Necessity of an Eclectic Intervention Module to Enhance Emotion Comprehension and Channelization in Minimally Verbal Individuals with Autism

Abstract

Aheterogeneous neurodevelopmental condition, autism spectrum disorder (ASD) is characterized by deficits in social communication and restrictive and repetitive behavior (RRBs).¹ The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) has provided a comprehensive diagnostic criterion of ASD, where not merely the deficiency of language competency but the overall deficits in social communication have been considered the central feature of ASD.¹ Symptoms often manifest through poor socio-emotional reciprocity, difficulty in non-verbal communication, developing and maintaining social connections, stereotypical movements, a fixed repertoire of interests, and atypical sensory needs² along with clinically significant internalizing and externalizing behavioral features which include anxiety, depression, somatization, aggressive emotional and behavioral outbursts, hitting others, inattention, hyperactivity, impulsivity, self-injurious behavior (SIB) and aggressive tantrums.³ From an epidemiological point of view, the prevalence of minimally verbal (MV) individuals with ASD has been 18.5 per 1,000 children, that is, one individual out of 54 is MV.^2,4 However, these MV individuals with ASD comprise a rapidly growing portion of this spectrum.⁵

Many children with ASD can produce significantly fewer functional words while communicating, and these children are often identified as MV individuals with ASD.⁶ Verbal skills are associated with multiple challenges across diverse domains, such as cognition, emotion, and behavior. One such important domain is emotional comprehension and appropriate channelization of emotion.⁶ Articles published in the last 10–15 years show that approximately 25%–30% of individuals within the autism spectrum cannot develop functional language spoken skills and remain MV even after age five.⁷ There are a few exclusive features of MV individuals with autism. Communication impairments in MV children often lead to social withdrawal.⁸ They are associated with oral-motor difficulties,⁹ as well as problems in adaptive behavioral skills, academic achievement, vocational success, and social relationships.¹⁰

Recent research in this domain highlights interventions aimed at improving language acquisition, comprehension, production, and verbalization. Therefore, a sustainable intervention specifically designed to address the unexplored challenging areas involving emotional comprehension and channelization is required.

Table 1 presents a systematic review of articles describing various evidence-based intervention plans for individuals with MV-ASD.

Table 1.

The Systematic Representation of the Reviewed Articles Involving Various Evidence-based Intervention Plans Designed for MV-ASD Individuals.

