Evidence based techniques for developing speech in non-verbal children Marti Weiner M.S. CCC-SLP,...

Evidence based techniques for developing speech in non-verbal

children

Marti Weiner

M.S. CCC-SLP, BCBA

September, 2014

What are evidence based techniques?

The term evidence-based practice refers to an approach in which current, high-quality research evidence is integrated with practitioner expertise and client preferences and values into the process of making clinical decisions. (Position Statement: www.asha.org)

What is a nonverbal child?

Childhood apraxia of speech Autism Cerebral palsy Developmental delay

What is a nonverbal child?

Childhood apraxia of speech Autism

What is CHILDHOOD APRAXIA OF SPEECH (CAS)?

(www.apraxia-kids.org)

•“…have great difficulty planning and producing the precise, highly refined and specific series of movements of the tongue, lips, jaw, and palate that are necessary for intelligible speech…”

•Can range from mild prosodic disruptions to severe lack of any speech

•Typically have better (though not necessarily normal) receptive language skills than expressive language skills

•Hypothesized to have sensorimotor impairments-difficulty processing sensory information and then producing sequences of movement; difficulty with imitation

•Can also have gross or fine motor apraxia

What is autism?

Autism spectrum disorder (ASD) is a range of complex neurodevelopment disorders, characterized by social impairments, communication difficulties, and restricted, repetitive, and stereotyped patterns of behavior. (National Institute of Neurological Diseases and Stroke: (www.ninds.nih.gov)

Speech skills in children with ASD range from verbal to nonverbal; echolalia may be present; conversely, inability to imitate speech/ initiate speech may be present

Do Children with ASD have CAS?

Unknown if nonverbal children with ASD have CAS, or if they only share characteristics of the disorder

Difficulty with imitation and motor planning/programing of speech

Do AAC systems promote speech in nonverbal children? Picture Exchange Communication System

Training Manual, Frost and Bondy, page 27: “…we do not teach PECS as a way to speak, we teach it as a way to communicate…the acquisition of speech can be viewed as a fortunate by-product of the approach and not its direct focus.”

Do AAC systems promote speech in nonverbal children?

Schwartz, I., and Garfinkle, A., “PECS: Communication Outcomes for Young Children with Disabilities”, Topics in Early Childhood Special Education, Fall, 1998, Volume 18, Issue 3: Subjects fell into two groups; “nontalkers” (56%) and “talkers” (44%); after PECS training, “…the “talkers” showed steady increase in vocabulary growth, whereas the “nontalkers”…showed little or no increase in the number of spontaneous words produced.”

“…the child’s ability to verbally imitate should be analyzed to determine whether this predicts which children will acquire speech more readily…”

Treatment Protocol (apraxia-kids.org)

Provide frequent and intensive practice of speech targets

Focus on the actual skill being trained (i.e., accurate speech movement)

Include enhanced external sensory input (not just auditory, but also visual, tactile, cognitive cues for speech production)

Give careful consideration to types of practice (random vs. blocked practice of target items)

Provide appropriate feedback (knowledge of results or knowledge of performance)

Current Popular Interventions for children with CAS and/or

Non-verbal ASD

K and K Sign and Say ($139)Kaufmann Speech Praxis Kit ($199

each for Level 1 and 2)PROMPT ($500-$700 training

workshop)PECS ($395 training workshop)

Applied Behavior Analysis

by Cooper, Heron and Heward; 1987, Prentice Hall, Inc.

INTERVENTION PROTOCOL

• Provide structured intensive program

• Combine evidence based principles of applied behavior analysis with therapeutic techniques used to treat CAS and nonverbal children with ASD

• Rather than using prepackaged programs, apply set of strategies to an individual child to develop a tailor made verbal imitation/sound sequencing program

Criterion for Success

The child will learn functional communication using speech in a variety of communicative environments

Augmentative modes of communication (PECS or sign language) will be used as supplemental support only as needed

Intervention Protocol

• 1) Establish Attending



• 2) Develop gross motor imitation




• 3) Increase frequency of child’s vocalizations





• 4) Develop imitation of a variety of individual sounds






• 5) As quickly as possible, combine those sounds into syllables and short words







• 6) Delayed Imitation








• 7) Develop syllable grids









• 8) Run on multiple parallel tracks-set the bar at different levels for different environments









