The Window to Language is Still Open: Distinguishing Between Preverbal and Minimally Verbal Children With ASD While a large number of preschool age children with autism spectrum disorder (ASD) use no or little spoken language, only a portion will remain minimally verbal into elementary school. Determining whether a child is likely to remain minimally verbal past the preschool years is of great importance to families and ... Article
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Article  |   March 31, 2016
The Window to Language is Still Open: Distinguishing Between Preverbal and Minimally Verbal Children With ASD
Author Affiliations & Notes
  • Charlotte DiStefano
    Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, Los Angeles, CA
  • Connie Kasari
    Human Development and Psychology, University of California, Los Angeles, Los Angeles, CA
  • Financial Disclosure: Charlotte DiStefano is a Postdoctoral Fellow at the University of California, Los Angeles. Connie Kasari is a professor at the University of California, Los Angeles. The writing of this article was made possible by an Autism Speaks Meixner Postdoctoral Fellowship in Translational Science to Dr. DiStefano and NICHD RO1HD073975 to Dr. Kasari.
    Financial Disclosure: Charlotte DiStefano is a Postdoctoral Fellow at the University of California, Los Angeles. Connie Kasari is a professor at the University of California, Los Angeles. The writing of this article was made possible by an Autism Speaks Meixner Postdoctoral Fellowship in Translational Science to Dr. DiStefano and NICHD RO1HD073975 to Dr. Kasari.×
  • Nonfinancial Disclosure: The authors have previously published in the subject area.
    Nonfinancial Disclosure: The authors have previously published in the subject area.×
Article Information
Special Populations / Autism Spectrum / Speech, Voice & Prosody / Part 1
Article   |   March 31, 2016
The Window to Language is Still Open: Distinguishing Between Preverbal and Minimally Verbal Children With ASD
Perspectives of the ASHA Special Interest Groups, March 2016, Vol. 1, 4-11. doi:10.1044/persp1.SIG1.4
History: Received September 10, 2015 , Revised November 14, 2015 , Accepted November 19, 2015
Perspectives of the ASHA Special Interest Groups, March 2016, Vol. 1, 4-11. doi:10.1044/persp1.SIG1.4
History: Received September 10, 2015; Revised November 14, 2015; Accepted November 19, 2015

While a large number of preschool age children with autism spectrum disorder (ASD) use no or little spoken language, only a portion will remain minimally verbal into elementary school. Determining whether a child is likely to remain minimally verbal past the preschool years is of great importance to families and clinicians, and can inform intervention efforts. Evidence from both behavioral and neuroimaging studies provide support for the idea that minimally verbal children with ASD have specific and unique expressive language deficits and are not simply at an earlier stage of language development. Intervention that focuses on pre-linguistic skills, such as joint attention, gestures, and vocalizations can be effective to increase language in pre- and minimally verbal children with ASD. The use of speech generating devices (SGD) has also been shown to support spoken language development in this population. Although many preschool aged children with ASD are using no or very little language, many of these children are in fact pre-verbal, and will continue to develop language skills. Targeted intervention, including a focus on pre-linguistic communication and SGD, will help support their language development.

Social communication difficulties are fundamental to the diagnosis of an autism spectrum disorder (ASD). While spoken language problems are no longer considered a core deficit in ASD (American Psychiatric Association [APA], 2013), delays in spoken language are still the most common concern that prompts parents to seek a diagnosis (Mitchell et al., 2006). Moreover, language outcomes in the ASD population are highly variable, and difficult to predict. Even with early diagnosis and access to intensive intervention, some children with ASD will continue to have minimal language, while other children make rapid gains. Determining which children are likely to remain minimally verbal has important implications for education and intervention.
Recent estimates indicate that somewhere between 25% (Anderson et al., 2007; Hus, Pickles, Cook, Risi, & Lord, 2007) and 50% (Pickett, Pullara, O'Grady, & Gordon, 2009) of individuals with ASD fail to develop functional spoken language. This minimally verbal group includes children who are completely nonverbal, as well as those who use some language but have a very restricted ability to communicate. Language in minimally verbal children is typically characterized by a very small repertoire of single words or fixed phrases that are used at very low rates and are only in limited contexts (e.g., to request a preferred item within a familiar context; Kasari, Brady, Lord, & Tager-Flusberg, 2013). Characterization of children as minimally verbal often occurs when children are well past critical milestones of combining words into functional sentences, often co-occurring with entry into kindergarten.
