Some minimally verbal autistic people show signs of written-language familiarity, study suggests

Minimally verbal autistic people demonstrate familiarity with spelling patterns, a new study suggests. But several communication researchers who were not involved in the work say they worry the finding could be used to support a controversial communication method.

In the study, 31 teenagers and adults with autism played a letter-tapping game reminiscent of Whac-A-Mole on a tablet computer, says lead investigator Vikram Jaswal, professor of psychology at the University of Virginia. The participants tapped letters on an alphabetical grid as they flashed one at a time. In some trials, the flashing letters spelled out a meaningful sentence that the researchers had previously read aloud to the participants.

About half of the participants tapped the letters faster when they were part of a meaningful sentence or common letter pairing (such as “he”). They also tapped letters faster than nonsense symbols and paused before tapping the first letter of a new word in the sentence.

These participants showed “foundational literacy skills,” Jaswal says, though hyperlexia, or an intense fascination with letters, could also explain these results, his team states in the study. The paper was published 21 February in Autism.

The reaction-time task is a standard way to measure implicit knowledge of orthographic regularities, or spelling patterns, says Nicole Conrad, professor of psychology at Saint Mary’s University in Halifax, Canada, who was not involved in the work. Although it’s a leap to say the observed patterns indicate literacy skills, she says, it “certainly shows that they are learning something that might be helpful for later reading.”

Every participant had used a letter board to communicate for at least a year prior to the study, and most had been in speech therapy for an average of almost 16 years, Jaswal’s team reported. “They have some familiarity with letters and how they go together. And that’s what we’re seeing on the task,” Conrad says. “It is interesting to show that can happen without explicit instruction.”

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one of the participants could communicate effectively through speech. Their individual abilities “ranged from not at all to a few word approximations to limited phrase speech,” the study states.

The study did not include detailed descriptions of the participants’ speech ability or any information about their receptive language ability, says Stephen Camarata, professor of hearing and speech sciences at Vanderbilt University, who was not involved in the work.

“If I tried to replicate this study, I wouldn’t necessarily know who to include,” Camarata says. “But overall, I think it’s credible. And I feel like they made a good-faith effort to really do this well.”

Jaswal did not assess receptive language skills because he could not identify a “measure that is quick, easy to administer, and which I can be confident provides an accurate indication of a nonspeaking autistic person’s receptive language ability,” he says.

A strength of the study, Camarata says, is that the tablet was propped up on a table in front of the participants; a facilitator did not hold the device or touch the participants.

But additional controls—such as scrambling letter order or using mirror-image and upside-down letters—would have made the conclusions more robust, says Katharine Beals, adjunct professor in the autism program at Drexel University, who was not involved in the study. “They’re hitting targets on something that looks very similar to the communication board they use all the time,” Beals says.

The experimenters also should have included a condition in which letters flashed in a meaningful sentence without the experimenters reading the sentence out loud beforehand, she says.

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hree researchers, including Beals, told The Transmitter they view Jaswal’s new study as a workaround for validating facilitated communication—a discredited technique in which a facilitator helps a nonspeaking person tap out a message on a letter board by holding their hand, shoulder or wrist—without testing the users outright.

“He’s looking to find evidence to make facilitated communication more plausible, because one of the questions that skeptics like me will raise is, ‘Do these kids really have literacy skills?’” Beals says.

Message-passing tests, in which an examiner gives information to the nonspeaking person but not their facilitator, discredited facilitated communication in the 1990s. The nonspeaking people could only answer questions correctly when their facilitator was privy to the information, indicating the facilitator was the true author of the communications.

Over the next few decades, the technique “went underground, and then it resurfaced under different names, including ‘spelling to communicate’ and ‘rapid prompting method,’” says Ralf Schlosser, professor of communication sciences and disorders at Northeastern University.

In the new methods, the facilitator holds the letterboard and does not touch the participant. “They’re saying they’re not physically manipulating messages so they shouldn’t be put in the same boat as facilitated communication,” but facilitators may unconsciously move the board while holding it, Schlosser says.

In 2018, a committee from the American Speech-Language-Hearing Association, which included Schlosser, reviewed the literature for studies that supported or discredited the rapid prompting method. “The review came out empty,” Schlosser says, meaning there were no studies that supported either the effectiveness or ineffectiveness of the technique.

The committee “felt comfortable enough” to extrapolate from the evidence against facilitated communication and conclude that rapid prompting “is a dangerous technique and should not be used,” Schlosser says. Unlike with facilitated communication, proponents of the rapid prompting method have refused to directly test message authorship, he adds.

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inimally verbal autistic people looked at each letter on a letterboard for about half a second before pointing to it, a 2020 study by Jaswal and his colleagues found. Jaswal and his team argued this eye-tracking work was evidence that letterboard messages were authentic communications from the participants.

The study faced backlash from critics of the rapid prompting method. “It just defies logic,” says Howard Shane, director of the Center for Communication Enhancement at Boston Children’s Hospital. “Why do they need to go to these extremes?”

Beals and Schlosser say they see the new letter-tapping study as another iteration of the eye-tracking paper: an attempt to indirectly prove message authorship without testing participants. Shane says if the nonspeaking people who participated in these studies can tap letters on a tablet without facilitator intervention, they should be able to communicate that way, too. “Why didn’t they just type?” Shane says.

Camarata says he understands this critique, but “I want to build a firewall here, between this [study] and support for rapid prompting,” Camarata says. “It does not, in my opinion, in any way, shape or form support rapid prompting.”

Jaswal also denies that his study attempts to validate rapid prompting. “I’m not sure where this interpretation of the study comes from,” he says. “This study was not about authenticating any method of communication. It was an attempt to use a reaction-time task—a cornerstone of methodology in cognitive psychology—to investigate whether some nonspeaking autistic people have acquired some foundational literacy skills.”

Despite the criticisms, “my hope is that our findings motivate more research about literacy in this population,” Jaswal says, “including how to measure it, how to support its acquisition, and how to leverage it to provide nonspeaking autistic people with access to effective alternatives to speech.”