Sl. No.	Title	Authors	Objectives	Methods (Variables)	Sample	Findings	Limitations	Future Scope
1	Enhancing Communication in Minimally Verbal Autistic Children: A Study on NAO-assisted Therapy	Di Cara et al., 2025¹⁸	If the integration of the NAO humanoid robot in a rehabilitation program can facilitate initiating social interaction in MV autistic children.	Single-blind, randomized, controlled clinical trial following the CONSORT guidelines.	37 children with a diagnosis of ASD following the DSM-5 criteria were randomly allocated to the experimental and control groups.	Experimental treatment by using the NAO-assisted therapy significantly enriched communication abilities, implicating robotic-assisted therapy to facilitate progress in language acquisition at a faster rate compared to traditional interventions	There was uncertainty about the generalizability of improvements in real-life settings and their long-term implications.	Specific features, such as reinforcement mechanisms and multimodal feedback, in NAO-assisted therapy should be explored to foster communication gains.
2	Using music to assist language learning in autistic children with minimal verbal language: The MAP feasibility RCT	Williams et al., 2024¹¹	To test the efficacy of music-assisted program vs. Social Communication Intervention as a best-practice treatment for language acquisition.	Feasibility of randomized control trials between two groups. Minimization randomization ensures better between-group comparability. 45-minute weekly sessions over 18 weeks were conducted for children and their parents.	27 preschool-aged children with ASD and minimal verbal language.	Social responsiveness, comprehension of words and phrases, the amount of spoken words, and parent–child interaction improved more in the music-assisted program. Parental acceptance was higher in this group.	Online mode intervention hindered the measurement of some aspects of the training sessions. Further, it was not possible to ensure the correct implementation of the training at home setup through video recording. Thus, some doubt regarding the validity of the intervention sessions was also evident.	Offline intervention should be provided. Parents’ views should be included; the app should be modified to include filming of home-based sessions and to lay the groundwork for the music-based sessions.
3	Parent-Therapist Collaborative Intervention Model using Contingent Imitation in a Minimally Verbal School-Aged Child with Autism Spectrum Disorder	Ishizuka et al., 2024¹⁹	To determine the impact of intervention facilitated by parents on minimally verbal children. This invention was achieved by mirroring the child’s actions and vocalizations and by providing speech production training.	Single case multiple baseline design.	Single sample.	The intervention proved effective in improving vocalization and vocabulary among minimally verbal children with ASD.
4	Peer mediation in play settings for minimally verbal students with autism spectrum disorder	Briet et al., 2023²⁰	To determine the impact of a peer-facilitated play-based intervention on the development of three interpersonal skills among minimally verbal children with ASD. These interpersonal skills involve play, social involvement, and participants’ ability to replicate behaviors in social situations.	Single case multiple baseline design.	Children with autism, N = 7, and children without any developmental disability, N = 14.	Post-intervention improvement was noted in functional play behaviors in the case of four children with ASD. Six children demonstrate enhanced reciprocal play. Further, progress was also evident in participants’ ability to replicate behaviors in a social setup. Thus, overall, peer-facilitated intervention was found to be effective in the case of minimally verbal children with autism.	This study failed to focus on the various forms of motor imitation and instead concentrated solely on overall motor imitation. Reciprocal imitation was not included in the intervention. Further, the application of the intervention in various settings, along with sustainability, was not explored.	Incorporating reciprocal imitation into the play-based peer-aided intervention and analyzing the impact of the intervention on various forms of motor imitation separately. Both applicability and sustainability of the intervention need to be explored. Finally, the effects of different social, cognitive, and behavioral features of TD children, as well as children with ASD, on intervention need to be explored.
5	The impact of imitation on engagement in minimally verbal children with autism during improvisational music therapy	Carpente et al., 2021¹²	The effectiveness of three IMT techniques with minimally verbal children for (a) exact imitation, (b) imitation with elaboration, and (c) contingent response.	Exploring the effectiveness of nine 30-minute sessions designed to consider one of the three treatment techniques.	N = 7 minimally verbal children with autism.	Exact imitation and imitation with elaboration resulted in a better overall engagement than contingent response.	Small sample size, therefore, difficulty in generalization.	Improvement of social involvement beyond therapeutic sessions needs to be explored.
6	Communicating Without Words: School-Based RCT Social Intervention in Minimally Verbal Peer Dyads with ASD	Bauminger-Zviely et al., 2019²¹	To determine the effectiveness of peer-facilitated intervention in a school setting on improving social involvement of minimally verbal children with autism. To monitor improvement in executive functioning.	Randomized Controlled trial.	58 children, with an average age of 6.61 years, were randomly assigned to peer dyads in each of the three groups.	The conversation group’s socialization skills improved, but communication did not. Children in the conversation group also improved their metacognitive executive skills (e.g., planning, monitoring, organization).	Duration and intensity of the intervention have been the foremost limitations. A longer intervention with repetition would be critical to achieve an effective result. Generalizability and having a long-lasting effect	Intervention efficacy should be evaluated by examining individual differences in treatment gains.
7	Symbolic Play in School-Aged Minimally Verbal Children with autism Spectrum Disorder	Chang, 2018¹⁴	The aim was to explore play behavior before and after the communication intervention. Another objective is to determine the connection between language and play behavior.	Pre- and post-intervention design and between-group design.	N = 58, two groups, JASP-EMT and JASP-EMT + AAC.	Significant gain in play behavior post-intervention. A positive interconnection was observed between play and expressive language.	(a) There was no control group; therefore, the possibility that the changes are due to the temporal impact, such as maturation, could not be verified. (b) Generalization beyond the clinic setup.	Efforts should be made to determine whether these newly acquired skills can be used in more naturalistic settings, such as school and home.
8	Auditory-Motor Mapping Training: Comparing The Effects of a Novel Speech Treatment on a Control Treatment for Minimally Verbal Children with autism	Chenausky, 2016¹³	The study aimed to determine the impact of Auditory-Motor Mapping Training on speech production, including the accurate production of syllables, consonants, and vowels. Comparison between Speech Repetition Therapy and Auditory-Motor Mapping Training on speech production.	Matched group and pre-post design.	N = 58, two groups, JASP-EMT and JASP-EMT + AAC.	(a) The participants who received AMMT showed remarkable improvement in the production of speech, the rate of consonant-vowel production. (b) Comparison between the two groups showed that the group that received AAMT improved more and performed better than the SRT group.	(a) A small number of participants in the control condition limits generalization. (b) AMMT for little older minimally verbal or non-verbal individuals has not been explored. (c) A shorter course of the therapeutic module has to be devised.	The presence of signs of Childhood Apraxia of Speech (CAS) in minimally verbal children with ASD had to be explored to yield better prognostic indicators and illuminate the nature of the challenges these children experience in acquiring spoken language.
9	Picture Exchange Communication System and Pals: A Peer-Mediated Augmentative and Alternative Communication Intervention for Minimally Verbal Preschoolers with autism	Thiemann-Bourque et al., 2016²²	To determine the impact of the Picture Exchange Communication System on the communication skills of minimally verbal children with autism when a peer group guides the intervention.	A series of single-subject design/A-B design.	N = 4 children with autism and	The findings showed improvement in communication and social involvement	Low social validity. Perspectives and observations from different social agents, such as parents, teachers, and peers, on improving social exchange were not incorporated. This study also failed to measure improvements in other domains besides social communications	Generalizing the study and fostering interaction with peers beyond those peer-involved in the study should be encouraged. Further, a more lengthy intervention should be implemented to foster sustainability.

