eISSN 1982-0216

DOI: 10.1590/1982-0216/20252716724 | Rev. CEFAC. 2025;27(1):e6724

Original articles

Morphosyntactic development in autistic children by

implementing the Development of Communication Skills
in Autism (DHACA) method
Matheus Phellipe Santos Felix da Silva1
Gabriela Nascimento Oliveira Moreira2
Aline Samara Silva de Freitas2
Ana Cristina de Albuquerque Montenegro1

1
Universidade Federal de Pernambuco -
UFPE, Programa de Pós-Graduação em
ABSTRACT
Saúde da Comunicação Humana, Recife, Purpose: to investigate whether the Development of Communication Skills in Autism
Pernambuco, Brasil.
(DHACA) method promotes morphosyntactic development in nonverbal and minimally
2
Universidade Federal de Pernambuco -
UFPE, Curso de Fonoaudiologia, Recife, verbal autistic children.
Pernambuco, Brasil. Methods: a case series study with a sample of 12 nonverbal or minimally verbal children
with autism spectrum disorder (ASD), aged 2 to 5 years. The intervention consisted of
16 to 20 sessions, using alternative communication through the DHACA method, by
employing a low-tech alternative communication book. Data were collected from each
child’s weekly progress records.
Results: after the intervention, two children (16.67%) developed the ability to produce
three-word sentences, eight children (66.67%) began producing 3-to-4-word sentences,
and two children (16.67%) produced sentences with varied parts of speech. Considering
the communicative skills achieved after the intervention, these children attained
morphosyntactic structures with 3 to 7 words and diverse pragmatic functions.
Conclusion: the intervention using the DHACA method contributed to morphosyntactic
development, evidenced by an increase in sentence length and complexity, development
of pragmatic functions, and expansion of vocabulary, ultimately promoting more functional
communication.
Keywords: Autistic Disorder; Communication; Speech, Language and Hearing Sciences;
Communication Aids for Disabled; Child Language

A study conducted at the Universidade

Federal de Pernambuco - UFPE,
Postgraduate Program in Human
Communication Health, Recife, PE, Brazil.
Financial support: Nothing to declare
Conflict of interests: Nonexistent

Corresponding author:
Ana Cristina Montenegro
Avenida Artur Rego, sn.
Cidade Universitária
CEP: 50740-525 – Recife, PE, Brasil
E-mail: ana.amontenegro@ufpe.br

Received on June 28, 2024

Received in a revised form on September
16, 2024 © 2025 Silva et al. This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits
Accepted on November 5, 2024 unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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INTRODUCTION through a robust alternative communication system

Language develops gradually, with its pragmatic, in speech-language-hearing interventions. It empha-
semantic, morphosyntactic, phonetic, and phonological sizes the development of linguistic aspects (pragmatic,
components evolving in alignment with their respective semantic, and morphosyntactic), expanding commu-
maturational stages – which are continuously influ- nicative functions. As children achieve new skills, they
enced by the environment and interactions with others1. begin to use diverse morphosyntactic elements, repre-
Morphosyntactic aspects are foundational pillars in sented within communicative contexts mediated by
communication development, as they address the the interlocutor10. The method employs strategies such
internal structural components of language, including as modeling and physical, visual, and verbal cues. It
word formation and syntax (function)1,2. also incorporates a playful and personalized approach
tailored to each child’s interests in objects or activities,
Autism spectrum disorder (ASD) is a neurodevelop-
fostering interaction and engagement. This strategy
mental disorder characterized by persistent deficits in
supports functional language learning8,10.
social communication, language, and social interaction;
This study aimed to investigate whether the DHACA
restricted, repetitive, and/or stereotyped patterns of
method promotes morphosyntactic development in
behavior; and limited interests or activities, present
nonverbal and minimally verbal autistic children, from
from early childhood3,4. Morphosyntax may be impaired
the perspective of linguistic process development,
in ASD, manifesting as difficulties in word combinations
using the DHACA communication book.
and grammatical aspects, including structural trunca-
tions and errors and word omissions and substitutions.
These impairments may involve errors in verb tense METHODS
marking, article and conjunction use, and generally The study was approved by the Human Research
reduced use of closed-class words (e.g., pronouns), Ethics Committee at the Universidade Federal de
particularly in the early language acquisition stages3,4. Pernambuco, PE, Brazil, under protocol number
Augmentative and alternative communication (AAC) 4.692.479 and CAAE 66933317.9.0000.5208, adhering
is one of the various resources available to develop to ethical principles and legal regulations in force. All
communication in individuals with ASD. AAC is a subfield parents/guardians who participated in the study signed
of assistive technology, providing individuals whose an informed consent form, ensuring they were fully
communication needs are complex with the means informed about the study’s objectives.
to improve and establish functional communication This longitudinal case series study had a sample
tailored to their specific characteristics, individualities, of 12 children with ASD. Participants were recruited
and realities5,6. The Development of Communication through the waiting list management of a speech-
Skills in Autism (DHACA) is a method adapted to the language-hearing teaching clinic affiliated with the
linguistic reality of Brazilian Portuguese7-10, employing Unified Health System (SUS). All research proce-
a robust AAC system to foster communication devel- dures were carried out at this clinic in a chronological
opment in children with ASD. sequence, including an interview/medical history
The DHACA method is based on Tomasello’s survey, assessment, intervention, and reassessment.
sociopragmatic theory11, according to which language The inclusion criteria were as follows: nonverbal
originated in the culture, emerging from linguistic or minimally verbal children, aged 2 to 5 years, with a
signs transmitted through daily interactions between positive medical diagnosis of ASD and support level 1
individuals. This process fosters language development or 2, who had never received speech-language-hearing
by viewing interlocutors as communication partners therapy with alternative communication. The exclusion
and intentional agents who contribute to the primary criteria were children with the following comorbidities:
transmission and communication modes. Additionally, intellectual disability, ophthalmological issues, hearing
during language acquisition, children perceive entire impairment, speech motor disorders, developmental
linguistic structures within the language input as coordination disorders, and/or untreated epilepsy.
effective units for constructing their own language. Clinical data collection began by surveying
Hence, communication partners have an essential role the children’s medical history with their parents/
in providing an AAC-supported linguistic model9-11. guardians, gathering information on general identifi-
The DHACA method is a pioneering, Brazilian cation, pregnancy (perinatal, prenatal, and postnatal),
approach designed to promote communication skills and the child’s overall development (motor, sensory,

