AJSLP
Tutorial
When Will He Talk? An Evidence-Based
Tutorial for Measuring Progress Toward
Use of Spoken Words in Preverbal
Children With Autism Spectrum Disorder
Jena McDaniela
Purpose: Professionals face substantial challenges determining
whether and when children with autism spectrum disorder
(ASD) who are not yet using spoken words will use spoken
language as their primary means of communication. This
tutorial provides speech-language pathologists with practical
guidance on how to measure expressive language predictors
for progress monitoring and making intervention decisions
for children with ASD who are preverbal.
Method: This tutorial is a repackaging effort that seeks to
make the research accessible to clinicians wishing to implement
evidence-based practice.
Results: We describe intentional communication, consonant
inventory in communication acts, and responding to joint
attention as particularly valuable prelinguistic skills to measure.
We explain how and when to efficiently assess progress using
published assessments periodically and using brief (5-min)
communication samples for more frequent progress monitoring.
F
or typical language learners, the milestone of first
words is expected around the first birthday (Oller
et al., 1999). Typically, by 2 years of age, toddlers
have a vocabulary of several hundred words and, between
2 and 3 years of age, children’s communication with multi-
word utterances blossoms. What is perhaps most remarkable
is how seamless and effortless learning to talk is for most
children. The same is not true for children with developmen-
tal disabilities, including autism spectrum disorder (ASD).
For children with ASD, first words often do not appear at
the anticipated time nor with great ease (Tager-Flusberg
a
Life Span Institute, University of Kansas, Lawrence
b
Department of Hearing and Speech Sciences, Vanderbilt University
Medical Center, Nashville, TN
Correspondence to Jena McDaniel: jena.c.mcdaniel@ku.edu
Editor-in-Chief: Julie Barkmeier-Kraemer
Editor: Danai Kasambira Fannin
Received July 11, 2020
Revision received September 28, 2020
Accepted October 26, 2020
https://doi.org/10.1044/2020_AJSLP-20-00206
American Journal of Speech-Language Pathology • Vol. 30 • 1–18 • January 2021 • Copyright © 2021 American Speech-Language-Hearing Association
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and C. Melanie Schueleb
Conclusions: Communication samples can be used to
show how a child performs within a therapeutic setting
during teaching (treatment data) and outside of the
therapeutic setting (generalization probe data). Both types
of data are critical for determining whether the child is
exhibiting progress and which aspects of intervention are
facilitating progress toward use of spoken words. These
recommendations also balance the evidence for best
practices for progress monitoring and the demands on
clinicians’ time and effort. To encourage the measurement
of prelinguistic skills of children with ASD who are preverbal
in clinical practice, we include (a) example data collection
documents, (b) examples with hypothetical data and
interpretation, and (c) guidance on communication sampling
procedures.
Supplemental Material: https://doi.org/10.23641/asha.
13557836
et al., 2005). In fact, parents commonly report lack of spo-
ken words as an early concern prior to their child’s diagno-
sis of ASD (Hess & Landa, 2012; Ozonoff et al., 2009).
During the early course of development, children with
ASD vary widely in their spoken language skills (Ellis
Weismer et al., 2010; Luyster et al., 2008; Pickett et al., 2009).
Some, albeit a small percentage, score within age expecta-
tions on early language measures (Ellis Weismer et al., 2010).
However, many preschool children with ASD are not yet
producing any words, and approximately 50%–70% are not
using spoken phrases (Ellis Weismer & Kover, 2015; Thurm
et al., 2015). Many of those children will learn to use spoken
words and phrases. However, approximately 25%–30% of
children with ASD are expected to remain minimally verbal
and not use spoken language as their primary means of
communication (Anderson et al., 2007; National Research
Council, 2001; Tager-Flusberg & Kasari, 2013; Tager-
Flusberg et al., 2005; Wodka et al., 2013). Age alone is an
insufficient predictor for whether a child will talk. Pickett
Disclosure: The authors have declared that no competing interests existed at the time
of publication.
1
 et al. (2009) concluded that, for children with ASD who are
not talking at age 5 years, the emergence of spoken words is
more likely before age 7 years than after. Yet, some children
with ASD reportedly started talking as late as 13 years of
age (Pickett et al., 2009; Williams, 1990).
A more robust ability to predict which children with
ASD will use spoken words would improve clinical deci-
sions about prioritizing intervention goals, particularly goals
related to communication modes. Some children with ASD
who are preverbal may benefit most from interventions with
a strong emphasis on spoken words. Others may benefit
from a strong emphasis on augmentative and alternative
communication (AAC). Complicating clinical decisions
further, a child’s relative benefit from different communica-
tion modes may change as his or her skills change. Knowing
the degree to which a child is exhibiting the necessary foun-
dational skills for spoken words provides critical informa-
tion as to whether or not intervention strategies should be
adjusted. Examination of prelinguistic skills may signal that
a child is progressing toward spoken words and provide en-
couragement for continuing current intervention efforts. In
contrast, if a child is not progressing toward spoken words
as expected, the current intervention plan should be reevalu-
ated and adjusted as appropriate (e.g., change intervention
strategies or intensity). These questions should be considered
on an ongoing and frequent basis. Thus, frequent data col-
lection is needed for making clinical decisions (e.g., whether
the strategies, goals, approach, and/or intensity of interven-
tion needs to be altered).
This tutorial applies empirical knowledge about pre-
dictors of expressive language growth in children with ASD
who are preverbal to evaluating change, including incremen-
tal change, in clinical and educational settings. We use the
term preverbal to convey that the children are using no or
few words at this time and whose treatment goals include
acquisition of spoken language. A portion of these children
(approximately 25%–30%) are expected to remain minimally
verbal based on current evidence. Determining that a child
is likely to remain minimally verbal requires examining their
prelinguistic skills and progress over time. Thus, the speech-
language pathologist (SLP) does not need to know whether
a child will use spoken words and phrases to implement the
empirically supported assessment approach described in this
tutorial. Some children will show progress toward spoken
words, and intervention will be tailored to maximize spoken
language gains. For other children, careful analysis of their
progress toward spoken words, even with changes to inter-
vention strategies, may lead to a reduced emphasis on spoken
words and increased emphasis on AAC. In both scenarios,
the analysis of key prelinguistic skills when the child is not
using spoken words facilitates clinical decisions to improve
outcomes.
In this tutorial, we describe the value of measuring
prelinguistic skills and then describe three particularly valu-
able prelinguistic skills for predicting expressive language
skills in children with ASD. We then describe how to assess
prelinguistic skills periodically and through frequent prog-
ress monitoring to capture incremental change. We conclude
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by explaining how to modify intervention based on assessment
data and by describing future research needs.
The Value of Measuring Prelinguistic Skills
Prelinguistic skills emerge prior to the onset of spo-
ken words and include the use of nonverbal means of com-
munication. Prelinguistic behaviors include gestures (e.g.,
waving, reaching, and pointing), vocalizations (e.g., cooing
and canonical babbling), and eye gaze (e.g., looking back
and forth between an object and another person and look-
ing at something another person is pointing toward; Watt
et al., 2006). Unlike spoken words, prelinguistic forms of
communication are not symbolic. Nonetheless, prelinguistic
communication is purposeful and conveys meaning. For ex-
ample, when a child reaches toward a container of bubbles
on a high shelf while looking back and forth between the
