A survey on professionals’ beliefs and practices related to emergent literacy skills in children with autism spectrum disorder

ABSTRACT

Professionals and educator’s beliefs and existing practices for children with autism spectrum disorder and families in the Indian context are less known. Hence, there is a need to review the current emergent literacy practices followed by healthcare professionals for children with autism spectrum disorder. The present study aimed to investigate the beliefs and practices among healthcare professionals for emergent literacy instruction in children with autism spectrum disorder in the Indian context. A total of 195 qualified healthcare professionals with a minimum experience of 3 years of literacy instruction to children with autism spectrum disorder, participated in a web-based survey. Many participants possessed accurate beliefs on emergent literacy concepts of children with autism spectrum disorder and followed evidence-based emergent literacy approaches in literacy instruction to children with autism spectrum disorder. Most healthcare professionals (78.5%) reported that shared book reading, phonological awareness intervention, and a literacy-rich environment are beneficial for acquiring emergent literacy skills in children with autism spectrum disorder. Healthcare professionals stated various effective emergent literacy interventions, several challenges in early literacy development, and the need for professional development programmes to assist literacy teaching to children with autism spectrum disorder. The results of the study confirmed the need to implement embedded-explicit emergent literacy intervention, which aligns with contemporary research. It further highlights the need for professional development programmes, research and evidence-based practices, an interdisciplinary approach, teaching resources and materials, parental awareness, and support programmes to assist literacy instruction in children with autism spectrum disorder.

Trial registration: Clinical Trials Registry India identifier: CTRI/2020/11/029417.

KEYWORDS:

• Emergent literacy practices
• ASD
• healthcare professionals
• challenges

According to the simple view of reading, language comprehension and word reading (or decoding) together explain reading comprehension (i.e., spoken language comprehension) (Gough & Tunmer, 1986). Children must develop code-related skills such as letter knowledge, print concepts, phonological awareness, and meaning-related skills such as narration and reading comprehension to become proficient readers (Nation, Clarke, Wright, & Williams, 2006). Emergent literacy skills such as alphabet knowledge, phonological awareness, print knowledge, rapid automatic naming, writing name and phonological memory are found to be strong predictors of later literacy achievement in school years (National Early Literacy Panel, 2008).

The reading profile of children with autism spectrum disorder (ASD) shows wide range of variability and discrepancy (Henderson, Clarke, & Snowling, 2014). Solari, Grimm, McIntyre, Zajic, and Mundy (2019) reported four reading profiles in children with ASD, such as (a) average reading comprehension and word reading; (b) difficulties with reading comprehension; (c) difficulties with reading comprehension and word reading, but good receptive vocabulary; (d) generalized low scores in word reading, reading comprehension and oral language. A recent systematic review of studies on emergent literacy skills suggested that code-related skills (i.e., alphabet knowledge) may be a relative strength for children with ASD (Westerveld et al., 2017). In contrast, meaning-related skills (vocabulary and oral narration) were inadequate in children with ASD (Westerveld et al., 2017). Various emergent literacy interventions that enhance code and meaning-related emergent literacy skills are reported in the literature for children with ASD (Hudson et al., 2017; Kimhi, Achtarzad, & Tubul-Lavy, 2018). Literacy interventions integrating both code (phonological awareness instruction) and meaning-related (whole-language intervention) emergent literacy skills through highly naturalistic daily opportunities and contextualized interactions are known as the embedded-explicit model (Justice & Kaderavek, 2004). Given that both code and meaning-related emergent literacy skills are affected, children with ASD require a balanced, comprehensive emergent literacy programme (Kimhi et al., 2018).

In India, although special educators (SEs) predominantly address early literacy skills, healthcare professionals such as speech language pathologists (SLPs), occupational therapists (OTs), and psychologists (Psychs) are also involved in providing early literacy intervention (Kharat & Banik, 2018; Sengupta, Lobo, & Krishnamurthy, 2017). A wide gap in service delivery has been observed for children with ASD in India due to limited awareness and knowledge among healthcare professionals (Daley & Sigman, 2002; Divan, Vajaratkar, Desai, Strik-Lievers, & Patel, 2012; Patra & Kar, 2021). Studies report inadequate knowledge of educational evaluation and intervention models among SLPs (Mendonsa & Tiwari, 2018). SEs in India were found to have poor knowledge of the best evidence-based educational practices and highlights the significance of professional development and training of educators (Tiwari & John, 2017). There is a scarcity of evidence on effective teaching strategies for children with ASD though few studies are reported globally (Westerveld & Paynter, 2021). There is a dearth of literature on research-based teaching strategies for children with ASD in South Asia (Sharma & Rangarajan, 2019). There are no existing studies on healthcare professional beliefs about emergent literacy practices for children with ASD in India. It is critical to evaluate the current beliefs of healthcare professionals in regard to emergent literacy skills, literacy practices, literacy challenges for children with ASD, as well as the support and training that they require to meet the needs of these children. Therefore, the present study aimed to investigate the beliefs and practices among healthcare professionals for emergent literacy instruction in children with ASD in the Indian context. The study objectives were (a) to investigate the beliefs of healthcare professionals on emergent literacy skills of children with ASD; (b) to investigate the emergent literacy practices used by healthcare professionals for children with ASD; and (c) to identify the effective emergent literacy interventions and factors influencing emergent literacy development in children with ASD. Given, the lack of studies on emergent literacy skills and interventions in Indian children with ASD, we hypothesize that healthcare professionals involved in emergent literacy intervention will have inaccurate beliefs and practices on emergent literacy skills in children with ASD.