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behavioral, language, speech, breastfeeding, nutrition, the DHACA method, filling out progress forms with
sleep, health history, and early signs of ASD). In the specific topics for later analysis.
second phase, the 12 children were assessed with The DHACA method gradually stimulates children
formal protocols. Then, interventions began using a according to each of the five skills, as outlined in
robust low-tech alternative communication system from Chart 1.

Chart 1. Skills of the Development of Communication Skills In Autism method (Montenegro et al., 2024)10

Number DHACA method’s skills

1 Initial Communicative Intention
2 Request with Lexical Expansion in Accessory Vocabulary
3 Request with Lexical and Morphosyntactic Expansion
4 Morphosyntactic, Lexical, and Communicative Functions Expansion
5 Dialog

Each child received a DHACA book, consisting of needs are added to the accessory vocabulary, with
66 pictograms representing essential vocabulary on tabs being added beyond the child’s interests, allowing
a single page with pre-established figures, along with communication partners to use the DHACA book.
tabs containing additional vocabulary pictograms. The third (3) skill introduces greater complexity, as it
These were added as the child’s skills progressed, involves “Request with Lexical and Morphosyntactic
in a personalized manner based on the objectives of Expansion,” where the child is encouraged to construct
each skill (Appendix 1). The pictograms were overlaid the sentence “I + Want + 2 Pictograms.” The picto-
with single lines, representing lexical categories such grams used to form sentences can come from either
as colors, numbers, alphabet, people, time, feelings, the accessory or essential vocabulary tabs. In the fourth
shapes, foods, fruits, vegetables, places, hygiene, (4) skill, “Morphosyntactic, Lexical, and Communicative
attributes, body parts, greetings, animals, means of Functions Expansion,” the child is expected to form
transportation, toys, children’s videos (YouTube), and sentences with three or more words, expressing
so forth. These were added according to the child’s various communicative functions, such as questions
linguistic development, family needs, and other social with interrogative pronouns (when, what, who, where,
contexts during the intervention. Parents/guardians etc.), comments, spontaneous information, expression
received guidance at the end of each session to of feelings, ideas, and greetings (salutations, farewells,
encourage the use of the DHACA book beyond the and thanks). In the fifth (5) and final skill, “Dialog,” the
clinical therapeutic environment. child is stimulated to develop greater communicative
The intervention initially stimulated all children complexity, being able to communicate through the
to develop the first (1) skill, “Initial Communicative book with an expanded lexicon and demonstrating
Intention,” aimed at constructing the sentence “I + Want improved conversational skills – e.g., narrating, telling
+ Pictogram” by inserting a single pictogram above and retelling stories, telling jokes, and sustaining and
the essential vocabulary page, reaching up to four maintaining conversations in various communicative
pictograms. The second (2) skill focuses on “Request contexts.
with Lexical Expansion in Accessory Vocabulary,” Thus, 20 individual sessions lasting 30 to 45 minutes
where the child is encouraged to request something were held weekly over 9 months. The therapeutic
from the communication partner by constructing the room where the sessions took place measured 3 m2,
sentence “I + Want + Pictogram.” In this case, the with an infant-sized table and chair (60 cm), rubber
pictogram is no longer isolated but is present in the mats on the floor, and a two-door wooden cabinet.
accessory vocabulary tabs, which are inserted in this The latter was used to store the therapeutic materials
skill. It is important to note that, starting from this skill, presented throughout the session according to the
in addition to the child’s specific demand and restricted child’s interests and requests through the personalized
and repetitive interests, pictograms related to family pictograms in the DHACA book. Additionally, at the end