bubbles and an adult, she is likely requesting that the adult
retrieve the bubbles for her. As another example, a child
lifts his arms while looking at his caregiver in an apparent
request to be picked up. The child may add a vocalization,
if the initial gesture is ineffective. A child also may extend
her arm toward an adult to show a ball or other favorite
toy in order for the adult to enjoy that item as she does. Thus,
even without spoken words, children direct requests and
comments about ongoing activities toward other people.
Importantly, prelinguistic skills predict expressive
spoken language skills in children with and without ASD.
For example, Watt et al. (2006) reported that joint attention
and consonant inventory in the second year of life predicted
age 3 years expressive language outcomes for children with
typical development. Morales et al. (2000) also found that
responding to joint attention accounted for unique variance
in later vocabulary development in children with typical de-
velopment. For children with ASD, a recent meta-analysis
revealed a strong association between vocalizations and
later expressive language (mean r = .50, 95% CI [0.23, 0.76];
McDaniel et al., 2018). Other prelinguistic skills, such as
responding to joint attention (Paul et al., 2008; Thurm
et al., 2007; Yoder et al., 2015), intentional communication
(Charman et al. 2005; Plumb & Wetherby, 2013; Yoder, 2006;
Yoder et al., 2015), and gestures (Luyster et al., 2008), also
have predicted later expressive language outcomes in children
with ASD. Describing a child’s prelinguistic skills provides
a rich picture of the child’s progress toward spoken words.
Particularly Valuable Prelinguistic Skills
for Predicting Expressive Language
Skills in Children With ASD
Selecting prelinguistic skill predictors that yield the
most useful information increases progress monitoring effi-
ciency and provides data for evidence-based, data-driven
intervention planning. Replicated findings support the value
of three prelinguistic skills for predicting expressive language
growth in preverbal children with ASD: intentional commu-
nication, consonant inventory in communication acts (also
 known as diversity of key consonants used in communica-
tion acts), and responding to joint attention (Charman
et al., 2005; Paul et al., 2008; Plumb & Wetherby, 2013;
Thurm et al., 2007; Wetherby et al., 2007; Woynaroski et al.,
2016; Yoder et al., 2015). Measuring these skills improves
the prediction of expressive language outcomes above and
beyond other tested variables. Thus, investing time in evalu-
ating these three predictors is expected to yield more “bang
for your buck” than other predictors.
Yoder et al. (2015) identified these three predictors
(as well as parent linguistic responses) as improving the pre-
diction of expressive language skills even when accounting
for seven other empirically supported predictors (i.e., recep-
tive language, attention during child-directed speech, motor
imitation, nonimitative oral motor functioning, object play,
cognitive impairment level, and ASD severity). They evalu-
ated the predictors across 16 months (beginning at a mean
age of 34.7 months). Across a longer period of time, Charman
et al. (2005) found that the rate of nonverbal intentional
communication acts at age 2 years predicted language skills
at age 7 years. Similar to Yoder et al. (2015), Wetherby
et al. (2007) identified consonant inventory in communi-
cation acts as a particularly valuable predictor of expressive
language skills in children with ASD at age 3 years. Siller
and Sigman (2008) identified responding to joint attention
as the strongest predictor of language development in children
with ASD. Thus, replicated findings support using inten-
tional communication, consonant inventory in communica-
tion acts, and responding to joint attention for monitoring
spoken language development in children with ASD who
are not yet talking or just beginning to talk.
In the following sections, we first define intentional
communication, consonant inventory in communication acts,
and responding to joint attention and describe how each of
these predictors connects with expressive language. We then
explain the development of these skills in children with typi-
cal development and children with ASD in Table 1.
Intentional Communication
Intentional communication can be defined as a child’s
use of gestures, vocalizations, gaze, and/or spoken words to
convey meaning to another person (Wetherby et al., 1988).
Gestures used by young children who are not yet talking or
just beginning to talk can be classified as contact gestures
(e.g., reaching, showing, and giving objects), distal gestures
(e.g., raising arms to be picked up and pointing at some-
thing at a distance to request or direct another person’s atten-
tion), and representational gestures (e.g., waving, nodding
and shaking head, and blowing a kiss). When a child displays
intentional communication, which includes attention to an-
other individual and an object or event, these behaviors
or groups of behaviors are referred to as communication
acts. Communication acts may include multiple forms of
communication, such as pointing to an object while looking
back and forth between an object and a person or vocalizing
while giving an object in apparent request for help.
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Intentional communication is important to capture
because children with ASD who frequently engage in inten-
tional communication acts to express their wants, needs,
and thoughts and to direct others’ attention show an un-
derlying desire to communicate (Bruner, 1974). Caregivers
may respond to their children’s prelinguistic intentional com-
munication acts with linguistic input that supports the child’s
understanding of spoken words, a necessary skill for expres-
sive language use (McDaniel et al., 2017; Yoder, 2006). One
example of such linguistic input is linguistic mapping, wherein
the adult describes the child’s action and/or underlying
message. For example, a child points to a ball and says,
“Uh,” and then the caregiver says, “That’s a ball,” as a lin-
guistic map (Yoder & Warren, 2002). Children who frequently
exhibit intentional communication acts may elicit more fre-
quent and/or more complex linguistic input from caregivers
that supports language development (Gros-Louis et al., 2006).
They also may engage in more interactions that facilitate
object knowledge. Such object knowledge is one cognitive
basis for learning early words (McDaniel et al., 2017).
Consonant Inventory in Communication Acts
Consonant inventory in communication acts (the
number of different consonants used communicatively) is a
measure of phonological complexity. Use of more conso-
nants within communication acts indicates more developed
phonological skills than a relatively restricted consonant in-
ventory. Consonant inventory in communication acts also
includes a communicative component because only conso-
nants within communication acts are counted. Thus, conso-
nants produced in vocalizations that do not appear to serve a
communicative function (e.g., repetitive or self-stimulating
behaviors) are not counted. Children who use a wide variety
of consonants during communication acts may be attempt-
ing to say words they understand prior to those words being
understood by listeners (Woynaroski et al., 2016). Those
children who use a wide variety of consonants during com-
munication acts also may be exhibiting oral motor skills
shared with spoken language (McDaniel et al., 2017).
Responding to Joint Attention
Responding to joint attention requires a child to shift
his or her gaze from a current focus to the referent of the
adult’s bid for attention (Yoder et al., 2015). Adults’ bids
can include pointing, spoken words, and/or eye gaze (Bottema-
Beutel, 2016; Yoder et al., 2015). For example, a child may
be looking down at a book when his father points at a bird
outside the window while saying, “Look!” The child then
lifts his head and shifts his gaze to his father and follows his
father’s point to look at the bird. In contrast to initiating
joint attention, responding to joint attention can only hap-
pen if and when a communication partner provides a bid to
the child. Thus, this skill necessitates that the child is moni-
toring another person’s communication and that monitoring
leads to a response. When children consistently respond to
joint attention, they may attend to and benefit more from
McDaniel & Schuele: When Will He Talk? 3
 Table 1. Comparison of particularly valuable prelinguistic skills in children with typical development and children with autism spectrum disorder.