Method

The present study adopted a cross-sectional research design and a convenience sampling method for the sample collection. Ethical approval was obtained from institutional ethics committee (No: 400/2020), and the study was registered under the clinical trial registry of India (CTRI/2020/11/029417).

Participants

A total of 195 participants took part in the survey. The participants were SLPs, SEs, OTs, Psychs, and others (applied behaviour analysis therapists, rehabilitation therapists and school teachers). All the participants were involved in literacy instruction and teaching of children with ASD and had a minimum of 3 years of experience. The survey completion rate was 97.43%. Table 1 shows the demographic and professional details of the participants.

Table 1. Demographic and professional information about participants (n = 195).

Demographic details	n	%
Gender
Male	24	12.31
Female	171	87.69
Profession
Speech-language pathologist	64	32.82
Special educator	64	32.82
Occupational therapist	36	18.46
Psychologist	22	11.28
Others	9	4.62
Highest academic qualification
Graduate	118	60.51
Undergraduate	48	24.61
Doctorate & MPhil	15	7.69
Diploma & Certified Therapist	14	7.17
Duration of clinical experience
0–5 years	86	44.10
6–10 years	57	29.2
≥ 11 years	52	26.66
Duration of emergent literacy practice
0–5 years	113	57.94
6–10 years	51	26.15
11–15 years	21	10.76
≥ 16 years	10	5.12
Type of work setting
Combined	43	22.05
Private clinics	54	27.69
Special school	32	16.41
Academic institutions	36	18.46
Hospitals	19	9.74
Government schools	8	4.1
Others	11	5.64
Type of literacy instruction given
Both	120	61.54
Individual	65	33.33
Group	10	5.13
Number of children in group literacy intervention
0–5	115	58.97
6–10	28	14.35
> 11	11	5.64
Age range of children with ASD
2–3 years	71	36.41
4–6 years	133	68.20
7–9 years	96	49.23
> 10 years	87	44.61
Language used in literacy instruction
Native language	35	17.94
English	48	24.61
Both	112	57.43
Number of participants who received emergent literacy training	74	37.94
Professional training on emergent literacy instruction
Undergraduate and Graduate coursework	78	40
In-service programmes	69	35.38
Conference/ Seminar/ Workshop	106	54.36
Assistance from teachers and professionals	114	58.46
Self-directed / Online learning/ Professional materials	131	67.18

Survey

Based on the review of literature related to evidence-based emergent literacy knowledge and practices, a survey was developed by compiling questions/items from relevant questionnaires (Berthelsen, 2013; Khurana & Rao, 2011; McDonnell et al., 2014; Wright, 2014). Formal permissions were sought from the authors to use and adapt items from these questionnaires. Relevant items were compiled from the questionnaires reviewed, and necessary adaptations were made.

The developed survey was subjected to content validity by six independent experts having a minimum of five years of experience in the field of ASD. All experts were asked to rate and mark the relevance of the pooled items in the survey on a 5-point rating scale (marking ‘0’ as not relevant and ‘5’ as highly relevant), and to provide their feedback and comment(s) specific to an item or domain. The final version of the survey comprised of four sections and 21 questions (supplementary material S1). Section 1 consisted of demographic and professional information containing the sequence of questions related to participants’ background information, work experience, training, and professional learning. Section 2 consisted of statements about professionals’ beliefs on emergent literacy concepts in children with ASD. Section 3 consisted of emergent literacy practices in children with ASD containing the approaches and emergent literacy instructions used by professionals during literacy intervention. Section 4 consisted of two open-ended questions on effective emergent literacy interventions, and factors influencing emergent literacy development in children with ASD (challenges faced by healthcare professionals in the delivery of emergent literacy intervention and support or training required to assist healthcare professionals). The survey was piloted on five experienced healthcare professionals working for children with ASD and was found to be suitable in terms of clarity, ease of following instructions, and answering the items.

Procedure

After establishing content validity, the survey was designed and administered on a web-based platform using Google forms. The electronic survey link was sent to professional groups and social networking groups. The survey link was sent personally via emails (n = 218), WhatsApp (n = 200), and LinkedIn (n = 345) to professionals who had a minimum 3 years’ experience of teaching literacy to children with ASD. The survey directed participants to a brief description about the study including objectives of the research, followed by the link to answer the survey. The time estimated to complete the study was around 10–15 min. The survey responses were collected over a period of 4 months.