Language in Preschool Children With ASD
In the preschool years, approximately 50–70% of children have not yet attained phrase speech (Ellis Weismer & Kover, 2015; Thurm, Manwaring, Swineford, & Farmer, 2014). Many of these children will go on to develop expressive language, while a portion will continue to be minimally verbal. While the average age of attaining first words is 8-14 months in the general population, a retrospective study of children with autism found that they attained first words at an average age of 38 months (Howlin, 2003). Because the onset of language can be significantly delayed in children with ASD, it should not be assumed that slow acquisition of language in the preschool years is necessarily predictive of an individual child's later language status. Although research may refer to preschool children with limited language as “minimally verbal”, many of them will in fact develop more fluent language and so are more appropriately identified as “pre-verbal”. Determining whether a preschool age child with ASD is likely to develop spoken language or remain minimally verbal is not only a topic of great interest to parents and professionals, but also influences education and intervention decisions.
Variability in Early Language Trajectories
The preschool years are a time of great variability in the abilities and developmental trajectories of children with ASD. A recent records review examined assessment records of 535 children with ASD who did not have flexible phrase speech by age 4 (Wodka, Mathy, & Kalb, 2013). The researchers found that 70% of these children did go on to attain phrase or fluent speech by age 8, based on assessment results. Another study tracking social–communication development in 330 preschool children with ASD classified children into three categories based on their initial ability profiles: ASD alone, ASD plus language impairment, and ASD plus intellectual disability (with or without language impairment) (ASD+ID). Of the 25 children who were classified as ASD + Language Impairment, 16 had “caught up” in terms of expressive language one year later. Of the 221 children initially classified as ASD+ID, 38 no longer showed additional impairments in language and cognitive skills one year later (Bennett et al., 2014). These findings demonstrate how highly variable developmental trajectories are in this age group of children with ASD. Many children with ASD who have limited expressive language in the preschool years develop more speech in subsequent years; a smaller percentage of children will continue to have very limited language.
Of critical importance is determining whether a preschool age child with limited language is truly minimally verbal, or if they would be more accurately described as pre-verbal. A child who is minimally verbal has plateaued in terms of their expressive language development (though other abilities may continue to improve), while a pre-verbal child is still developing foundational pre-linguistic skills that will lead to the development of speech. This distinction has important implications for treatment targets and methods, and well as predicting outcomes. Children who are minimally verbal may benefit from intervention that targets these missing pre-linguistic skills (such as joint attention and gestures), in order to promote language development. Additionally, the introduction of alternate methods of communication can provide access to communication and foster the development of communicative intent even in the absence of spoken language.
Distinguishing Between Pre-Verbal and Minimally Verbal Children
Both pre-verbal and minimally verbal children evidence significant impairments in expressive language. Careful consideration of pre-linguistic skills and developmental trajectory can help to distinguish between these two categories.
Children who are not yet using flexible expressive language, but are continuing to move along a developmental trajectory that is building towards linguistic communication, may most accurately be considered “pre-verbal”. Although their abilities are impaired compared with their typically developing peers, they show emerging pre-linguistic skills. They may respond to and initiate joint attention (though at low rates), use basic gestures, and vocalize using a range of consonant sounds. These skills have all been identified as predictors of later language development in children with ASD, even in children who have initially limited language (Ellis Weismer & Kover, 2015; Hellendoorn et al., 2015; Thurm et al., 2014; Woynaroski, Yoder, & Watson, 2015).
In contrast, children who are truly minimally verbal may have leveled off or greatly slowed in terms of their expressive language development. Children in this group often have a restricted consonant inventory, and are limited in the range of sounds that they use to vocalize (Yoder, Watson, & Lambert, 2015). They may have more difficulty responding to and initiating joint attention than their pre-verbal counterparts, and use few or no gestures. Children in this group often demonstrate communicative intent (i.e., purposeful behavior intended to transmit a message) without the language skills necessary to make themselves understood (Tager-Flusberg, Paul & Lord, 2005). In our clinical experience, their expressive language is likely more impaired than their overall developmental level (e.g., Kasari et al., 2014).
