1. Dr. Buckendorf on the early stages of language development for autistic children

Image from "Engagement and Mutual Exchange: Lessons from Autism - Bob Buckendorf" on Vimeo.

In this blog post, I will share insights I gained from observing sessions with Dr. Bob Buckendorf and his young autistic clients. I will begin by providing some context and explaining the evidence that informed Bob's approach with his pre-language autistic clients.

In his lectures "Engagement and Mutual Exchange: Lessons from Autism" and "The Lost Art of Communication," Bob explained that healthy language development in typical children involves a "dance" between the child and parent, starting with pre-linguistic forms of language such as eye gaze, gestures, sounds, and touch. These pre-linguistic skills build the child's sense of social-emotional reciprocity, which is essential for communication. Most children develop a sense of eye gaze by 9 to 11 months of age, which is an attraction to another person's eyes, the understanding that eyes are used to see, and the ability to follow a line of sight.

In 2010, Bob gave a lecture entitled "Engagement and Mutual Exchange: Lessons from Autism" that serves as a helpful explanation for his approach with his pre-language autistic clients. The following insights reflect a synthesis of information contained in that talk, as well as a separate talk Bob gave in 2010 called "The Lost Art of Communication", along with several interviews and sessions in the Master Clinician Network archive.

In terms of typical children, Bob describes healthy language development as a "dance" between the parent(s) and a child. As they get older this dance gets more complex. The dance starts with pre-linguistic forms of language like eye gaze, gestures, sounds, or touch, which are stimulating for typical children (as well as parents) and can thus become virtuous cycles that help build early communication skills. The first time a typical child coos at a parent, it's an accident, but then the parent coos back and that's stimulating for the child, and they learn they can coo again to get the coo back that they want. Over time, developing these pre-linguistic skills also build the child's sense of social-emotional reciprocity, being sensitive to another person, an important skill for communication. These concepts will be further discussed in subsequent blog posts.

Most children begin learning the pre-linguistic building blocks of language remarkably early in life. For typical children, by 9 to 11 months of age most kids naturally develop a sense of eye gaze with their caregiver(s) - that is an attraction to another person's eyes, as well as an understanding that their eyes are used to see and an ability to follow their line of sight and recognize what the other person may be looking at. The concept of two people intentionally focusing their shared attention on the same thing is referred to as joint attention, also an important skill for communication. These concepts will also be further discussed.

For young children with provisional diagnoses of autism, studies show they are more likely to focus on a person's mouth rather than their eyes in the first few years of life, as eyes aren't as naturally stimulating for them. (To what extent it is desirable to help autistic kids establish eye gaze is a topic of intense debate and may depend on the child. For some children, building these skills could be helpful for communication. For others, it could be painful, functionally unnecessary, and potentially result in PTSD.)

According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), which Bob describes as the "bible that describes disorders", autism spectrum disorder is defined as an impairment of social interaction related to three core areas:

1. Deficits in social emotional reciprocity.

   1. One way autistic children experience this deficit is a reduced ability to interpret facial expressions compared to typical children, so if you frown many autistic children may not recognize that you may be sad.

2. Impaired verbal communication skills and ("probably more importantly" in Bob's words) a developmental delay in non-verbal communication skills like gestures and pointing.

   1. As Bob explains, "We don't realize how significant a point is until a child doesn't develop it." Like eye gaze, gestures reflect reciprocity. To interpret a point, you need to begin from where the other person is, and follow the direction of their point, reflecting a capacity for joint attention.

3. Deficits in developing and maintaining relationships, which can be linked to repetitive and stereotyped behaviors.

   1. One common form of repetitive behavior is repetitive hand flapping; for older children who have language this can manifest in a compulsion to repeat a topic or stay stuck on a topic. Sometimes this can result in a child developing interests and surprising degrees of familiarity in specific topics, which reminds me of a 7 year-old patient of Bob's named C, who had very limited vocabulary yet somehow knew the word "dromedary" as in the one-humped camel. These areas of surprising knowledge can be fascinating but not very useful when you're on the playground and other kids don't want to hear about them.

These are the three core areas that are part of the constellation of symptoms we call autism spectrum disorder.

Divided in a different way, the core issues of autism could be understood as 1) social relatedness and 2) communication.

1. Social relatedness refers to many of the impaired non-verbal skills mentioned by DSM-5 in #2 (eye gaze, proximity, and reading facial expressions) in addition to reciprocity (DSM-5 #1), since these concepts are interconnected.

2. Communication refers to how words and gestures are used for expressive and receptive language skills (DSM-5 #2). If autism is understood in this way, then challenges with social relationships (DSM-5 #3) could be seen as a consequence of difficulties with social relatedness and communication.

As a typical child reaches preschool and kindergarten age, the sense of reciprocity they've developed from years of pre-linguistic forms of language like eye gaze, and pointing, and recognizing facial expressions prepare the child to blossom out and engage with others.

For autistic children, these challenges begin with pre-linguistic forms of language like difficulties recognizing their parent's facial or verbal or gestural expressions. As a result, the parent may naturally choose not to make those types of expressions as often in the future. Herein lies an opportunity for SLPs to help ensure parents of autistic children are aware of the importance of these types of experiences, regardless of how naturally sensitive the child may be to respond.

Throughout one's life, non-verbal forms of communication like gestures, eye gaze, proximity to others, and the orientation of your body remain essential aspects of expressive and receptive language. For typical children, fluency of these skills helps establish a sense of reciprocity that allows for advanced forms of verbal communication such as genuine listening and asking good questions, which are invaluable tools for building and sustaining relationships.

As the autistic child gets older, instead of blossoming out and making friends, they often become increasingly focused on a narrow stereotyped area of interest - at the expense of engaging with others. This can be insidious for the child's overall development. In Bob's words, it's human experience and relationships that "builds brains".

With this context in mind, suddenly we can see Bob's clinic of bubbles and balloons and toys and blocks and games and snacks - not to mention a giant swing that hangs from the ceiling of his OT room - in a new light. For his young autistic clients, this vast array of sensory-rich toys, games, and other items are tools to engage the child, build a range of verbal and non-verbal skills, and establish a sense of reciprocity.

In Bob's words, "As an SLP you get to work with kids all day. Do you know why this is hard? Because this is work. I spend my life blowing bubbles and balloons and driving cars with little 3 year old kids, but it’s work because there’s a point to all these things that we’re doing."

Link to the next blog post:

Blog Post 2: Establishing the pre-linguistic building blocks of language