Children with typical Children with autism spectrum

Prelinguistic skill development (TD) disorder (ASD)

Intentional communication
Consonant inventory in
communication acts
Responding to joint
attention
• Emerges around 8–9 months (R. L. Carpenter
et al., 1983; M. Carpenter et al., 1998)
• Examples include an infant raising her arms to
request being picked up or handing a caregiver
an object to request help
• Use of conventional communication (e.g., pointing
and nodding) and symbolic communication
(e.g., spoken words and manual signs) emerges
around 12 months (Bates et al., 1975; Wetherby &
Prizant, 1989)
• Combine multiple forms of communication to
increase effectiveness (e.g., add vocalizations to
pointing when mother is not attending to child’s
object of interest; Wu & Gros-Louis, 2014)
• Initially produce reflective, primitive sounds based
on general state (e.g., comfortable, hungry, or tired)
and not intentional (Oller, 2000; Oller et al., 1999)
• Vocalizations become intentional and more
complex in first year of life (Oller, 2000; Oller
et al., 1999)
• Produce precanonical babbling (e.g., marginal
babbling, squeals, and full vowels) around
3–8 months (Nathani et al., 2006; Oller, 2000;
Oller et al., 1999)
• Produce canonical syllables (i.e., consonant–vowels
syllables with adultlike transitions between the
consonant and vowel, such as “buh” and “dah”)
around 5–10 months
• Use canonical syllables within intentional
communication, which emerges around
8–9 months (e.g., “buh-buh” while reaching
for a toy and looking toward an adult or
using “dadada” to gain an adult’s attention)
• Follow an adult’s point under certain conditions
around 9 months (M. Carpenter et al., 1998;
Lempers, 1979)
• Reliably respond to bids for joint attention around
12–15 months (Bakeman & Adamson, 1984;
M. Carpenter et al., 1998)
• Ability to follow another individual’s point usually
precedes the ability to follow a person’s gaze to an
object (M. Carpenter et al., 1998; Lempers, 1979)
• May use forms of communication not
observed in children with TD (e.g., another
person’s hand as a tool; Lord, 1995; Stone
et al., 1997)
• Lower rates of intentional communication
(Wetherby et al., 2007) and smaller inventory
of conventional gestures than children with
TD and children with other developmental
disabilities (Charman et al., 2003; Watson
et al., 2013)
• Rate of nonverbal communication acts for
2-year-old children with ASD predicted
outcomes in multiple domains (e.g., social
and communication skills) 5 years later
(Charman et al., 2005)
• Smaller consonant inventories than children
without ASD (Landa et al., 2013; Wetherby
et al., 2007)
• Produce more nonspeech and atypical
vocalizations (e.g., high-pitched squeals
and low-pitched growls or glottal sounds),
which tend to include few or no consonants,
than children without ASD (Landa et al.,
2013; Plumb & Wetherby, 2013; Sheinkopf
et al., 2000; Wetherby et al., 2007)
• Decreased responsivity to bids for joint
attention compared with children with TD
(M. Carpenter et al., 1998, 2002; Chawarska
et al., 2012; Wetherby, 2006)
• Difficulty following adults’ points, other
gestures, and eye gaze (Baron-Cohen, 1989;
Baron-Cohen et al., 1997; M. Carpenter et al.,
2002)
• As a group, children with ASD followed the
same pattern of joint attention as children
with TD (e.g., sharing attention, then following
attention, and then directing others’ attention),
but 25% of them followed a different pattern
(e.g., directing others’ attention before following
bids for joint attention; M. Carpenter et al.,
2002)
• Some children with ASD appear to follow
gaze later than expected relative to other
joint attention skills (Paparella et al., 2011)

language input from adults than when they do not respond may also develop greater expressive language skills compared
to joint attention or respond inconsistently. For example, with children with ASD with lower joint attention skills.
children with ASD who tend to respond consistently to bids
for joint attention may benefit more from linguistic map-
ping, follow-in comments, and expansions compared with
children who less consistently respond to bids for joint atten-
How to Assess Prelinguistic Skills
tion (McDaniel et al., 2017; Siller & Sigman, 2008). As a Monitoring progress is a critical component of pro-
result, children with ASD with greater joint attention skills viding evidence-based intervention. SLPs must determine