• 8) Run on multiple parallel tracks-set the bar at different levels for different environments

• 9) Pair meaning with sound sequences to create functional words

Establish Attending

Establishing Attending

•Behavior—Attending—Learning

BEHAVIOR

ATTENDING

LEARNING



•Work in a quiet nondistracting environment

Marie Anzalone “Sensory Integration Without the Gym”, Overland Park, KS, April 11, 2003)

Overstimulation

Behavioral Disorganization

Zone of Optimum Arousal

Attending

Learning

Understimulation

“Typical child”

Overstimulation

Behavioral Disorganization

Zone of Optimum Arousal

Attending

Learning

Understimulation

Child with attending challenges

Overstimulation

Behavioral DisorganizationZone of Optimum Arousal

Attending

Learning

Understimulation




•Use principles of reinforcement

What is a Reinforcer?“DISC”

D: Deprivation/Satiation I: ImmediateS: SizeC: Contingency





•Intersperse periods of focused work with frequent breaks

Treatment Protocol (apraxia-kids.org)

Provide frequent and intensive practice of speech targets

Focus on the actual skill being trained (i.e., accurate speech movement)

Include enhanced external sensory input (not just auditory, but also visual, tactile, cognitive cues for speech production)

Give careful consideration to types of practice (random vs. blocked practice of target items)

Provide appropriate feedback (knowledge of results or knowledge of performance)





•Intersperse periods of focused work with frequent breaks

•Establish eye contact, followed by imitation

Establishing Eye Contact

Hand to cheek: Cue EC Rf


Hand to cheek: Cue EC Rf Tracking object: Cue EC Rf


Hand to cheek: Cue EC Rf Tracking object: Cue EC Rf Sustained eye contact:

Cue EC (pause) Rf


Hand to cheek: Cue EC Rf Tracking object: Cue EC Rf Sustained eye contact:

Cue EC (pause) Rf Chaining

Cue EC Target Rf

Develop Gross Motor Imitation

Motor & Sensory Homunculus

Gross Motor Imitation

• Teach without objects (clap, wave, hooray) and with objects (tap drum, roll car, shake bell)

• Gross motor imitation easier to teach than verbal imitation

• Establishes imitation chain: EC IM Rf

• Very important skill for later corrective feedback (i.e., should never reinforce incorrect verbal imitation, BUT can insert gross motor imitation and reinforce that)

Increase Frequency of Child’s Vocalization

Increase Frequency of Child’s Vocalizations

If child can imitate at least two sounds, this step is not necessary

Use high preference reinforcers EC Cue: “TALK” Rf any sound May have to wait as long as a minute at first, but

eventually child will vocalize faster to get reinforcer

Goal is to get vocalization on request within 1-2 seconds

“This is still too hard…”

“This is still too hard…”

Set aside time period Use high preference edible

reinforcer; Every sound that child incidentally

spontaneously makes, reward with praise “Good talking!” and edible reinforcer

Develop Imitation of a Variety of Sounds


Probe to see which vowels and consonants a child can imitate- will not follow developmental hierarchy of acquisition

Always have child attend to your face Constantly probe to see what sounds child can

imitate on request-may change over time Imitation of nonverbal oral movements (e.g.,

blowing, lip smacking) not a necessary prerequisite, but these movements may be shaped into speech sounds

Never reinforce incorrect imitation- no “nice try”

“The vast majority of the legitimate research shows no changes in speech sound productions because of non-speech oral motor exercises.” Gregory L. Lof, Ph.D.

www.apraxia-kids.org


Probe to see which vowels and consonants a child can imitate- will not follow developmental hierarchy of acquisition

Always have child attend to your face Constantly probe to see what sounds child can

imitate on request-may change over time Imitation of nonverbal oral movements (e.g.,

blowing, lip smacking) not a necessary prerequisite, but these movements may be shaped into speech sounds

Never reinforce incorrect imitation- no “nice try”

Always Reinforce a Correct Response

Adult “Get ready” Child: EC Adult “k” Child “d” Adult (pause), “mmm” Child “mmm” Rf

OR Adult “do this”, claps hands Child claps hands Adult “Good clapping hands!” Rf

Combining Individual Sounds into Syllables and

Short Words

Combining Sounds into Syllable and Short Words Shortest sequence of connected speech is the

syllable

Want to practice CVs and VCs that can: Immediately be turned into functional words