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of each session, the caregivers received guidance on (Appendix 2), including communicative skills acquired
how to use the DHACA book in other contexts (such per session, the number of pictograms used in each
as church, park, school, etc.), beyond the clinical skill, the pictograms used in each session according
environment. to the parts of speech, the total number of pictograms
As the sessions advanced, the follow-up therapists used after the intervention, and the sentences they
filled out progress forms systematically while the fixed constructed. It is important to note that the productions
therapist conducted the intervention in the therapy were considered based on communication mediated
room. These forms contained information about the by the DHACA AAC book, not on verbal production
method’s skill being stimulated and acquired, the associated with the resource.
pictograms the child used in sentences, and whether
they used the pictograms spontaneously or after the
RESULTS
communication partner prompted a response. After
each session, the progress form was corrected by the Male children predominated among the 12 partici-
therapist who conducted the intervention. This infor- pants, as 10 (83.3%) were males, and only two (16.7%)
mation was entered into a Google Excel spreadsheet were females. As shown in Table 1, age was distributed
along with general data initially collected in the medical as follows: five children (50%) were 36 to 47 months
history survey, including details such as the child’s old, five children (50%) were 48 to 50 months old, and
sex and age and their and their caregivers’ education only two children were 25 to 35 months old. Six (50%)
levels. Post-intervention data were collected in the children attended daycare, while the other six (50%) did
weekly progress record form from each child’s file not attend any educational institution.

Table 1. Distribution of sex, age group, and education in the sample

Sex n = 12 %
Males 10 83.3%
Females 2 16.7%
Age n = 12 %
25 to 35 months 2 16.67%
36 to 47 months 5 41.67%
48 to 50 months 5 41.67%
Children’s education level n = 12 %
Attending daycare centers 6 50%
Not attending daycare canters 6 50%
Captions: n = total sample number. % = percentage per sex, age and children’s education level.

Furthermore, C3, C4, C5, and C12 were nonverbal, (75%) mothers were high school graduates, while three
while C1, C2, C6, C7, C8, C9, C10, and C11 were (25%) had a bachelor’s degree. As for the fathers, eight
minimally verbal. Only C1 and C9 were females, while (66.67%) were high school graduates, three (25%) had
the remaining children were males. incomplete middle school, and one (8.33%) was illit-
Regarding the caregivers’ education level, nine erate, as shown in Table 2.

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Table 2. Parents/guardians’ education level

Parents/guardians’ education level Mother’s education (%) Father’s education (%)

Illiterate 0% 8.33%
Incomplete middle school 0% 25%
High school graduates 75% 66.67%
Bachelor’s degree 25% 0%
Caption: % = percentage of the parents/guardians’ education levels, divided between mothers and fathers, in relation to the total number of participants.

Table 3 presents the DHACA method’s communi- whereas 66.67% of the sample reached the third
cative skills data before and after the intervention. The skill (“Request with Lexical and Morphosyntactic
results indicate that all children had acquired the first Expansion”), and two (16.67%) children reached
skill (“Initial Communicative Intention”). Moreover, only the fourth skill (“Morphosyntactic, Lexical, and
two (16.67%) remained in the second skill (“Request Communicative Functions Expansion”). None of them
with Lexical Expansion in Accessory Vocabulary”), reached the “Dialog” skill.

Table 3. Skills of the Development of Communication Skills in Autism method present before and after the intervention

Number of children Number of children after

DHACA skills Children %
before the intervention the intervention
Initial Communicative Intention (1) 0 0 0 0%
Request with Lexical Expansion in
0 C8 and C11 2 16.67%
Accessory Vocabulary (2)
C2, C3, C4, C6,
Request with Lexical and
0 C7, C9, C10, and 8 66.67%
Morphosyntactic Expansion (3)
C12
Morphosyntactic, Lexical, and
0 C1 and C5 2 16.67%
Communicative Functions Expansion (4)
Dialog (5) 0 0 0 0%
Caption: % = percentage of the number of children who acquired the corresponding skills in the Development of Communication Skills in Autism method after the
intervention.