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 the degree to which a child is responding to an intervention
to determine whether and how services need to be adjusted.
Data collection for clinical decisions needs to be proactive
and frequent. Assessment does not just occur during the
child’s first appointment or during his or her eligibility eval-
uation. Furthermore, the type of assessment data collected
during therapy sessions for progress monitoring differs from
that collected during an initial or annual evaluation to de-
termine eligibility and general areas of strength and need.
The selected published assessments for evaluating prelin-
guistic skills described below are more appropriate for ini-
tial or annual assessments than progress monitoring due to
the time required to administer and score. For progress
monitoring, we recommend using brief, frequent commu-
nication samples during therapy sessions to provide data
needed for clinical decisions. Such progress monitoring helps
SLPs determine the degree to which a child is responding to
an intervention by assessing performance within and outside
of a therapeutic context (Olswang & Bain, 1994).
Selected Published Assessments for Evaluating
Prelinguistic Skills Periodically
Several published assessments use specific tasks or
activities to assess intentional communication, consonant
inventory in communication acts, and/or responding to
joint attention. See Table 2. These assessments look very
different than traditional speech-language assessments that
use books of picture stimuli and ask children to respond to
questions and directions. Published assessments that focus
on early communication skills provide a framework for
observing skills that may be particularly helpful to profes-
sionals with less experience assessing early communication
skills. The framework helps SLPs identify salient features
of early communication that may be underappreciated or
hard to notice without training.
Several limitations of these published assessments
should be acknowledged. Most notably, they require sub-
stantial time and expertise to score and interpret. The ad-
ministration times are comparable to or shorter than common
language assessments, but scoring video-recorded sessions
for specific behaviors can be quite time-consuming. There-
fore, even though some of the published assessments can
capture subtle changes in prelinguistic skills, they were not
designed to be administered frequently (e.g., weekly). Be-
cause some of these published assessments are not readily
available in a user-friendly form (e.g., Early Social Commu-
nication Scales; Mundy et al., 2003), SLPs may have to de-
vote substantial time to understanding the administration
procedures and gathering all of the supplies. Despite these

Table 2. Selected published communication assessments for children with ASD who are preverbal.

Assessment Description Developmental level Skill area(s) assessed

Communication • Norm-referenced assessment 6–24 months • Twenty types of behaviors are

and Symbolic of communicative competence
Behavior Scales • The 30-min behavior sample
Developmental includes communication
Profile Behavior temptations, book sharing,
Sample (Wetherby symbolic and constructive
& Prizant, 2002) play probes, and a language
comprehension probe
Communication • A scripted assessment with a
Complexity series of 12 play-based activities
Scale (Brady • 12-point scale that describes the
et al., 2012) early expressive communication
skills of individuals who primarily
communicate with presymbolic
or early symbolic means
• Approximately 20–30 min to
administer
Communication • An expressive communication
Matrix (Rowland, measure designed for individuals
2004) with complex communication
needs (e.g., difficulty producing
natural speech)
• Based on a series of questions and
observations, a graphical display
of the individual’s communication
skills is generated
• Approximately 10–60 min to complete
Early Social • A 15- to 25-min structured observation
Communication designed to measure nonverbal
Scales (Mundy communication skills
et al., 2003) • The examiner presents nine tasks,
such as object spectacle, social
interaction, gaze following, and
turn-taking tasks
Birth to word combinations
(words, signs, and/or
augmentative and
alternative communication
[AAC] symbols)
Birth to 24 months
8–30 months
scored including rates of intentional
communication, consonants used in
communication acts, and responding
to joint attention
• Social, speech, and symbolic composite
scores are provided
• Scale encompasses preintentional
(e.g., environmental awareness
and attending to object or person),
intentional nonsymbolic (e.g., gestures
and vocalizations), and beginning
symbolic communication (e.g., words,
signs, or AAC symbols)
• Inventories how an individual
communicates for four functions
(i.e., refuse, obtain, social interaction,
and information exchange) and at
seven stages of communication
development, including preintentional,
intentional, presymbolic, and symbolic
communication
• Focuses on the child’s ability to initiate
and respond to three types of behavior:
joint attention, behavioral requests,
and social interaction