Assessment Recommendations
Accurate assessment of minimally verbal children can be difficult due to challenges that arise from their limited spoken language. Discomfort with the testing situation, limited ability to understand and comply with directions, and inability to provide verbal responses (which are required by many assessments) all impact the reliability and validity of assessment results (Kasari et al., 2013). In order to maximize the information gathered from assessments, special consideration should be given to the testing context. Preparing the child for what to expect during testing, inclusion of breaks and materials for reinforcement, as well as the use of assessors who have experience with children with complex needs will increase the accuracy of assessment results. Additionally, using informal or observational measures in combination with standardized assessments will provide a more complete picture of the abilities of a minimally verbal child. See Kasari and colleagues (2013)  for a more complete discussion of assessment recommendations for minimally verbal children with ASD.
Neural Development Also Distinguishes Minimally Verbal From Verbal Children
Recent neuroimaging evidence supports the hypothesis that minimally verbal children with ASD may have particular deficits that set them apart from pre-verbal children. Rather than showing neural patterns consistent with an earlier stage of language development, children who are minimally verbal demonstrate unique patterns in both structural and functional neuroimaging. Studies have found that minimally verbal children with ASD have atypical asymmetry in the arcuate fasciculus (Wan, Marchina, Norton, & Schlaug, 2012) and reduced grey matter in the left middle temporal gyrus (Riva et al., 2011), both areas that are associated with language ability. With regard to functional neural imaging, reduced cortex activation in response to speech (measured with magnetoencephalography) is associated with poor language outcomes in children with ASD (Port et al., 2015), and unique neural signatures from magnetoencephalography and diffusion tensor imaging have been used to successfully classify children with ASD by language ability (Ingalhalikar, Parker, Bloy, Roberts, & Verma, 2014). Neural imaging evidence has also been used to predict language outcomes. In toddlers with ASD, neural response to speech during a sleep fMRI was associated with later language ability (Lombardo et al., 2015). The authors found that children with poor language outcomes showed a hypoactive response in the language-sensitive superior temporal cortices while children with a good language outcome showed a response similar to typically developing toddlers. These findings suggest that children with ASD who are minimally verbal are not simply earlier in the expressive language developmental trajectory, but are in fact demonstrating an expressive language deficit that can be distinguished from their overall ASD diagnosis.
Using a Typical Developmental Model to Guide Intervention
In typical development, there are many important precursors to spoken language. Before children learn to talk, they develop a variety of skills including joint attention, intentional communication, gesture use, and the ability to make speech sounds (Rowe, Ozcaliskan, & Goldin-Meadow, 2008). These skills serve multiple functions. First, they are foundational abilities from which spoken language emerges. Second, these pre-linguistic abilities are crucial for facilitating the social and play interactions that provide the context for language learning (Adamson, Bakeman, & Deckner, 2004; Tomasello, 1988). Preschool age children with ASD are often impaired in these foundational, pre-linguistic skills. These deficits impede the development of spoken language, both because the skills are themselves precursors to spoken language, and because they support the child's ability to engage in learning interactions.
Several studies have examined language growth in children with ASD, and can provide some guidance in determining whether a preschool child with limited language is likely to go on to develop more speech. Early skills that have been associated with language growth include motor skills and imitation (Hellendoorn et al., 2015), consonant inventory (Yoder, Watson, & Lambert, 2015), ASD symptom severity (Thurm, Manwaring, Swineford, & Farmer, 2014), non-verbal IQ (Ellis Weismer & Kover, 2015; Hellendoorn et al., 2015; Thurm et al., 2014), intentional communication and joint attention (Mundy et al., 1987; Loveland & Landry, 1986). Joint engagement with a communication partner has been well established as important for language learning. Joint engagement refers to the state in which the child and communication partner are actively sharing attention with each other and an object.