Table 4 shows a greater use of morphosyntactic verbs, nouns, articles, and adjectives, thus presenting
structures and longer sentences constructed using broader morphosyntactic structures. C1 and C5
the DHACA alternative communication book as the (16.67%) reached skill 4 and produced extensive and
children progressed through skills 2, 3, and 4. C8 and complex sentences with up to seven words and various
C11 (16.67%) reached skill 2, constructing three-word communicative functions, using constituent segments
sentences. C2, C3, C4, C6, C7, C9, C10, and C12 heterogeneously.
(66.67%) produced four-word sentences and used new

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Table 4. Sentence structured per skill after the intervention with the Development of Communication Skills in Autism method

Method’s skill Children Sentence structure

Request with Lexical Expansion in
C8 and C11 Pronoun + Verb + Noun
Accessory Vocabulary (2)
Pronoun + Verb + Verb + Noun
Request with Lexical and C2, C3, C4, C6, C7, C9, C10,
Pronoun + Verb + Noun + Adjective
Morphosyntactic Expansion (3) and C12
Pronoun + Verb + Article + Noun
Pronoun + Verb + Verb + Noun
Pronoun + Verb + Noun + Adjective
Pronoun + Verb + Article + Noun + Adjective
Morphosyntactic, Lexical, Pronoun + Verb + Article + Noun + Adverb
and Communicative Functions C1 and C5 Pronoun + Verb + Verb + Article + Noun +
Expansion (4) Adjective + Adverb
Article + Noun + Verb + Adjective
Article + Noun + Adjective + Verb + Preposition +
Article + Noun

Figure 1 and Table 4 show a significant variation as skills. This variation reflects the lexicon expansion and
they acquired more complex skills regarding morpho- the increase in parts of speech within morphosyntactic
logical word classification, according to the pictograms construction.
used in the sessions and DHACA’s communicative

Figure 1. Total number of pictograms used in the communication skills achieved after the intervention with the Development of
Communication Skills in Autism, per part of speech

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C1 and C5, upon reaching the fourth skill, used There was also an increased use of words and greater
more pictograms (approximately 53.5) than the other heterogeneity in the morphological sentence structure,
children, who were distributed across skills 2 and 3. as indicated by the data in Figure 2 and Table 4.

Figure 2. Number of pictograms used by children after the intervention with the Development of Communication Skills in Autism method

Figure 3 shows that C1 and C5 stood out for using a other communicative functions. The eight children in
greater variety of pictograms, as they had reached the the third skill used an average of ±22.8 different picto-
DHACA method’s fourth skill, with greater morphosyn- grams, as shown in Table 3, whereas C8 and C11 used
tactic extension and complexity, along with the use of approximately ±10 pictograms, as presented in Table 5.

Table 5. Children’s average use of word pictograms per communication skill achieved after the intervention with the Development of
Communication Skills in Autism method

Average number of pictograms

DHACA skills after the intervention Children (C)
used by the children
Request with Lexical Expansion in Accessory
C8 and C11 ±10
Vocabulary (2)
Request with Lexical and Morphosyntactic C2, C3, C4, C6, C7, C9, C10,
±22.8
Expansion (3) and C12
Morphosyntactic, Lexical, and Communicative
C1 and C5 ±53.5
Functions Expansion (4)

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Figure 3. Number of different sentences constructed by children after the intervention with the communication book of the Development
of Communication Skills in Autism method

Figure 3 shows a heterogeneous distribution of the The analysis found a uniform distribution between
number of different sentences each child constructed the 12 children’s education levels, without significant
after the intervention. C1 and C5 produced the most, variations. Six (50%) attended daycare centers, while
followed by C2, C4, C7, C9, and C12. the other six (50%) had not yet attended any formal
educational setting, regardless of the level. These
DISCUSSION results suggest an equal division between the groups
of children in the early stages of the intervention,
Language development in childhood is a dynamic
with no evidence of a direct influence on the devel-
process, characterized by the expansion of the lexicon
opment of communication and language skills19. It is
and morphosyntactic structuring12. However, in autism,
important to note that the analysis in this study showed
there is a deviation along the way, with significant
no significant relationship between the children’s
deficits that impair language acquisition and use.
education or the parents’ education levels influencing
Nonetheless, the literature scarcely addresses morpho-
the outcomes, given the heterogeneity in the method’s
syntactic development in ASD in detail3,4,13-15.
skills, highlighting the clinical relevance in autism, as
The data analysis indicated a significant predomi-
evidenced by the results in Table 3.
nance of males. This finding supports what the liter-
ature describes about the higher prevalence of the The DHACA method’s intervention results in
disorder in males than females – approximately four sentence construction, presented in Table 4, show
times higher (4.3%) than in females (1.1%), according that it favored and enhanced the linguistic organization
to the latest data published by the Centers for Disease and enabled higher levels of structuring the linguistic
Control and Prevention (CDC)16. Similar data have also system of the participating children with ASD. These
been reported in Brazil17,18, although these estimates results are rather important, considering the structural
may vary depending on different age groups, studies, morphosyntactic changes in autism requiring inter-
and regions. Moreover, the exact reason for this sex vention, as they are essential for functional commu-
difference in autism prevalence remains an ongoing nication development13,20,21. Furthermore, despite the
focus of investigation. This study found no implications efforts in various studies to better understand language
that could compromise the results due to the predomi- development in children with ASD, there is a lack of
nance of males. research with detailed results of grammatical structure