(“go”, “up”, “eat”) OR Become the building blocks for CVC, CVCV, and

increasingly longer sequences

Want to practice each consonant with a variety of vowels, both CV and VC

Combining Sounds Into Syllables and Words: Some : “Tips and Tricks”

• Consonants easiest to combine with vowels: /m,n,w,f,v,s,z,sh,l,r,th/, because you can “hang on to them”

Combining Sounds Into Syllables and Words: Some : “Tips and Tricks”

• Imitating 2 distinct sounds: Say /mmm/……say /ahahah/

• Blending: Say /mmm/..hold onto the sound, and as soon as the child starts to say /m/, you blend into /ahahah/

Say /mmmmahahah/

Say /mah/

Combining Sounds Into Syllables and Words: Some

“Tips and Tricks”

• If child doesn’t have many vowels when you do your sounds probe, start with ah/ee/oo

• They are very visible

• They can be combined for other sounds

/ah/ + /ee/= “kite”

/ee/ + /oo/= “cute”

/oo/ + /ee/= “we”

Combining Sounds Into Syllables and Words: Some

“Tips and Tricks”

When teaching voiceless consonants, teach imitation of /p/, not /puh/; when teaching “plosives” (p,b,t,d,k,g), sometimes easier to start with VC syllables

Voiced plosives will have a little vowel sound after them called a “schwa”: /duh/ is acceptable, but not /duh/

Delayed Imitation

Delayed Imitation

Delayed imitation is often taken as a more complex form of imitation since it involves remembering the modeled stimulus, rather than direct stimulus control (www.termwiki.com)

Teaching Delayed Imitation

Cue “Get Ready” EC


Cue “Get Ready” EC Adult “Say (sound) Child imitates


Cue “Get Ready” EC Adult “Say (sound) Child imitatesAdult “AGAIN (sound) Child

Imitates Rf


Cue “Get Ready” EC Adult “Say (sound) Child imitatesAdult “AGAIN (sound) Child

Imitates Rf

After multiple trials of practice, PROBEAdult “AGAIN(pause)”

Child Imitates Rf

Develop Syllable Grids

CV ah(pot) Ee(me) oo(too) uh(up) VC

m -------- -------- -------- -------- m

n n

p p

b b

t t

d d

s s

z z

k k

g g


m -------- -------- -------- -------- m

n n

p p

b b

t 5-20-14 t

d d

s s

z z

k k

g g


m -------- -------- -------- -------- m

n n

p p

b b

t 5-20-14

6-10-14 t

d d

s s

z z

k k

g g


m -------- -------- -------- -------- m

n 7-12-14 n

p 7-16-14 p

b b

t 5-20-14

6-10-14 t

d d

s s

z z

k k

g g


m -------- -------- -------- -------- m

n 7-12-14

8-04-14 n

p 7-16-14 p

b b

t 5-20-14

6-10-14 t

d d

s s

z z

k k

g g


m -------- -------- -------- -------- m

n 7-12-14

8-04-14 n

p 7-16-14

9-01-14 p

b b

t 5-20-14

6-10-14 t

d d

s s

z z

k k

g g

Multiple Parallel Tracks:Setting the Bar at Different

Levels for Different Environments

Run On Multiple Parallel Tracks: Setting the Bar at Different Levels for Different Environments

•Simultaneously work on imitation of new individual sounds, syllables of mastered single sounds, new word approximations, new target words



•/m/ can mean “more”, “mom”, “mine” in functional environment before the child has learned to imitate syllables in structured imitation practice




•Generalize imitation practice to functional settings




•Generalize imitation practice to functional settings

•Accept word approximations in functional environment until child can easily imitate target word in structured practice, then raise the level of expectation

Pair Meaning with Sound Sequences to Create

Functional Words

Pair Meaning with Sound Sequences to Create

Functional Words

“Reception precedes expression”- continue to work on receptive language acquisition

Requesting items- first way to teach meaning

Expressive picture labeling-flashcards, favorite books

Setting up opportunities for commenting in functional environment

Directing another’s behavior: “go, up, out, on”

Singing songs with selected word approximations

Remember: You may need to provide a reinforcer for communication until your child understands its intrinsic value

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