al. Caregiver-mediated intervention for
low-resourced preschoolers with autism: An RCT. Pediatrics. 2014; 134(1):e72–e9. https://doi.org/10.
1542/peds.2013-3229 PMID: 24958585
57. Kim J, Wigram T, Gold C. The effects of improvisational music therapy on joint attention behaviors in
autistic children: A randomized controlled study. J Autism Dev Disord. 2008; 38(9):1758–66. https://doi.
org/10.1007/s10803-008-0566-6 PMID: 18592368
58. Ryan C, Charragain CN. Teaching emotion recognition skills to children with autism. J Autism Dev Dis-
ord. 2010; 40(12):1505–11. https://doi.org/10.1007/s10803-010-1009-8 PMID: 20386975
59. Soorya LV, Siper PM, Beck T, Soffes S, Halpern D, Gorenstein M, et al. Randomized comparative trial
of a social cognitive skills group for children with autism spectrum disorder. J Am Acad Child Adolesc
Psychiatry. 2015; 54(3):208–16. https://doi.org/10.1016/j.jaac.2014.12.005 PMID: 25721186
60. Baron-Cohen S. Mind reading: The interactive guide to emotions. London UK: Jessica Kingsley Pub-
lishers; 2003.
61. Gluud LL. Bias in clinical intervention research. Am J Epidemiol. 2006; 163(6):493–501. https://doi.org/
10.1093/aje/kwj069 PMID: 16443796
62. Liberati A, Altman D, Tetzlaff J, Mulrow C, Gøtzsche P, Ioannidis J, et al. The PRISMA statement for reporting systematic and meta-analyses of studies that evaluate interventions: explanation and elabora-
tion. PLoS Med. 1999; 6(7):1–28.
63. Gerenberg M. Promoting resilience in children and youth: Preventive interventions and their interface
with neurescıence. New York Academy of Sciences. 2006; 1094:139–50.
64. Chan JM, Lang R, Rispoli M, O’Reilly M, Sigafoos J, Cole H. Use of peer-mediated interventions in the
treatment of autism spectrum disorders: A systematic review. Res Autism Spectr Disord. 2009; 3(4):
876–89.
65. Watkins L, O’Reilly M, Kuhn M, Gevarter C, Lancioni GE, Sigafoos J, et al. A review of peer-mediated
social interaction interventions for students with autism in inclusive settings. J Autism Dev Disord. 2015;
45(4):1070–83. https://doi.org/10.1007/s10803-014-2264-x PMID: 25272953
66. Rao PA, Beidel DC, Murray MJ. Social skills interventions for children with Asperger’s syndrome or
high-functioning autism: A review and recommendations. J Autism Dev Disord. 2008; 38(2):353–61.
https://doi.org/10.1007/s10803-007-0402-4 PMID: 17641962
67. Kransy L, Williams BJ, Provencal S, Ozonoff S. Social skills interventions for the autism spectrum:
Essential ingredients and a model curriculum. Child and Adolescent Psychiatric Clinics. 2002; 12:
107–22.
68. Spence S. Social skills training with children and young people: Theory, evidence and practice. Child
and Adolescent Mental Health. 2003; 8(2):84–96.
69. Williams White S, Keonig K, Scahill L. Social skills development in children with autism spectrum disor-
ders: A review of the intervention research. J Autism Dev Disord. 2007; 37(10):1858–68. https://doi.org/
10.1007/s10803-006-0320-x PMID: 17195104
Pragmatic language interventions for children with ASD
PLOS ONE | https://doi.org/10.1371/journal.pone.0172242 April 20, 2017 36 / 37
70. Oono IP, Honey EJ, McConachie H. Parent-mediated early intervention for young children with autism
spectrum disorders (ASD). Evidence-Based Child Health: A Cochrane Review Journal. 2013; 8(6):
2380–479.
71. Chiang C-H, Soong W-T, Lin T-L, Rogers SJ. Nonverbal communication skills in young children with
autism. J Autism Dev Disord. 2008; 38(10):1898–906. https://doi.org/10.1007/s10803-008-0586-2
PMID: 18491223
Pragmatic language interventions for children with ASD
PLOS ONE | https://doi.org/10.1371/journal.pone.0172242 April 20, 2017 37 / 37
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