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advancements after AAC intervention, particularly with interests, highlighting the importance of a personalized
a robust alternative communication system. alternative communication book.
The DHACA book10 (which contains a robust, The children who advanced in the DHACA method’s
low-tech alternative communication system) combined communicative skills made varied functional use of new
with appropriate strategies during the intervention verbs, understanding the aspects that give meaning
promoted the functional use of more robust linguistic to an object through language and its application.
structures, as shown in Table 4. This was accompanied Furthermore, the visual and concrete nature of the
by an expanded vocabulary (Figure 2, Table 5) and DHACA alternative communication book facilitated the
various parts of speech, as described in Figure 1. association between morphosyntactic structures (form
Some recent studies22,23 show significantly improved and function)28, as the children understood the different
functional communication with sentence construction uses of verbs in communicative situations through the
development after using AAC in children with ASD. DHACA book. This aligns with the perspective that AAC
However, they do not describe the sentence structures promotes transversal communicative and behavioral
achieved in detail. performance – i.e., across different contexts, situations,
Tomasello’s sociopragmatic theory, which and environments29.
underpins the DHACA method, asserts that language Tables 4 and 5 and Figures 1 and 2 show a
develops through its use11,24. Thus, children produced noticeable heterogeneous expansion of linguistic struc-
sentence structures during playful activities in thera- tural elements. The two (16.67%) children who acquired
peutic sessions – i.e., they developed functional skill 2 demonstrated initial sentence constructions for
communication by using and appropriating the alter- requesting, using pronoun-verb-noun combinations
native communication system. such as “I want ball,” “I want water,” “I want milk,” “I
Although no Brazilian study has detailed the devel- want juice,” with varied noun usage always tied to their
opment of typical or atypical children’s vocabulary, interests. The children who reached skill 3 – the largest
children with ASD in this study have noticeably made group (66.67%) of children per skill – used sentences
functional use of simple and complex sentence with more diversified communicative functions and
constructions, according to the communicative skills pronouns, verbs, nouns, adjectives, adverbs, and
outlined in the DHACA method (2, 3, and 4). Their prepositions – e.g., “I want to drink water,” “I’m going
vocabulary using the DHACA alternative communi- to get the car,” “I want more snacks,” “I want to go out
cation book ranged from eight to 58 words, as shown in now,” “I want to eat pasta,” forming more extensive
Figure 2. The lack of studies presenting the number of and complex morphosyntactic structures with four
words typical children use in AAC books is a significant to five words. Moreover, the two (16.67%) children in
gap in communication and language development skill 4 expanded their morphosyntax, lexicon, and
research, as the absence of complementary param- communicative functions as proposed. As a result, their
eters limits analytical generalization. morphosyntactic constructions had greater diversity,
Furthermore, noun use increased significantly. with more elaborated sentences and the use of other
Using nouns with pictograms representing objects, parts of speech – e.g., “I’m going to get the blue car,”
food, and activities related to the children’s preferences “I’m going to get the red circle,” “The doll is inside the
is part of the DHACA method’s intervention strategy house,” “The water is hot,” “The cow is outside the
for early skills. Literature discussions indicate that the house,” “I want to play with the ball,” “I want to play
high number of nouns may be linked to restricted and with the yellow ball,” “The doll is sad,” and so on. They
repetitive interests, focusing on specific items or activ- used more pictograms with diverse communicative
ities – the increased noun usage could be attributed to functions, forming sentences of up to seven words. The
these interests, a clinical characteristic of children with 12 children constructed 191 sentences altogether after
ASD25. It is important to note that this strategy helps the intervention, a significant value considering the lack
them acquire initial sentence construction (subject + of parameters in other studies and the fact that such
verb + noun), encouraged in the DHACA method’s first morphosyntactic constructions had not been observed
skill (“Initial Communicative Intention”). It also helps before the intervention.
children strengthen their ability to communicate26,27 Furthermore, the children constructed diverse
and expand their vocabulary. Moreover, the nouns sentences after the intervention, as shown by the
were selected individually for each child based on their data in Table 5 and Figure 3. This demonstrates