Communication during periods of joint engagement (symbol infused joint engagement; for example, child and adult discussing the blocks they are building with) appears to facilitate language development as the amount of time a toddler spends in symbol infused joint engagement predicts their later language ability (Adamson et al., 2004) over and above their early language skills. Initiating and responding to joint attention are powerful concurrent and future predictors of language ability in children with autism (Luyster & Lord, 2009; Mundy et al., 1987; Mundy, Sigman & Kasari, 1990) and typically developing children (Watt, Wetherby, & Shumway, 2006). Research by Woynaroski and colleagues has documented that children with ASD who have higher expressive language abilities spend more time in supported joint engagement (in which the adult is helping the child remain engaged). This in turn is associated with greater expressive language growth (Woynaroski et al., 2015). This highlights the cyclical nature of these deficits, where the language deficit itself limits the child's access to situations that promote further language development. This interaction is crucial when considering intervention strategies for preschool children with limited language.
Interventions That Focus on Pre-Linguistic Goals to Support Spoken Language
Interventions that focus on teaching pre-linguistic skills to preverbal children with ASD have demonstrated success in facilitating spoken language (Kasari, Paparella, Freeman, & Jahromi, 2008; Yoder & Stone, 2006). Yoder and Stone (2006)  compared two communication interventions (Responsive Education and Prelinguistic Milieau Teaching [RPMT] and Picture Exchange Communication [PECS] in a group of 36 preschool age children with ASD. Both interventions include a focus on pre-linguistic communication skills. RPMT focuses on teaching gestures, gaze vocalizations and simple words during a play interaction, while PECS involves directly teaching children to participate in a communicative exchange, in which they use picture symbols to make requests and comments as well as respond to prompts. Children in both groups showed an increase over the course of the study in the amount of spoken communication that they used in a parent-child play interaction.
Intervention focusing directly on joint attention has been successful in increasing spoken language in children with ASD. In a randomized controlled trial of 58 children with ASD, a joint attention intervention and symbolic play intervention were compared to a control group. Children in each intervention group showed increases in the targeted skills (either joint attention or symbolic play; Kasari, Freeman, & Paparella, 2006), along with an increase in spoken language (Kasari et al., 2008). Children with the least amount of language made the most progress in the joint attention intervention, indicating that this approach might be especially suited to minimally verbal children (Kasari et al., 2008). Joint attention gestures in the preschool years, specifically pointing to share interest and showing, uniquely predicted language in the elementary school years, and children who were initially randomized to the joint attention intervention had the highest growth trajectory in showing and coordinated joint looking over the years from preschool to elementary school (Gulsrud, Hellemann, Freeman, & Kasari, 2014). Taken together, these results highlight the importance of addressing pre-linguistic skills when trying to improve communication in pre- and minimally verbal children.
When Changing Intervention Approach May Be Needed
Children who are continuing to struggle with expressive language may benefit from a change in intervention strategies and supports in order to promote communication, whether preverbal or minimally verbal. Many children may have exposure to common, recommended interventions, such as applied behavior analysis approaches of Discrete Trial Training (DTT) and Pivotal Response Teaching (PRT). These approaches focus strongly on spoken language with much less emphasis on ASD core deficits and pre-linguistic communication abilities. This heavy focus on spoken language as an isolated skill may not be sufficient to support expressive language development especially for minimally verbal children with ASD. Indeed, language outcomes are the weakest for children with autism who are receiving comprehensive DTT interventions (Smith, 2000). In contrast, developmental, behavioral interventions that focus on joint engagement, joint attention gestures and play have demonstrated increases in communication and spoken language in children with ASD, including minimally verbal children (Almirall et al., in press; DiStefano et al., in press; Goods, Ishijima, Chang, & Kasari, 2012, Kasari et al., 2008, 2014). Children who do not develop these foundational pre-linguistic skills easily will likely show increased benefit from interventions that focus broadly on linguistic and pre-linguistic communication, rather than exclusively on spoken language.