McDaniel & Schuele: When Will He Talk? 5

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 limitations, the published assessments can yield useful infor-
mation when used with children displaying early communi-
cation skills. Additionally, they can provide a framework
for communication samples. The manuals often include help-
ful descriptions of key behaviors, such as definitions and
examples of joint attention and intentional communication.
Frequent Progress Monitoring of Prelinguistic Skills
to Capture Incremental Change
Progress monitoring measures must be relatively
brief in time to administer and score so that they can be
administered repeatedly across short time intervals. In addi-
tion, progress monitoring measures must capture change at
relatively small increments (not just large changes) to docu-
ment change over these short time intervals. It is essential
to capture not only the achievement of a goal (i.e., large
change) but also any incremental changes so as to inform
intervention planning on a week-to-week basis. For exam-
ple, let us assume a long-term goal of spoken words for a
child with ASD who is 3 years old and not yet talking. In-
tervention focused on spoken language may yield many
changes that are evidence of moving toward the goal long
before the goal of spoken words, or even the subgoal of first
words, is actually achieved. A progress monitoring measure
that captures change only at the level of number of spoken
words will not be adequate to individualize intervention.
Selecting and administering appropriate progress
monitoring assessments can be difficult for an SLP work-
ing with young children with ASD. Children with ASD
may have difficulty understanding assessment tasks, and
social impairments may interfere with test performance
(Barokova & Tager-Flusberg, 2018; Tager-Flusberg, 2000).
Furthermore, methods for progress monitoring prelinguis-
tic skills are fewer than for progress monitoring skills be-
yond the preverbal stage (Tager-Flusberg et al., 2009).
One progress monitoring tool that is designed for the
prelinguistic stage is the Early Communication Indicator
(ECI; Greenwood et al., 2019). It is one of the Individual
Growth and Development Indicators developed to assess
progress in children birth to 3 years of age (Greenwood et al.,
2019, 2011, 2006; Luze et al., 2001; Priest et al., 2001). The
ECI assesses total communication, gestures, vocalizations,
single words, and multiple words during a 6-min play-based
assessment with a standardized set of toys (i.e., house or
farm set). The ECI could be used to measure intentional
communication. However, it is not designed to be scored
in sufficient detail to collect data on the consonant inven-
tory in communication acts and does not include specific
opportunities for responding to joint attention. Thus, we
describe how to use data from therapeutic activities and
communication sampling to collect the necessary data for
evidence-based clinical decisions in place of or in addition
to published assessments.
We apply the framework described by Olswang and
Bain (1994) to discuss the details of data collection for mak-
ing intervention decisions (i.e., progress monitoring) for chil-
dren with ASD who are preverbal. It often is very helpful
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to know how a child performs within a therapeutic setting
when teaching is occurring (i.e., treatment data) as well as
outside of the therapeutic setting (i.e., generalization probe
data; Olswang & Bain, 1994). Seeing progress within a
treatment session provides encouraging data; however,
ultimately, the child needs to be able to use those skills
in everyday environments with a variety of communication
partners. We consider (a) what to measure, (b) how to mea-
sure, and (c) when to measure to make intervention deci-
sions for children with ASD who are preverbal.
What to Measure
For what to measure, we focus on intentional com-
munication, consonant inventory in communication acts,
and responding to joint attention. As we have already dis-
cussed, these variables are particularly predictive of expres-
sive language skills for children with ASD who are not yet
talking.
Supplemental Material S1 includes blank example
data collection documents for monitoring intentional com-
munication, consonant inventory in communication acts,
and responding to joint attention in communication sam-
ples. These documents can be adapted by SLPs for specific
children. They do not need to be used in their current form.
Instead, SLPs are encouraged to modify the number of tar-
get trials, communication sample context, format, level of
prompting provided, and other features to meet the prog-
ress monitoring needs of the children they serve. The details
of the progress monitoring procedures also should continue
to evolve as the evidence base for intervention for children
with ASD develops.
Intentional communication. Intentional communica-
tion may be quantified in different ways, including the total
number of intentional communication acts or the number of
communication acts with a certain feature (e.g., total types
of functions and forms) within a specified period of time (e.g.,
5 min). Examining a child’s repertoire of functions and forms
may highlight specific areas of need for intervention. Be-
cause intentional communication includes prelinguistic as
well as linguistic communication acts, measures of inten-
tional communication are appropriate for children at the pre-
linguistic level and those beginning to use linguistic forms,
such as spoken words or signs. SLPs can weight higher level
forms of intentional communication with more points to
show growth over time. For example, children receive
1 point for nonsymbolic intentional communication acts,
2 points for communication acts with a single spoken (or
signed) word, and 3 points for communication acts with
spoken (or signed) phrases for the weighted frequency of
intentional communication (also known as weighted triadic
communication; Greenwood et al., 2006; Yoder et al.,
2009). The example data collection form for intentional
communication in Supplemental Material S1 divides the
observed communication acts into nonsymbolic, single
spoken words/signs, and spoken/signed phrases to permit
differential weighting, if desired. Alternatively, one could
focus on nonsymbolic communication with separate boxes for
acts that use vocal communication, gestural communication,
 or both. Such a system would specify how a child is using
nonsymbolic communication and whether over time he or
she is more frequently combining modes (i.e., vocalization
plus gesture) to communicate more effectively.
For children who are not producing intentional com-
munication acts, consider marking intentional behaviors
that they demonstrate, which an adult can interpret. Inten-
tional behaviors are actions that the child does on purpose
but that are not yet directed toward another individual. For
example, the child may smile and/or vocalize when he or
she sees a favorite toy character without looking between
the character and a person. Thus, the child produces an
intentional behavior(s) that suggest he or she would like
the character but does not direct the behaviors to another
person. Even though the act is not intentional communica-
tion, it includes several skills foundational to intentional
communication (e.g., apparent interest in object/activity, vo-
calizing, and displaying appropriate facial expressions). As
another example, the child may push away a food in appar-
ent protest while only looking at the food. The child signals
that he or she does not want the food but does not direct
that message toward a communication partner. In contrast,
when the child hands food back to his communication part-
ner, that action would be classified as intentional commu-
nication. Intentional behaviors, such as those described in
these examples, may become the child’s means of intentional
communication especially with targeted intervention. Moni-
toring the frequency and diversity of intentional behavior
can indicate forms and/or functions of intentional commu-
nication most likely to develop with continued support.
Consonant inventory in communication acts. The di-
versity of key consonants used in communication acts is an
empirically supported way to measure consonant inventory
in communication acts (Wetherby et al., 2007; Woynaroski