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that the DHACA method allows the child to make after the intervention with a robust alternative commu-
their own analyses and generalizations in language nication system – they did not have significant or
development11. even rudimentary communicative abilities before. The
It was also observed that as children began using advancements evidenced after the intervention with
longer sentences with various pragmatic functions and the DHACA method were linked to a notable expansion
expanded the possibilities and gains in communicative and complexity in the morphosyntactic structure of the
functions, they used nouns less often. As a result, they sentences, an increase in vocabulary, and the devel-
were no longer limited to using language for requesting opment of pragmatic functions used by the children,
and intentionally manipulated morphosyntactic struc- providing them with the necessary tools for more
tures. Given that language structure emerges from its functional communication.
use11,24, the children developed language primarily by Communication development also promoted
communicating with the interlocutor and understanding autonomy and greater inclusion in social contexts, as
how they use language. In the context of this study, they could express themselves using the method’s
this development was facilitated by the DHACA book10. robust alternative communication system. This
Some authors state in their studies that children with research has vast and multifaceted implications. Its
ASD show positive correlations with visual attention, results provide a foundation for future investigations
their inputs, and receptive language. Therefore, the exploring in greater depth and breadth the morpho-
greater the capacity for comprehension and repre- syntactic development in children with ASD, using the
sentational understanding of pictographic symbols DHACA method.
and the relationship between them, the greater their
language comprehension and expansion of pragmatic
ACKNOWLEDGMENT
functions28,30,31.
It can also be inferred that the children with ASD Gratitude is extended to the families of the children
analyzed in this study developed not only their commu- who participated in this study.
nication and language but also their cognitive perfor-
mance, as they enhanced their ability to understand REFERENCES
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purposes of this research only and cannot be made publicly available.
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org/10.1590/2317-6431-2023-2824en

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12/15 | Silva MPSF, Moreira GNO, Freitas ASS, Montenegro ACA

APPENDIX 1 – SKILLS OF THE DEVELOPMENT OF COMMUNICATION SKILLS IN AUTISM (DHACA)

Skill Objectives Strategies

Initial communica- The child should have communi- 1. The therapist initially places a single pictogram related to an item of the child’s
tive intention cative intention, requesting some- preference at the top of the core vocabulary page.
thing from the interlocutor, point- 2. The activity should be prepared to trigger in the child the desire to ask for preferred
ing to the pictograms I + WANT items.
(in the communication book) + 3. As the child shows interest in objects, the therapist uses physical and verbal cues
single pictogram* of what they to help them point to the pictograms that form the sentence: I + WANT + item. Visual
desire. The child should build the cues are used to gradually remove physical ones. If the child has difficulty identifying
sentence in sequence, pointing to I + WANT, colored adhesive tape can be used to indicate the pictograms.
the respective pictograms, pos-
4. When the child is able to perform the above task, another pictogram is included;
sibly accompanied by speech. To
physical cues may be used again.
advance to the next skill, the child
must be able to discriminate up 5. The therapist uses the communication book to guide their talk with the child, point-
to four single pictograms and in- ing to pictograms in the core vocabulary page, modeling their communication – i.e.,
dependently (i.e., spontaneously, pointing to the pictograms of the words they are saying.
without cues) build the sentence I 6. Enable parents to use the book continuously, showing how to use it in the therapeu-
+ WANT + pictogram. tic setting, and train other relatives and professionals from various contexts.
7. When the child uses up to four pictograms to build the sentence, discriminating
each one by independently pointing at them, they can move on the develop the next
skill.
8. The therapist must instruct caregivers to promote skill acquisition, by showing
how they use it with the child and then ask the caregiver to practice with the child in
the therapeutic setting. The therapist must help the caregiver with feedback during
practice.
Requesting with The child should be able to ask 1. The therapist should dismiss the single pictograms and bind with a spiral initially
lexical expansion the interlocutor for something one or two tabs of fringe vocabulary pictograms. Each tab has a line with up to 10
from the fringe vo- by pointing to the pictograms I pictograms in lexical categories related to the items of preference used in the previous
cabulary + WANT + a pictogram in the skill.
fringe vocabulary from one of 2. The activity must be planned to trigger in the child the desire to ask for some of
the two tabs with distinct lexical their preferred items.
categories. They should build the 3. When the child wants an object but cannot ask for it by pointing independently at
sentence in sequence by point- it, they must be guided with physical, visual, and/or verbal cues or modeling to point
ing to the pictograms, possibly to the pictograms of the sentence: I + WANT + item in one of the fringe vocabulary
accompanied by speech. To ad- tabs.
vance to the next skill, the child
4. The therapist begins using the communication book by talking to the child, pointing
must request with the construc-
to pictograms in the core vocabulary page and fringe vocabulary tabs, modeling their
tion “I + WANT + a pictogram
communication (i.e., pointing to the pictograms of the words they are speaking), and
in the fringe vocabulary”, inde-
enabling parents to use the book continuously, as demonstrated in the therapeutic set-
pendently, spontaneously, and
ting. They should also train other relatives and professionals from different contexts.
without cues.
5. The therapist can model by showing the child how to form the desired sentences.
6. When the child is able to ask for up to two different items in the fringe vocabulary,
pointing at them independently, they can move on to develop the next skill.
7. The therapist must instruct caregivers to help the child acquire the skill, demon-
strating how to do it with the child and then having the caregiver practice with the
child in the therapeutic setting. Thus, they enable parents to use it continuously and
train other relatives and professionals from various contexts. The therapist must help
caregivers, by providing feedback during practice.