Scoring and analysis

Content validity index (CVI) showed that the overall item-level CVI scores ranged between 0.83–1.00 (excellent content validity; Polit, Beck, & Owen, 2007), and scale-level CVI for each section was 1.00 (excellent content validity; Polit et al., 2007). The Cronbach’s alpha ranged from 0.77–0.96, which indicated high internal consistency. Since all 21 items received excellent CVI scores and high internal consistency, no item was rejected from the survey. A few of the questions and options were rephrased to improve clarity, based on the experts’ feedback.

Statistical Package for the Social Sciences (version 16) was used to analyse the results. Results from Sections 1–3 of the survey were presented as frequency and percentage of responses, and the Kruskal Wallis test was used to compare beliefs and practices across healthcare professional groups (SLPs, SEs, OTs and Psychs), years of practice (0–5 years, 6–10 years, 11–15 years and ≥16 years) and educational qualification (undergraduate, graduate and doctorate). The ‘others’ group which included miscellaneous professionals were excluded from this sub-analysis due to small sample size (N = 9).

Data analysis of open-ended questions was carried out using six steps qualitative thematic analysis procedure, wherein inductive coding was used to identify themes and subthemes from the data (Braun & Clarke, 2006).

Results

Results obtained from the study are presented under the following sections:

Healthcare professionals’ beliefs about emergent literacy in children with ASD

Table 2 presents the results on professionals’ beliefs on emergent literacy skills in children with ASD. Almost 68.72% of respondents disagreed that children with ASD are not ready for emergent literacy intervention at preschool. When examining the items based on children with autism’s emergent literacy skills, 47.68% agreed that children with autism have good alphabet knowledge, 26.14% agreed that children with autism have good phonological awareness, 41.02% agreed that children with autism have good print concept knowledge, and 65.13% agreed that children with autism have poor comprehension and narration of stories. When examining evidence-based beliefs about emergent literacy and emergent-literacy interventions, 75.38% agreed that children’s oral language skills are an indicator of later reading success, 67.70% agreed that children with autism who have good phonological awareness, alphabet knowledge, and oral language skills, learn to read more easily. Nearly 85.64% agreed that literacy enriched play setting and print enriched environment contribute to children’s literacy development. Almost 45.64% agreed that children with ASD should have good speech and language skills to start emergent literacy intervention.

Table 2. Beliefs about emergent literacy in children with ASD.

SL No	Survey statements	Strongly disagree	Disagree	Neither agree nor disagree	Agree	Strongly agree
1	Children with ASD are not ready for emergent literacy intervention at preschool	57 (29.23%)	77 (39.49%)	26 (13.33%)	30 (15.38%)	5 (2.56%)
2	Children with ASD have good alphabet knowledge.	3 (1.53%)	20 (10.25%)	79 (40.51%)	74 (37.94)	19 (9.74%)
3	Children with ASD have good phonological awareness	9 (4.61%)	43 (22.05%)	92 (47.17%)	48 (24.61%)	3 (1.53%)
4	Children with ASD have good print concept.	5 (2.56%)	30 (15.38%)	80 (41.03%)	68 (34.87%)	12 (6.15%)
5	Children with ASD have poor comprehension and narration of stories.	1 (0.51%)	47 (24.10%)	20 (10.26%)	114 (58.46%)	13 (6.67%)
6	Children’s oral language skills are an indicator of later reading success.	0	47 (24.10%)	1 (0.51%)	121 (62.05%)	26 (13.33%)
7	Children with ASD who have good phonological awareness skill, alphabet recognition, and oral language skills learn to read more easily.	0	30 (15.38%)	33 (16.92%)	87 (44.61%)	45 (23.07%)
8	Literacy enriched play setting and print enriched environment contribute to children’s literacy development.	0	0	28 (14.36%)	99 (50.77%)	68 (34.87%)
9	Children with ASD should have good speech and language skills to start emergent literacy intervention.	0	28 (14.36%)	78 (40%)	75 (38.46%)	14 (7.18%)

Emergent literacy practices in children with ASD

Table 3 presents the results from section 3 on emergent literacy approaches and instructions in children with ASD. Almost 78.46% reported that shared reading, phonological awareness intervention, and a literacy-rich environment are beneficial for acquiring emergent literacy skills in children with ASD. The most and least difficult emergent literacy skills reported were narration (80.51%) and alphabet knowledge (10.76%), respectively.

Table 3. Emergent literacy practices in children with ASD.