Discussion

Interventions Based on Modalities

Music-assisted Intervention

Williams et al. compared two types of interventions – music-assisted intervention and social communication intervention and found that music-guided intervention was effective in enhancing social interaction and communication.¹¹ In music-assisted intervention, target words were taught through music. However, both interventions were implemented at home and set up online. Thus, it was challenging to ensure the intervention was implemented correctly. Hence, the intervention’s validity is also doubtful. Another music-based intervention was employed by Carpente et al., known as Improvised Music Therapy.¹² The prime purpose of this intervention was to foster social involvement among MV-ASD through engaging them with various musical instruments. The therapist improvised music following the child’s footsteps. Despite its effectiveness, this intervention has restricted generalizability due to a small sample size.

Auditory-motor Mapping Training

Chenausky et al. implemented Auditory-Motor Mapping Training (AAMT) to promote linguistic skills in MV-ASD.¹³ In this training, the auditory and motor representations of the same manual and vocal actions are jointly activated by coupling the recitation of 2-syllable target words or phrases with the beating of electronic drums using the same tunes as in the recitation. This intervention was found to be effective in enhancing the percentage of correct consonant and vowel production and refining the rate of syllable approximation.¹³ However, the impact of AMMT on the older MV-ASD group was not explored in this study. Furthermore, the limited sample size restricted the generalizability of the findings.

Communication-based Intervention

Two more intervention strategies were reported by Chang et al. JASP-EMT and JASP-EET+AAC.¹⁴ JASPER-EMT is the combination of two techniques.¹⁴ It includes interventions on joint attention, symbolic play, engagement, and regulation.¹⁵ along with Enhanced Milieu Teaching involving systematic prompts to facilitate speech.¹⁶ On the other hand, JASP-EET-AAC includes a speech-producing device along with all other elements of JASP-EMT.¹⁷ Both interventions were administered to participants in a natural setting while engaging in their preferred play-based activities. These interventions were found to be quite effective in facilitating play behavior among the MV-ASD cohort.

Intervention Involving the NAO Humanoid Robot

Di Cara et al. introduced an experimental treatment using NAO-assisted therapy with the Humanoid Robot NAO in a Single-blind, randomized, controlled clinical trial involving 37 individuals with ASD, following the CONSORT guidelines.¹⁸ The intervention significantly enriched communication abilities, suggesting that robotic-assisted therapy can facilitate faster language acquisition than traditional interventions. However, there was uncertainty about the generalizability and long-term implications of individuals’ independent functioning.