AAC Considerations
In addition to focusing on pre-linguistic skills, minimally verbal children are likely to benefit from access to an augmentative and alternative communication (ACC) device. Common forms of AAC include picture symbol systems or speech generating devices (SGD). Picture symbol systems, such as the Picture Exchange Communication System (PECS) are visually-based systems in which the child uses picture symbols to communicate with others. Studies of PECS have generally found that while PECS may increase requesting and vocalizations, children do not show overall gains in spoken language (e.g., Howlin, Gordon, Pasco, Wade, & Charman, 2007; Gordon et al., 2011). In contrast, SGD's display symbols that produce voice output when activated (often utilizing touch screens). A study investigating the effect of using an SGD within a play and joint attention based intervention (JASPER) plus a naturalistic behavioral language intervention, Enhanced Milieu Teaching (EMT; Kaiser & Roberts, 2013) found that minimally verbal school-age children with ASD showed greater gains in spoken language when they received intervention including the SGD, compared to children who received the same intervention without the SGD (Kasari et al., 2014). The study design allowed us to determine the effect of timing of the SGD with some children receiving the SGD at the beginning of JASPER+EMT intervention or after 3 months if they were responding slowly and had received JASPER+EMT without the SGD. Results indicated that improvements were greatest for children who received the SGD right from the start. These findings are very important, given that clinicians and parents are often concerned that the introduction of an SGD will impede a child's language development. Access to an SGD along with a developmentally appropriate intervention has the potential to support expressive language development in minimally verbal children. Multiple mechanisms have been suggested to explain this effect. It may be that using an SGD and hearing voice output as the therapist models SGD use gives children an additional avenue to communication, allowing them to sustain engagement in interactions, thus supporting their language development (Almirall et al., in press; DiStefano et al., in press). The SGD also provides phonemically consistent language modeling, which is likely helpful for the minimally verbal child learning to produce speech (Kasari et al., 2014).
Considerations of Age
There are few data to suggest the age at which we can determine if a preschool aged child will be minimally verbal at school aged. Children's language status is clearer by age 4 but the extent to which they will still be minimally verbal at age 5 or 6 years of age depends on many factors including whether they have had access to earlier interventions. When children have reached school age, and are still minimally verbal, clinicians are more likely to use a SGD. Yet our results suggest that beginning earlier may be more effective than waiting. The question is how early one should begin?
Romski et al. (2010)  found benefit of using SGD with 2-year-olds where children receiving intervention with the SGD showed greater increase in spoken and augmented communication than children who received intervention without the SGD. Our clinical experience with using a SGD (iPad) with preschool aged children is consistent with our experience with older children. Younger children also increase their communication rate, and spoken language with the addition of the SGD within JASPER, but if they are able to use spoken language they decrease the use of the SGD fairly quickly. Thus, spoken language naturally becomes more frequently used than the SGD.
Recommendations and Conclusion
Although a large number of preschool age children with ASD use no or limited spoken language, many of these children will go on to develop spoken language while a subset will continue to be minimally verbal past age five. The behavioral and neuroimaging research reviewed here supports the idea that minimally verbal children with ASD have specific and unique expressive language deficits, and are not simply at an earlier stage of language development. Distinguishing truly minimally verbal children from those who are pre-verbal, and thus are likely to attain language in the future, has the potential to inform intervention efforts.
There is abundant evidence that the use of a SGD can provide access to communication for minimally verbal school-aged children. We have no evidence that the addition of a SGD slows the development of spoken language at older or younger ages. For children who may not develop spoken language, the addition of a SGD provides critical access to communication. All indications are that for children with significantly delayed language at any age access to a SGD may jump start spoken language. The addition of a SGD should be considered within the context of an effective behavioral social communication intervention.
In summary, preschool aged children should be considered pre-verbal whereas minimally verbal children are more often school aged. Children who are minimally verbal often struggle with pre-linguistic skills, but display communicative intent without the language necessary to communicate clearly. These children will likely benefit from intervention that focuses on these impaired pre-linguistic skills (such as joint attention and gestures), as well as introduction of an AAC device (specifically a SGD). Because use of an SGD appears to have a positive effect on spoken language even in younger children, both pre-verbal and minimally verbal children may benefit from additional visual and auditory supports in the form of SGDs.
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The 19 individual SIG Perspectives publications have been relaunched as the new, all-in-one Perspectives of the ASHA Special Interest Groups.