SL No	Survey Questions	n	%
14	Beneficial emergent literacy intervention
	Phonological awareness instructions	21	10.76
	Shared book reading	13	6.66
	Literacy rich environment	23	11.79
	All of the above	153	78.46
15	Most to less difficult emergent literacy skills for children with ASD
	Phonemic awareness	71	36.41
	Alphabet knowledge	21	10.76
	Concept about print (CAP)	32	16.41
	Vocabulary knowledge	68	34.87
	Listening comprehension	126	64.61
	Narration	157	80.51
16	Days per week for literacy instruction
	One day	13	6.67
	2–4 days	90	46.15
	4–6 days	35	17.95
	All days	57	29.23

Quality of shared reading

Many participants acknowledged the importance of the quality of shared reading to improve emergent literacy skills in children with ASD (Table 4). Nearly 69.74% of the participants agreed that they read storybooks, 91.79% named pictures, 87.69% asked wh- and open-ended questions, 64.6% asked children to relate their own experiences with story, 87.18%, talked about the feelings the stories convey, 77.94% interrupted with comments and questions, 68.71% focused on alphabets and sounds during shared reading, and 82.56% encouraged them to retell the story during shared reading.

Table 4. Emergent literacy instructions in children with ASD.

SL No	Survey statements	Strongly disagree	Disagree	Neither agree nor disagree	Agree	Strongly agree
Quality of shared reading
1	I frequently read storybooks to children with ASD.	7 (3.59%)	26 (13.33%)	26 (13.33%)	100 (51.28%)	36 (18.46%)
2	I name pictures while I read aloud.	2 (1.02%)	3 (1.54%)	11 (5.64%)	107 (54.87%)	72 (36.92%)
3	I ask ‘wh’ and open-ended questions while reading.	7 (3.59%)	17 (8.71%)	0	125 (64.10%)	46 (23.59%)
4	I ask children with ASD to relate their own experiences to the stories I read.	10 (5.12%)	53 (27.17%)	6 (3.08%)	95 (48.71%)	31 (15.89%)
5	I talk about the feelings the stories convey.	6 (3.07%)	10 (5.12%)	9 (4.62%)	123 (63.08%)	47 (24.10%)
6	I allow children with ASD to interrupt with comments and questions while reading aloud.	6 (3.07%)	9 (4.61%)	28 (14.36%)	104 (53.33%)	48 (24.61%)
7	I focus on alphabets, sounds, and words while implementing shared book reading.	4 (2.05%)	26 (13.33%)	31 (15.89%)	100 (51.28%)	34 (17.43%)
8	I encourage children with ASD to retell the story in their own words.	6 (3.07%)	9 (4.61%)	19 (9.74%)	104 (53.33%)	57 (29.23%)
Alphabet Knowledge
1	I help children with ASD become familiar with the alphabet.	4 (2.05%)	5 (2.56%)	18 (9.23%)	117 (60%)	51 (26.15%)
2	I teach children with ASD that letter has a name and a sound and match the sounds to letters e.g., ‘M’ is called ‘em’ but it says the sound, ‘mmmm’.	5 (2.56%)	23 (11.79%)	30 (15.38%)	94 (48.21%)	43 (22.05%)
3	I teach children with ASD to recognize letters in their own names.	3 (1.54%)	18 (9.23%)	18 (9.23%)	113 (57.94%)	43 (22.05%)
4	I encourage children with ASD to play with alphabet puzzles, magnetic letters, letter stamps, and sponges.	0	6 (3.1%)	13 (6.7%)	91 (46.7%)	85 (43.6%)
5	I read alphabet books to children with ASD.	4 (2.05%)	18 (9.23%)	24 (12.31%)	91 (46.67%)	58 (29.74%)
6	I teach the difference between upper- and lower- case letters.	8 (4.10%)	32 (16.41%)	44 (22.56%)	71 (36.41%)	40 (20.51%)
Phonological awareness
1	I read books with rhyming texts and point out rhyming patterns.	3 (1.53%)	17 (8.71%)	33 (16.92%)	102 (52.31%)	40 (20.51%)
2	I demonstrate the sounds letters make.	4 (2.05%)	8 (4.01%)	17 (8.71%)	107 (54.87%)	59 (30.26%)
3	I help children sound out words (i.e., /buh/ + /oy/ =  boy)	9 (4.61%)	19 (9.74%)	22 (11.28%)	96 (49.23%)	49 (25.13%)
4	I teach that words can be broken down into sound parts (syllables), e.g., ‘tomato’ has three sound parts, /to/, /ma/, and /to/?	6 (3.08%)	15 (7.69%)	19 (9.74%)	94 (48.21)	61 (31.28%)
5	I teach words with the same beginning sound/s (e.g., cat, car, cap)?	6 (3.08%)	11 (5.64%)	26 (13.33%)	91 (46.67%)	61 (31.28%)
6	I teach some words with the same ending sound/s (e.g., cat, rat, bat)?	6 (3.08%)	16 (8.21%)	22 (11.28%)	90 (46.15%)	61 (31.28%)
Concepts about book and print
1	I demonstrate how books work (i.e., front and back, hold the right way up, turn pages right to left, etc.).	8 (4.10%)	10 (5.13%)	22 (11.28%)	99 (50.77%)	56 (28.72%)
2	I demonstrate how print works (i.e., words are read left to right, up to down, etc.)	5 (2.56%)	14 (7.18%)	30 (15.38%)	97 (49.74%)	49 (25.12%)
3	I introduce books by talking about the title, author, and illustrator.	17 (8.72%)	36 (18.46%)	56 (28.72%)	59 (30.26%)	27 (13.85%)
4	I use my finger to follow words as I read aloud.	6 (3.08%)	5 (2.56%)	16 (8.21%)	108 (55.38%)	60 (30.77%)
Emerging reading and writing
1	I help children write their own names	4 (2.05%)	11 (5.64%)	29 (14.87%)	100 (51.28%)	51 (26.15%)
2	I help children read simple words	6 (3.08%)	2 (1.03%)	10 (5.13%)	118 (60.51%)	59 (30.26%)
3	I engage children in shared interactive writing opportunities.	5 (2.56%)	9 (4.62%)	22 (11.28%)	109 (55.89%)	50 (25.64%)
4	I listen while children read or pretend to read aloud	4 (2.05%)	4 (2.05%)	13 (6.67%)	102 (52.31%)	72 (36.92%)