Interventions Involving Varied Stakeholders

Ishizuka et al. designed parent-therapist collaborative interventions to enhance speech production in the MV-ASD cohort and found them quite effective.¹⁹ Likewise, several peer-mediated interventions are also reported in this review. One such peer-meditated play-based intervention was employed by Briet et al. to enhance social reciprocity among individuals with MV-ASD.²⁰ First, peers were educated on various techniques for communicating with children with ASD, and subsequently, they were encouraged to play with the children using those techniques. Another such peer-involved intervention was reported in the study conducted by Bauminger-Zviely et al.²¹ However, this was implemented in a school setting. A notable aspect of this intervention was its emphasis on enhancing executive functioning and social involvement. Thiemann-Bourque et al. also incorporated peers in picture exchange communication interventions.²² In this intervention, peers assumed an active role in fostering social interaction through picture symbols among MV-ASD under the supervision of experts. All these facilitated interventions are identified as equally fruitful in promoting social interaction, engagement, and executive functioning of the individuals with MV-ASD. Thus, based on this observation, it can be assumed that involving different stakeholders in therapeutic sessions yields quite fruitful outcomes. However, these interventions have several limitations. First, the sustainability and generalizability of these interventions are questionable due to the small sample size. Besides, these interventions failed to incorporate the perspectives and observations of different stakeholders such as parents, peers, and teachers. Finally, apart from social communication, these interventions ignored improvements in other domains.

Limitations of Existing Research

Interventions explored to date have focused on the MV group, primarily on improving social communication skills, reciprocal interaction, and maladaptive behavioral manifestations. In addition, these interventions have drawbacks, such as their online delivery mode, which limits their practical implementation, and confusion about their applicability beyond therapeutic sessions. Further, the scope of these interventions has been restricted to communication domains. Apart from this, the usage of RRBs, internalizing-externalizing manifestations, and various emotional and cognitive aspects are not within the scope of these interventions. Additionally, the sustainability of the intervention even after the follow-up sessions was in question. Therefore, a sustainable intervention module is required to address this reported gap.

Future Recommendations

Therefore, a personalized treatment plan is suggested for addressing the unique hindrances that MV individuals with ASD face in comprehending and responding to emotional experiences.⁶ An eclectic intervention plan involving theoretical, evidence-based approaches such as applied behavior analysis and the functional communication system, as well as experiential approaches such as projective art therapy, play-based intervention, and occupational approaches, is highly recommended. Further, a multi-sensory approach involving tactile, physical movements, and so on to alleviate linguistic burden should be incorporated. This eclectic intervention approach will include a dyadic interaction pattern in some sessions, with the parent or therapist, or a group setup, where play sessions will be encouraged among peer groups. Further, this intervention should become a part of their everyday curriculum. The strength of such an intervention lies in its design: the involvement of different modalities in separate sessions, with immediate family members, peer group, teachers, and other caregivers participating in dyadic or group modes. This may provide an opportunity to orient stakeholders on how to follow up on the techniques in everyday scenarios. Thus, sustainability can be ensured. This would be the first, to the best of our knowledge, involving a multimodal approach.

Conclusions

Our article highlights the urgency of developing a composition of intervention plans drawn from comprehensive approaches, such as applied behavior analysis, creative art interventions, play therapy, and augmentative and alternative communication modes, directed toward enhancing emotion comprehension and its channelization exclusively for individuals with MV-ASD. Therefore, we highly recommend a personalized, sustainable, and multimodal intervention plan for the MV-ASD.

Data Sharing Statements

Our article does not deal with any primary data. Hence, data sharing is not applicable.

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Declaration Regarding the Use of Generative AI

None used.

Ethical Approval

The authors communicated the research work officially to the institutional review committee. The committee waived off the need for consent. Name of the Institutional Ethics Committee/ Independent Review Board: NA. Approval Ref. No: NA. Date: NA.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Patient Consent

The article does not entail any active participation of human participants. Therefore, informed consent from participants is not required.

Prior Presentations

NA.

PROSPERO/CTRI Details

NA.

Registration

Not applicable as the article is not an experimental or clinical trial. Trial registry name: NA. URL: NA. Registration number: NA.

Simultaneous Submission to Another Journal or Resource

Not submitted to any journal.

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