Rev. CEFAC. 2025;27(1):e6724 | DOI: 10.1590/1982-0216/20252716724

 Desenvolvimento da Morfossintaxe no TEA | 13/15

Skill Objectives Strategies

Requesting with The child should be able to form 1. The therapist must include fringe vocabulary tabs such as foods, toys, qualities,
lexical and mor- sentences with the pictograms: I and places, besides the ones used in the previous skill.
phosyntactic ex- + WANT + two pictograms from 2. The activity must be planned to trigger in the child the desire to ask for preferred
pansion either the fringe or core vocabu- items.
lary. Three or more tabs should 3. When the child desires an object, action, person, or some help but has difficulty
be added. They should build the finding the desired pictogram or leafing through the tabs, they can be helped with
sentence in sequence by point- physical, visual, and/or verbal cues or modeling to leaf through them independently
ing to the pictograms, possibly and point at the pictograms of the sentence: I + WANT + two pictograms from either
accompanied by speech. To ad- the fringe or core vocabulary.
vance to the next skill, the child
4. The therapist must use the communication book by speaking to the child, pointing
must be able to point to I +
to pictograms in the core vocabulary page and fringe vocabulary tabs, and modeling
WANT + two pictograms from ei-
their communication.
ther the fringe or core vocabulary,
independently, spontaneously, 5. The therapist can model by demonstrating to the child how to form the desired
without cues. sentences.
6. When the child is able to ask for up to two items from different tabs, leaf through
the tabs independently, and point to the pictograms of the sentence I + WANT + two
pictograms from either the fringe or core vocabulary independently, they can move on
to develop the next skill.
7. The therapist must instruct caregivers to help acquire the skill by demonstrating
how to use the book with the child and then asking them to practice with the child
in the therapeutic setting. The therapist must help the caregiver with feedback during
practice, enabling them to use it continuously and train other relatives and profession-
als from various contexts.
8. The family must be encouraged to further use new words from the core and fringe
vocabulary stimulated during the sessions.
Morphosyntactic, The child should be able to form 1. The therapist can include new fringe vocabulary tabs, such as feelings, the notion
lexical, and com- sentences with three or more of time, other verbs, and social greetings, besides the tabs used in the previous skill.
municative func- words, with different goals: 2. The activity should be planned to encourage the development of communicative
tion expansion Developing communicative func- functions with four or more pictograms.
tions: 3. When the child wants to use any communicative function and has difficulties finding
• Informative/interrogative func- the desired pictogram or leafing through the tabs, they can be helped with physical,
tion, asking questions with visual, and/or verbal cues or modeling to point at the four pictograms independently.
interrogative pronouns (who, 4. The therapist must use the communication book to speak to the child, pointing at
when, which, where, etc.). pictograms in the core vocabulary page or fringe vocabulary tabs, and modeling their
• Commenting: making com- communication.
ments, giving spontaneous in- 5. The therapist can model by demonstrating to the child how to form the desired
formation, showing something, sentences.
demonstrating pain, giving 6. The therapist can use structured visual resources to help develop the skill.
opinions, and sharing ideas.
7. When the child is able to form sentences with four or more words with different
• Expressing feelings, gratitude. pragmatic goals, using items from different tabs, and leafing through the tabs inde-
• Social-interactive function: pendently, then they can move on to develop the next skill.
greeting, saying goodbye, 8. The therapist must instruct the caregiver to help the child acquire the skill by dem-
thanking, apologizing, and onstrating how to use the book with the child and then having them practice with
showing off. the child in the therapeutic setting. The therapist must help caregivers with feedback
They should build the sentence in during practice, enabling them to use it continuously, and training other relatives and
sequence by pointing to the pic- professionals from various contexts.
tograms, possibly accompanied 9. The family must be encouraged to further use new words from the core and fringe
by speech. They must use them vocabulary used to stimulate the child to form new sentences during the sessions.
with interlocutors in various con-
texts to begin acquiring the next
skill.