Alphabet knowledge

Participants acknowledged the need to focus on alphabet knowledge in emergent literacy instruction for children with ASD. Almost 86.15% of the participants agreed that they make children familiar with alphabets; 70.26% teach matching of sounds to letters; 80% teach children with ASD to recognize letters in their own name; 76.41% read alphabet books; 56.92% teach the difference between upper- and lower-case letters.

Phonological awareness

Participants indicated the importance of providing phonological awareness training to develop emergent literacy skills in children with ASD. Nearly 72.82% of the participants agreed that they read books with rhyming texts and pointed out rhyming patterns while reading stories; 74.36% helped children to sound out words; and 79.49% teach that words can be broken down into sound.

Concepts about book and print

Participants emphasized the need to teach the concept of books and print to children with ASD. Around 79.49% of the participants agreed that they demonstrated the front and back of books, turned the pages to show how books work, and held the book in the right way. Further, 74.86% participants agreed that they demonstrated how words are read from left to right, and 86.15% followed the words with fingers while reading aloud.

Emerging reading and writing

Around 77.43% of the participants agreed that they helped children to write their names; 90.77% helped children to read simple words; 81.53% engaged children in shared interactive writing opportunities; 89.23% listened to the children when they either pretend to read or actually read.

Further analysis comparing across healthcare professional groups showed significant differences in beliefs and practices on quality of shared reading (X²(3) = 12.38, p = 0.006) and alphabet knowledge (X²(3) = 11.76, p = 0.006). No differences were found for participants’ beliefs and practices on educational levels and years of practice.

Open-ended questions

Table 5 shows themes and subthemes derived for open-ended questions.

Table 5. Themes and subthemes derived for open-ended questions.

SL No	Questions	Theme(s)	Subtheme(s)
1	What emergent literacy interventions are most effective for supporting emergent literacy learners with ASD?	Code-related / Code-focused / explicit emergent literacy intervention.	Exposure to print Alphabet identification Phonological awareness training
		Meaning-related / Meaning-focused / embedded emergent literacy intervention.	Oral language and communication intervention Shared reading Storytelling and narration Read aloud Reading comprehension intervention
		Embedded-explicit emergent literacy intervention
		Literacy-rich environment
		Emergent literacy teaching methods	Structured early intervention programmes Interactive learning and modelling Individualized education planning (IEP) Implementation of sensory strategies Use of Augmentative and alternative communication (AAC) for minimally verbal children
2	What are the factors influencing emergent literacy development?
a	List the challenges faced by professionals in the delivery of emergent literacy intervention	Clinical characteristics of children with ASD.	Prelinguistic skills Communication skills Challenging behaviours Sensory processing Social and cognitive challenges
		Poor early literacy environment
		Educational infrastructure, resources, and inclusion
		Lack of parental knowledge and unrealistic expectation
		Lack of training for professionals
		Practical issues related to intervention delivery
b	Support, information, and training to assist professionals	Professional development programmes	Workshop Webinars Seminars Certification courses
		Research and evidence-based practices
		Multidisciplinary approach
		Teaching resources and materials for children with ASD
		Parental awareness and support programmes

Effective emergent literacy interventions in children with ASD

Participants’ responses for this question indicated five themes. Code-related or code-focused, explicit emergent literacy intervention was further divided into subthemes (a) exposure to print; (b) alphabet identification; and (c) phonological awareness training, ‘phonological and phonemic awareness training’ (SLP1) and ‘exposure to logos, exposure to subtitles, exposure to texts, rhymes, word games, letter games’ (SLP26). Meaning-related or meaning-focused or embedded emergent literacy intervention was further divided into subthemes (a) oral language and communication intervention; (b) shared reading; (c) storytelling and narration; (d) read aloud; and (e) reading comprehension intervention, ‘shared book reading and guided reading’ (SLP1) and ‘higher skills such as story narration, narration of personal experience’ (SLP24). The theme embedded-explicit emergent literacy intervention was identified when participants supported an approach that included both code and meaning-related emergent literacy skills. The fourth theme reported was a literacy-rich environment, ‘rich communication environment, practice reading and writing with the child, modelling’ (SE20).