et al., 2016; Yoder et al., 2015). To calculate the diversity
of key consonants used in communication acts, count the
number of specific “key” consonants (i.e., /m/, /n/, /b/ or /p/,
/d/ or /t/, /g/ or /k/, /j/, /w/, /l/, /s/, and /ʃ/) that the child uses
communicatively. These consonants were identified as “key”
because most appear relatively early in typical development
and listeners can reliably identify them. Because voiced–
voiceless cognates (i.e., /b/ vs. /p/, /d/ vs. /t/, and /g/ vs. /k/)
are hard to distinguish reliably, children receive only 1 point
for each pair regardless of whether they use one or both of
the consonants. Thus, the maximum score is 10. The conso-
nants may be produced in nonword vocalizations or spoken
words, as long they are in communication acts. Whether
the consonant was used in a communication act is the focus
of the analysis, not whether it was produced in a word
(McDaniel et al., 2019). Consonants produced outside of
communication acts are not counted. An SLP can use a
form similar to the blank example data collection form for
consonant inventory in communication acts in Supplemen-
tal Material S1 to circle the consonants observed within a
communication sample.
For children who are not producing consonants, re-
cording the types of sounds the child is producing (in addi-
tion to continuing to listen for consonants) and the degree
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to which he or she is using sounds communicatively may
be informative. Progress may be seen first in a reduction of
atypical vocalizations (e.g., high-pitch squeals and low-pitch
growls) or an increase in using vowels within communica-
tion acts. This approach to documenting progress focuses
on what the child is doing, rather than what he or she is not
doing. Observing what the child is doing enables the SLP
to make week-to-week decisions about whether and how
the focus and/or approach of intervention needs to change
in light of the incremental progress and long-term goals.
For example, a child may exhibit increasing use of vowels,
but not consonants, within communication acts. A logical
focus for intervention would be building from that commu-
nicative intent and providing many opportunities for the
child to use consonants within meaningful contexts to elicit
communicative use of consonants. Possible strategies include
recasts, follow-in comments, and linguistic mapping from
the adult to provide rich linguistic input.
Responding to joint attention. Children must be pro-
vided with opportunities to demonstrate their responses to
bids for joint attention because responding to joint atten-
tion inherently follows another individual’s action. Sufficient
opportunities are required for stable estimates. The exam-
iner also must attend to the type(s) of cues he or she pro-
vided (e.g., pointing toward versus looking toward the
object of interest). The example data collection form for
responding to joint attention in Supplemental Material S1
provides spaces to note the type of joint attention bids
provided, accuracy for each trial, and overall accuracy for
the session.
For children who currently do not respond to bids
for joint attention independently, documenting the type and
amount of support necessary to elicit a response can capture
progress even though the child is not demonstrating the
skill independently. SLPs can adjust the level of support
to identify the child’s current skill level and then increase
difficulty over time. For example, saying “Look!” while
looking toward and pointing to a picture on the wall
provides more support than saying, “Wow!” when look-
ing at an exciting toy because the first includes a pointing
gesture.
How to Measure
Communication samples address multiple weaknesses
of published assessments (e.g., long administration and/or
scoring time and limited flexibility). They provide an excel-
lent opportunity to collect treatment data and generalization
probe data regarding prelinguistic skills of interest in clini-
cal and educational settings (Barokova & Tager-Flusberg,
2018; Kasari et al., 2013; Tager-Flusberg et al., 2009). In-
tentional communication, consonant inventory in commu-
nication acts, and responding to joint attention can be (but
do not have to be) measured within a single communica-
tion sample. We use the term communication sampling rather
than language sampling to emphasize the assessment of pre-
linguistic skills rather than spoken words. Nonetheless, most
language sampling principles and recommendations apply.
Communication sampling typically involves video-recording
McDaniel & Schuele: When Will He Talk? 7
 a child in a context that offers opportunities to communi-
cate and identifying and analyzing specific behaviors by
reviewing the video recording. If only a limited number of
behaviors are of interest, live communication sampling may
be possible. However, recording samples is preferred to per-
mit multiple viewings of subtle cues or details, which may
not have been of interest initially and to share with other
team members. In this section, we describe how communica-
tion samples can be used to collect generalization probe
data as well as treatment data.
For generalization probe data, we are interested in
how the child performs outside of a therapeutic context. When
using communication samples for generalization probe data,
it is advantageous to keep many of the features of the sam-
ple constant across repeated measures. For example, for
each sample, use the same communication partner, same
room, same length (e.g., 5 min), and the same set of toys
for the communication samples, ones that are not used in
therapy. This consistency not only reduces the number of
factors that may influence the child’s performance day to
day but also makes the sampling procedure more routine
and less cognitively demanding for the SLP. The generaliza-
tion probe data can be gathered from the treating SLP inter-
acting with the child without using all of the supports that
are typical in treatment. The SLP sets up the environment
to support engagement and communication. Engagement
is supported by following the child’s lead and joining in
play at the child’s demonstrated level of play. Communica-
tion is supported by talking about topics related to the
child’s focus of attention, monitoring utterance length and
complexity (while maintaining grammatical utterances),
and avoiding directives (except when needed for safety).
This interaction style minimizes modeling and prompting
of communication and language, which differentiates it
from interaction styles often used in therapeutic activities.
Consequently, this communication sample is likely to re-
semble those used during evaluation sessions more than a
typical therapy session.
The sample data collection pages (see Supplemental
Material S1) include spaces to record the context of the
sample (e.g., activity, communication partner, and setting).
If an SLP uses the same interaction style for all generaliza-
tion probe communication samples, a shorthand phrase,
such as “communication sampling procedure,” can be used
to describe the support. See the intentional communication
page in the Appendix for an example. Generalization data
also can be collected during communication samples with
a peer or teacher who is unlikely to use therapeutic strategies
during the sample. This communication sample could take
place in the therapy room, classroom, cafeteria, playground,
or other common location. The data collection documents in
Supplemental Material S1 can still be used. They include
spaces to write the context of the sample.
For treatment data, we are interested in how the child
performs with therapeutic support. Thus, the communica-
tion sampling context is the therapeutic context rather than
using the interaction style described for collecting gen-
eralization probe data. For example, an SLP may provide
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opportunities for the child to request and comment while
building Mr. Potato Head to facilitate intentional commu-
nication acts. The SLP can record the number of inten-
tional communication acts observed during the sample, which
includes support from the therapeutic strategies (e.g., with-
holding objects, offering choices, follow-in comments, and
linguistic mapping). See the Appendix for an example. The