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14/15 | Silva MPSF, Moreira GNO, Freitas ASS, Montenegro ACA

Skill Objectives Strategies

Dialog The child should be able to use 1. The therapist can insert new fringe vocabulary tabs, according to the child’s and
the following communicative family’s demands in the child’s various social and school contexts.
functions: 2. The activity must be free to encourage dialog using various communicative func-
Reporting: telling a fact or retell- tions, maintaining conversation, creating, telling, and retelling stories, and reporting
ing a story. facts.
Imagination: creating a story or 3. When the child wants to use any communicative function but had difficulties finding
telling a joke. the desired pictogram, they can be helped by rephrasing with modeling.
Conversation: maintaining a con- 4. The therapist must use the communication book to speak to the child, modeling
versation. their communication.
They should build the sentence in 5. The therapist can also model by demonstrating to the child how to form the desired
sequence by pointing to the pic- sentences.
tograms, possibly accompanied 6. The therapist can use structured visual resources to help the child develop the skill.
by speech. They must use it with 8. The therapist must instruct caregivers to help the child acquire the skill by dem-
interlocutors in various contexts. onstrating how to use the book with the child and then including the caregiver in the
conversation for them to also use the AAC book with the child and the therapist. The
therapist must help the caregiver with feedback during practice enabling them to use it
continuously and train other relatives and professionals from various contexts.
9. Acquiring this skill indicates independence to use the DHACA communication book,
beginning the assisted discharge process, and allowing caregivers to insert new tabs
as needed.
*Single pictogram – loose laminated pictogram, separate from the fixed communication board.

Rev. CEFAC. 2025;27(1):e6724 | DOI: 10.1590/1982-0216/20252716724

 Desenvolvimento da Morfossintaxe no TEA | 15/15

APPENDIX 2 – WEEKLY PROGRESS RECORD FORM

WEEKLY PROGRESS RECORD DATE: ____/____/______

Child: _______________________________________________ Therapist: ______________________________________

Note-taker: ___________________________________________ Session no.: ________
Goal: _______________________________________________________________________________________________
Stimulate the skill: ( ) Request with single picture ( ) Request with 1A lexical expansion ( ) Request with 2A or 1E1A
( ) Request for information/comment ( ) Narrative
Acquired skill: ( ) Request with single picture ( ) Request with 1A lexical expansion ( ) Request with 2A or 1E1A
( ) Request for information/comment ( ) Narrative
Skill present in the child: ( ) Request with single picture ( ) Request with 1A lexical expansion ( ) Request with 2A or 1E1A
( ) Request for information/comment ( ) Narrative
Lexical categories used: _____________________________ Cues: ( ) Yes ( ) No Which ones? ( ) Visual ( ) Physical
________________________________________________ ( ) Verbal
Eye contact: ( ) No ( ) Sometimes ( ) Yes
Pictograms most used by the therapist: ________________ Vocalizations: ( ) Yes ( ) No
________________________________________________ Verbalizations: ( ) Yes ( ) No Which ones? ____________
________________________________________________ ________________________________________________
________________________________________________
Onomatopoeia: ( ) Yes ( ) No Which ones? ___________
________________________________________________
Pictograms used by the child with the therapist’s cues:
Echolalia: ( ) Yes ( ) No ( ) Late ( ) Immediate
________________________________________________
Singing along when music was used: ( ) Yes ( ) No
________________________________________________
________________________________________________ ( ) Imitation ( ) Independent
Making gestures when music was used: ( ) Yes ( ) No
The child used pictograms without cues: ( ) Imitation ( ) Independent
( ) Spontaneously ( ) Independently ( ) Alone ( ) In a sentence Spontaneous speech without the board: ( ) Yes ( ) No
( ) With verbalization Spontaneous speech with the board: ( ) Yes ( ) No
( ) Yes ( ) No Physical stimulation: ( ) Yes ( ) No
Toys used:
Please, describe the context: __________________________ ________________________________________________
________________________________________________ ________________________________________________
________________________________________________ ________________________________________________
________________________________________________ ________________________________________________
Start time - Child’s initial behavior - Child’s emotional behavior - Interest and exploration of the environment - Child’s reaction
to the communication book - How did they accept and use the book? - Activities carried out - Child’s response to the activity -
Engagement - Did the activities need to be readapted? - Difficulties in the session and how they were overcome - What were
the facilitating means to overcome the difficulty? – Guardian’s participation in the session (description) - End time - Were there
any guidelines for the guardians? - What guidelines? - Did the guardians point out any issues? - Did they request the inclusion
of pictograms in the book?

DOI: 10.1590/1982-0216/20252716724 | Rev. CEFAC. 2025;27(1):e6724