In addition to emergent literacy interventions, participants reported using emergent literacy teaching methods, further divided into five subthemes. The first subtheme reported was structured early intervention programmes such as the reading readiness programme, montessori methods, and communication developmental eclectic approach to language learning (Com-DEALL) programme, ‘Com-DEALL programme focuses on all aspects of learning, communication, joint attention, sharing, and other pre writing skills which make them school ready in 1–2 years of time’ (OT18). The second subtheme reported was interactive learning and modelling instructions, ‘activity-based learning, reading aloud, echo reading, interactive and collaborative learning’ (SE55). Use of individualized education plan emerged as third subtheme that could support children with ASD to acquire early literacy skills. Participants reported the fourth subtheme as implementation of sensory strategies, ‘sensory rich environment – provided in all possible methods – visual, auditory, kinaesthetic; sensory story narration, etc.’ (OT21). The fifth subtheme reported was use of augmentative and alternative communication (AAC) for emergent literacy instructions in minimally verbal children with ASD, ‘reading books to the child in a group setting with resources like flash cards or voice generating devices’ (SE2).

Factors influencing emergent literacy development of children with ASD

Challenges faced by healthcare professionals in the delivery of emergent literacy intervention: Participants listed a range of challenges in supporting the literacy development of children with ASD as following six themes (see Table 5). The first theme was the clinical characteristics of children with ASD, which are barriers to emergent literacy development. Five subthemes identified under this theme, were (a) inadequate pre-linguistic skills; (b) challenges in communication skills; (c) challenging behaviours; (d) differences in sensory processing; and (e) social and cognitive challenges. Participants reported that difference in development of pre-linguistic skills such as joint attention, attention span, and eye-hand coordination impede children with ASD’s readiness to attend early literacy sessions, ‘prerequisite learning skills – eye gaze, sitting tolerance, joint attention, interest’ (SLP23). Early communication challenges such as difficulty acquiring vocabulary and language concepts, reduced listening and verbal comprehension, narration challenges, and apraxia can affect children with ASD to develop early literacy skills, ‘inadequate language comprehension and expression of children with ASD’ (SLP10) and ‘difficulty in comprehending narrative texts’ (SE 51). Respondents suggested that challenging behaviours such as difficulty in transitions, insistence on sameness, and strict routine affect their ability to learn or achieve emergent literacy skills, ‘behaviours – obsession towards a particular character in the book/poor compliance’ (SLP24) and ‘communication difficulties often leading to meltdowns and non-participation’ (OT21). Differences in sensory processing such as sensory modulation (hypersensitivity and hyposensitivity), sensory discrimination (visual, auditory, and proprioceptive), and sensory-based motor (impaired fine motor coordination) differences were reported by participants, ‘sensory issues like auditory and visual processing differences’ (OT6), ‘inadequate fine motor skills’ (OT8), and ‘sensory regulation challenges’ (PSY2). Social and cognitive challenges were also reported as characteristics that interfere acquisition of early literacy skills in children with ASD, ‘executive functions issues’ (PSY2) and ‘poor visual perceptual skills/low IQ’ (OT21). The second theme, was the early literacy environment of children with ASD. Participants stated that an insufficient home literacy environment affects early literacy acquisition and training in children with ASD, ‘they are often excluded from rich and meaningful literacy like reading and writing stories book clubs acting and performing’ (SE57).

The third theme was improper execution of educational policies, poor infrastructure, lack of resources, and non-inclusive education that creates a hurdle in implementing literacy training in children with ASD, ‘in mainstream settings, regular teachers are often skeptical about how these children will learn due to environmental and other sensory issues’ (SE49). The fourth theme was lack of parental knowledge and unrealistic expectations from children with ASD. They also reported poor parental support, ignorance, myth, and parents’ lack of knowledge/maladaptive teaching methods, ‘parental participation is very poor (SLP13)’.

The fifth theme was the lack of training for healthcare professionals, ‘skilled knowledge of professionals in literacy training in this spectrum is sparse’ (SLP58). The sixth theme was practical issues related to intervention delivery. These issues included, time constraints to execute emergent literacy goals, ‘limited time with children who need literacy intervention’ (SLP59), loss of follow-up and lack of continuous and consistent intervention (SE29), and frequent changes in the therapist, ‘lack of consistency in intervention by different therapists’ (PSY12).

Support, Information, and Training to assist healthcare professionals: Participants reported the support and training required to assist the healthcare professionals as following five themes (see Table 5). Participants reported that professional development programmes ‘workshops/seminars on strategies and implementation of literacy training’ (SLP28), ‘webinars and seminars on evidence-based literacy practices in the Indian setting, certification courses such as jolly phonics’ (SE 34), would assist in teaching children with ASD. Research on culturally appropriate evidence-based practices, ‘evidence-based research and development is essential for a healthcare professional to be efficient in working with students with special needs’ (SE55) is considered to assist literacy teaching in children with ASD. Teaching resources and materials such as visual supports, storybooks, multimedia technologies, apps, lesson plans, etc., might also assist healthcare professionals in improving literacy teaching in children with ASD. Participants further described that parental awareness programmes and support programmes for healthcare professionals about the importance of early literacy, ‘more supportive studies and professional development classes with hands-on sessions’ (SLP13) can improve the execution of early literacy intervention programmes.