example document divides the intentional communication
acts into nonsymbolic acts, single words, and phrases to
capture key changes in the onset of spoken words. The
use of nonsymbolic communication acts is expected to pre-
cede spoken words and to increase across the prelinguistic
period. We also record the activity and supports on the
document to provide context for interpreting the results.
Similarly, SLPs can use the example documents for
consonant inventory in communication acts and respond-
ing to joint attention. They can record the data live during
a therapeutic activity (which is the communication sample)
or watch the brief video recording after the session. If a re-
cording is used, it would be possible to document multiple
prelinguistic skills (i.e., intentional communication, conso-
nant inventory in communication acts, and responding to
joint attention) from a single sample. SLPs can weigh these
options based on the degree to which it is possible to re-
cord data live, the logistics of recording sessions, and the
frequency with which data need to be collected, which we
consider in the next section.
When to Measure
For when to measure treatment data, we recommend
collecting some data during every treatment session. Such
data will not necessarily cover every goal in every session.
Nonetheless, the data should be related to the child’s long-
term goal. For children with ASD who are preverbal, asses-
sing intentional communication, consonant inventory in
communication acts, or responding to joint attention would
all relate to the long-term goal of use of spoken words. For
example, if the SLP sees a child 2 times per week, the SLP
might collect treatment data for each of two of the three
subgoals during one activity per session. That plan would
permit treatment data from one or two sessions per week
to inform planning for the next week.
For generalization probe data, we recommend starting
by collecting weekly 5-min communication samples with
children with ASD who are preverbal. This frequency and
length balance the available empirical evidence and the
current demands on clinicians’ time and effort. For many
variables, we do not have empirical support for the exact
amount of time needed to collect a stable estimate that re-
sults in individuals being similarly ranked across testing occa-
sions separated by short periods of time (e.g., 2 or 4 weeks).
In contrast, an unstable measure fluctuates between adminis-
trations and is influenced by extraneous factors beyond the
skill being assessed (e.g., fatigue, attention, and social en-
gagement). Samples increase in stability as they increase in
length and as the child’s level of skills increases (McDaniel,
in press; Sandbank & Yoder, 2014; Yoder et al., 2018).
When a child is just beginning to show a new skill, more
 variability is observed. Relevant to assessing prelinguistic
skills, we found that consonant inventory in communica-
tion acts was sufficiently stable with only two 6-min ECI
(Greenwood et al., 2019, 2011) samples for young children
with ASD (13–30 months of age; McDaniel, Yoder, et al.,
2019). Twelve months later, only one 6-min ECI was needed
for this same sample of children with ASD.
Based on the available empirical evidence and known
demands on SLPs’ time, we anticipate that this level of
treatment data (i.e., each session) and generalization probe
data (i.e., weekly) will be sensitive to change but not overly
burdensome for collection and interpretation. The data are
likely to provide the SLP with sufficient information to read-
ily describe the child’s progress and current skills, including
the information needed to update annual Individualized Fam-
ily Service Plans (before age 3;0 [years;months]) or Individ-
ualized Education Programs (after age 3;0). For students
receiving services from a third-party payer, assessments may
be required to demonstrate the need for continued services,
in addition to the treatment and generalization probe data.
The published assessments described in the prior section and
Table 2 may fulfill that need. Nonetheless, some children
are going to require more frequent and/or longer samples
for adequate stability to show incremental change. In such
cases, consider increasing the length of the sample or com-
bining samples from multiple sessions in an effort to reduce
variability from one observation to the next (e.g., Wetherby
et al., 1988; Yoder et al., 2018). For example, consider col-
lecting a 5-min sample 3 times per week, adding the results
together, and examining the results on a week-to-week basis
rather than session-by-session basis to make patterns and
progress more salient. This viewpoint is analogous to exam-
ining the stock market over a period of weeks or months
rather than day to day. Also consider confirming that the
features of the sample context are as consistent as possi-
ble to minimize other potentially influential factors (e.g.,
communication partner, activity/set of toys, time of day,
and level of fatigue). For example, the SLP may discover
that a child shows greater success in the morning relative
to the afternoon. Collecting the sample at the same time
of day would be expected to reduce the observed variabil-
ity. Another approach to gathering more data would be
to ask the child’s caregivers or teachers to provide input.
The SLP could ask the caregivers or teachers about how
the child is communicating with them or using different
consonant sounds, for example.
Modifying Intervention Based
on Assessment Data
The progress monitoring data enables SLPs to evalu-
ate week-to-week progress to adjust intervention strategies
as needed to maximize outcomes. By keeping track of the
child’s level of success with different levels of support, the
SLP can interpret which supports are helpful, which are in-
effective, and which can be faded because the child exhibits
the skills in at least some contexts without support.
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For data interpretation and intervention planning, it
is important to distinguish between predictors of expressive
language growth and malleable factors in children with ASD
who are preverbal. Being a predictor of expressive language
does not in and of itself indicate that the predictor should
be targeted. For example, chronological age often correlates
with expressive language; however, we cannot target the
child’s chronological age as an intervention target. None-
theless, if a predictor is a malleable factor with theoretical
and empirical support that its relation with expressive lan-
guage is or could be causal, it can be considered for an in-
tervention target. Recognizing the underlying rationale for
why these predictors might affect language growth and the
expected patterns of development in children with typical
development and children with ASD can guide interven-
tion planning decisions. The three predictors we describe in
this article differ in the state of the evidence. Intentional
communication presents with more supportive evidence than
consonant inventory in communication acts and responding
to joint attention. Nonetheless, the latter two still present
with supportive theoretical and empirical evidence. When
implementing the progress monitoring procedures described
above, the SLP will be able to determine the degree to
which these variables are changing and make informed clini-
cal decisions regarding changes in intervention approaches
and focuses.
Intentional Communication
A number of intervention strategies including, but not
limited to, Hanen More Than Words (Carter et al., 2011),
Parent-Mediated Communication-Focused Treatment in
Children With Autism (Green et al., 2010), Picture Ex-
change Communication System (Yoder & Stone, 2006),
Pivotal Response Treatment (Hardan et al., 2015), and
Responsive Education and Prelinguistic Milieu Teaching
(Yoder & Stone, 2006) have demonstrated success in im-
proving language skills of children with ASD. Thus, inten-
tional communication can be addressed via multiple avenues.
Targeting intentional communication necessarily involves
attending to how the child uses a variety of forms of com-
munication. Intentional communication includes nonverbal
forms of communication (e.g., gestures, vocalizations, and
eye gaze) as well as signs and aided forms of AAC. Chil-
dren with ASD have demonstrated benefit from AAC for