Discussion

The current study aimed to investigate the beliefs and practices among healthcare professionals for emergent literacy instruction in children with ASD in the Indian context. The results of our study revealed that healthcare professionals held accurate beliefs regarding emergent literacy skills in children with ASD. Our results confirmed the need to implement embedded-explicit emergent literacy intervention, that aligns with contemporary research. Hence, the hypothesis that, healthcare professionals will have inaccurate beliefs and practices regarding emergent literacy of children with ASD, is rejected. Further analysis showed that the belief and practices of the participants varied as a function of profession, but not as a function of years of practice and educational qualification. Our results further highlight the need for professional development programmes, research and evidence-based practices, an interdisciplinary approach, teaching resources and materials, parental awareness, and support programmes to assist literacy instruction in children with ASD.

Demographic and professional details

A total of 195 healthcare professionals participated in the survey, including SLPs, SEs, OTs, Psychs, and other rehabilitation professionals. A good number of responses were received from different professional group indicating that the scope of emergent literacy practice for children with ASD is spread across disciplines (Kharat & Banik, 2018; Sengupta et al., 2017). Healthcare professionals’ focus on both native and English language, encourages literacy growth in both languages, and does not disrupt English-language acquisition (Restrepo & Towle-Harmon, 2008). Although many healthcare professionals delivered emergent literacy intervention to children with ASD in the present study, only a few of the respondents reported having received professional training in early literacy practices. Previous researchers also have reported a lack of training for healthcare professionals involved in the early intervention of children with ASD in India. Training opportunities for healthcare professionals involved in the rehabilitation of children with ASD are limited in India, unlike in other countries (Sengupta et al., 2017). Therefore, the results of our study imply the need for further training the healthcare professionals on emergent literacy intervention for children with ASD.

Healthcare professional’s beliefs about emergent literacy skills in children with ASD

Participants disagreement to the statement that children with ASD are not ready for emergent literacy intervention at preschool reflects positive attitude. Most of the participants in the present study believed that children with ASD who have good phonological awareness, oral language, and alphabet recognition learn reading easily, and this is consistent with the reported studies (Dynia, Lawton, Logan, & Justice, 2014). Participants belief on oral language as a predictor of emergent literacy skills and necessity of good oral language skills to start emergent literacy intervention align with research findings that spoken language impairment is associated with poor emergent literacy skills in children with ASD (Dynia et al., 2014; Lanter, Watson, Erickson, & Freeman, 2012). Besides, a few studies suggest that children with spoken language impairment can acquire literacy and language skills if provided with a high-quality literacy learning environment and opportunities (Afacan, Wilkerson, & Ruppar, 2017). Westerveld et al. (2017) reported that meaning-related skills such as oral narration and comprehension were impaired in children with ASD, which is similar to the majority of the respondent’s belief in our study. The difference in beliefs on emergent literacy in children with ASD across healthcare professional groups signifies the difference in education and training of the professional groups (Thatcher & Fletcher, 2008).

Healthcare professionals’ emergent literacy practices in children with ASD

Our study results showed that majority of the participants believed in a comprehensive emergent literacy programme or the embedded-explicit emergent literacy intervention (a combination of shared reading, phonological awareness intervention, and literacy-rich environment), as beneficial for children with ASD. This finding aligns well with recent research suggesting that interactive book reading (embedded) and phonological awareness (explicit) training is required to acquire code and meaning-related emergent literacy measures in children with ASD (Hudson et al., 2017). Early literacy activities such as scribbling, copying words, and letters, sound awareness games, and alphabet identification target code-related skills such as print concepts, alphabet knowledge, emergent writing, and phonological awareness (Puranik & Lonigan, 2011). Interactive storybook reading and engagement in meaningful activities target meaning-related skills (Roskos, Burstein, Shang, & Gray, 2014). Besides, the remaining less than 50% of respondents in the study, who are not engaging children with ASD in early literacy experiences, warrant the need for early literacy training and awareness programmes among healthcare professionals.

Effective emergent literacy intervention for children with ASD

Participant’s responses in this section lead to five main themes. These derived themes align with evidence-based emergent literacy intervention reported in the literature for children with ASD (Dynia et al., 2014; Fleury & Schwartz, 2016; Hudson et al., 2017; Whalon, Martinez, Shannon, Butcher, & Hanline, 2015). Evidence-based interventions targeting code and meaning-related emergent literacy skills focuses on two aspects (a) children’s engagement in daily opportunities for meaningful, naturalistic, self-initiated, contextualized interaction with oral and written language, and (b) highly focused, systematic clinician-directed training occurring on a regularly scheduled session. The final subtheme, literacy enriched environment, stimulates exposure to print and literacy materials that encourage the literacy development of children with ASD (Piasta, Park, Farley, Justice, & O’Connell, 2020). Participants’ perspectives on effective emergent literacy interventions and research evidence confirm the need to adopt embedded-explicit emergent literacy intervention for children with ASD.

Another theme evolved from participants’ responses, i.e., ‘emergent literacy teaching methods’, and subthemes were structured programmes for early literacy learning, interactive learning and modelling (Justice & Kaderavek, 2004), implementation of sensory strategies (Mostafa, 2018), and use of AAC for minimally verbal children (Clendon, Paynter, Walker, Bowen, & Westerveld, 2021).

Factors influencing emergent literacy development of children with ASD

Challenges faced by healthcare professionals in the delivery of emergent literacy intervention

In order to overcome the challenges faced during emergent literacy training in children with ASD, professionals should focus to (a) explore strengths and weakness of children with ASD (b) employ strategies to facilitate social communication skills (c) implement positive behaviour interventions (d) modify the curriculum for children with cognitive challenges (e) consistent collaboration and interaction with parents or caregivers at a very young age (Catalano, Fives, McKeating, & Barnes, 2020). Information on effective shared reading practices to parents of young children with ASD would facilitate better home literacy experience leading to emergent literacy development. Finally, an interdisciplinary team approach would promote engagement and learning for children with ASD in an inclusive setup (Kunze & Machalicek, 2022).

Support or training to assist literacy teaching in children with ASD

Professional development programmes would support healthcare professionals in imparting best emergent literacy practices to meet the needs of a heterogeneous population of ASD. Also, research indicates that hands-on practice to carry out the literacy instructions in a diverse population is more relevant than didactic presentations or workshops (Morrier, Hess, & Heflin, 2011). Com-DEALL programme, ummeed’s parent programme for autism, action for autism’s parent–child training programme, and parent mediated intervention model at different hospital settings are few programmes that exist in India as intervention model for children with ASD. A substantial gap in research on the development and evaluation of intervention models in India indicate the need for research and evidence-based emergent literacy practices (Sengupta et al., 2017). Despite these challenges in the delivery of emergent literacy intervention for children with ASD, the survey results indicate that healthcare professionals follow evidence-based emergent literacy practices consistent with the available literature. However, future research needs to address culturally relevant interventions for children with ASD in the Indian population (Dababnah, Ghosh, Campion, Hussein, & Downton, 2018). Further, a multidisciplinary approach, can help to improve early literacy skills and address various developmental skills in children with ASD. The availability of teaching resources/materials for children with ASD, is limited, and is one of the immediate needs in our cultural context. Also, parental awareness, and support programmes are vital in a resource-poor setting to provide external support and knowledge of coping strategies to help them deal with stress. Parents are a vital source of intervention and support to children with ASD in a populous country like India, where trained human resources are scarce (Sengupta et al., 2017).

Strengths and limitations

This study was the first of its kind in India that explored healthcare professionals’ beliefs and practices on emergent literacy skills of children with ASD. Further, strength of the study lies in the content validation and internal consistency of the survey, which makes it an appropriate tool to explore beliefs and practices related to emergent literacy for future research. One of the limitations of the study was that it did not capture the emergent literacy practices used with minimally verbal children with ASD. Another limitation of the study was that, the questions only elicited evidence-based emergent literacy practices from the healthcare professionals. The priming of this question as well as the wordings could have possibly influenced the response of the participants to open-ended questions, by limiting the responses to evidence-based approaches and negative factors only. Hence, future research could be directed to explore the whole range of emergent literacy approaches and practices (evidence-based/not evidence-based) among healthcare professionals. Furthermore, considering the number of multidisciplinary healthcare professionals in India, the present study represents only a small sample size. We, therefore recommend future studies in this regard.

Conclusion

Findings from the current study suggest that the healthcare professionals perceived the strengths of children with ASD and believed that every child has a place in the literacy learning continuum (Erickson, 2000). Further, healthcare professionals dealing with children with ASD in India held varied beliefs regarding emergent literacy concepts in children with ASD. The results of our study showed the use of evidence-based emergent literacy practices and the need to implement embedded-explicit emergent literacy intervention, which aligns with the recent research. The findings of our study further highlight the need for professional development programmes, research and evidence-based practices, multidisciplinary approach, teaching resources and materials, parental awareness, and support programmes to assist literacy teaching for children with ASD. Furthermore, the present study signifies the need to create a meaningful literacy-rich environment at home, early intervention centre, classroom, and in the community, encompassing the communication, sensory, movement, and cognitive differences in children with ASD.

Statement of Ethics

The authors declare that the study followed ethical guidelines for human research. Written informed consent was obtained from all participants. The study protocol was approved by the Institutional Ethics Committee on human research.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

The author(s) reported there is no funding associated with the work featured in this article.