developing intentional communication and other language
skills (Ganz et al., 2012; Kasari et al., 2014). An SLP may
consider introducing AAC strategies and track the degree
to which the child uses those strategies for intentional com-
munication and whether increased use of spoken language
is used simultaneously. For example, when introduced to a
speech-generating device (SGD), a child may initially show
increased requesting with the SGD, followed by increases
in vocalizations. This pattern would support continued use
of the SGD to augment spoken communication. In con-
trast, another child who is also introduced to an SGD may
initially show increased requesting with the SGD but no in-
creases in vocalizations. This pattern would support in-
creased emphasis on the use of the SGD and potentially
McDaniel & Schuele: When Will He Talk? 9
 other forms of AAC to support intentional communication
(Schlosser et al., 2007). In addition to considering the fre-
quency and forms (e.g., use of vocalizations, signs, and
AAC) of communication, functions of communication should
be considered as well when selecting more specific interven-
tion targets.
Consonant Inventory in Communication Acts
Consonant inventory in communication acts helps
maintain the focus of intervention on the communicative
use of consonants and the complexity of vocal communica-
tion rather than on nonspeech oral motor skills. Nonspeech
oral motor exercises should be avoided due to a lack of
supportive evidence, even if used in an attempt to expand
a child’s consonant inventory (McCauley et al., 2009). Al-
though limited information is known about the specific
means through which children with ASD expand their con-
sonant inventory in communication acts, intentional com-
munication and parent linguistic responses may facilitate its
growth through receptive vocabulary (Woynaroski et al.,
2016). Increases in intentional communication and parent
linguistic responses may first result in receptive vocabulary
growth and then expansion of the child’s consonant inven-
tory in communication acts. Theoretically, once children
understand words, they begin to try to say those words in
communication acts, even if they are not identifiable words
to the listener (Woynaroski et al., 2016). Additional evidence
shows that expanded consonant use is at least partially re-
sponsible for the increase in intentional communication
leading to increased expressive language skills (McDaniel
et al., 2017). Thus, seeing change in consonant use in com-
munication acts is encouraging for progress toward use of
spoken words. However, we do not yet know the degree to
which directly targeting consonant use improves expressive
language skills in children with ASD who are preverbal. If
progress is not observed in the child’s use of consonants in
communication acts despite data-driven adjustments to the
intervention approach, the SLP may consider shifting to-
ward initiating or emphasizing AAC strategies (e.g., SGD,
picture symbols, or signs) to support expressive language
skills. The child’s consonant inventory in communication
acts should still be monitored across that time to know
whether a shift toward spoken language is warranted as
the child develops further.
Responding to Joint Attention
To document incremental progress in responding to
joint attention, careful observation of the cues provided (e.g.,
proximal point, distal point, or eye gaze with or without a
verbalization such as “Look!”) and the child’s response (e.g.,
looking to speaker’s hand or looking to the object of inter-
est) is needed. Because the cues from the communicative
partner can dramatically change the communicative difficulty
level, the specific cues provided should be noted during inter-
vention. Improvements in responding to joint attention fol-
lowing developmental and behavioral interventions have
been reported (Kasari et al., 2006, 2010; White et al., 2011).
For example, Kasari et al. (2006) reported that preschool
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children with ASD exhibited greater improvement in respond-
ing to joint attention after a joint attention intervention that
combined developmental and applied behavioral analysis
strategies than did children randomly assigned to the sym-
bolic play group or the control group.
Future Research Needs
Continued research is needed to predict more accurately
the communication and language outcomes of children with
ASD who are preverbal, to develop and refine valid and re-
liable measures of prelinguistic and early language skills in
children with ASD for use in clinical practice, and to de-
velop interventions that maximize spoken language outcomes
for children with ASD. Measures for clinical practice must
consider feasibility including the amount of training, adminis-
tration time, and scoring time required. These measures may
use a combination of direct observation, caregiver and/or
teacher report, and automated (computer) analyses for vocal
analysis for example (LENA Research Foundation, 2015).
Related to intervention development, more evidence about
the rate and type of progress expected during specific inter-
ventions will improve SLPs’ and related professionals’ abili-
ties to determine whether an individual child is making
expected progress or whether his or her progress is slower
than expected and intervention changes need to be consid-
ered. As mentioned above, we also need additional evidence
of the degree to which interventions directly targeting con-
sonant use improve expressive language skills in children
with ASD who are preverbal. Achieving these goals could
improve dramatically the long-term outcomes of children
with ASD who are preverbal and support them and their
families across the life span.
Conclusions
In this tutorial, we have discussed the identification,
measurement, and application of three particularly strong
predictors of expressive language growth in preverbal chil-
dren with ASD (i.e., intentional communication, consonant
inventory in communicative acts, and responding to joint
attention). Changing the questions posed for progress mon-
itoring for children with ASD who are preverbal could in-
fluence intervention practices positively. By changing the
question from “How many words does he use?” to questions
about predictors of expressive language growth, such as
“Which sounds is he using communicatively?” and “How
is she expressing her wants and needs?” the response changes
from “Zero,” to descriptions of what the child with ASD can
do. Focusing on skills rather than deficits is not only more
encouraging but also more informative for intervention. Eval-
uating predictors of expressive language growth could eluci-
date small but meaningful changes in communication skills
and, when needed, provide the impetus for changing the
course of intervention. Observing these meaningful changes
or the lack of these meaningful changes is particularly sig-
nificant for SLPs serving children with ASD who are prever-
bal and their families. Currently, there is limited guidance
 for decisions regarding how to measure expressive language
predictors for progress monitoring and making intervention
decisions for children with ASD who are preverbal. By using
the clinical procedures described in this tutorial, SLPs can
be more confident in their decisions to continue with a cur-
rent intervention approach or to change course. These deci-
sions enable children with ASD who are preverbal to receive
high-quality, effective intervention services that are tailored
to their specific needs and growth over time.
Acknowledgments
All authors read and approved the final manuscript. This re-
search was supported by a U.S. Department of Education Prepa-
ration of Leadership Personnel grant (H325D140087; PI: Schuele)
and the National Institute of Child Health and Human Develop-
ment (U54HD090216; PI: Colombo Kansas Intellectual and De-
velopmental Disabilities Research Center).
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Data Collection Documents With Hypothetical Data

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Data Collection Documents With Hypothetical Data

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Data Collection Documents With Hypothetical Data

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Data Collection Documents With Hypothetical Data

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