Pre Linguistic Kids

7/21/2019 Pre Linguistic Kids

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Establishing a Basic Speech Repertoire without Using NSOME: Means, Motive,and Opportunity Barbara Davis, Ph.D., 1 and Shelley Velleman, Ph.D. 2

ABSTRACT

Children who are performing at a prelinguistic level of vocalcommunication present unique issues related to successful interventionrelative to the general population of children with speech disorders. These children do not consistently use meaning-based vocalizations tocommunicate with those around them. General goals for this group of children include stimulating more mature vocalization types and con-necting these vocalizations to meanings that can be used to communi-cate consistently with persons in their environment. We propose ameans , motive , and opportunity conceptual framework for assessing andintervening with these children. This framework is centered on stim-

ulation of meaningful vocalizations for functional communication. It isbased on a broad body of literature describing the nature of early language development. In contrast, nonspeech oral motor exercise(NSOME) protocols require decontextualized practice of repetitivenonspeech movements that are not related to functional communica-tion with respect to means, motive, or opportunity for communicating.Successful intervention with NSOME activities requires adoption of the concept that the child, operating at a prelinguistic communicationlevel, will generalize from repetitive nonspeech movements that are notintended to communicate with anyone to speech-based movements that will be intelligible enough to allow responsiveness to the child’s wantsand needs from people in the environment. No evidence from theresearch literature on the course of speech and language acquisitionsuggests that this conceptualization is valid.

KEYWORDS: Prelinguistic development, vocalization, languagedevelopment, NSOMEs, intervention, generalization

1Department of Communication Sciences and Disorders,University of Texas at Austin, Austin, Texas; 2Departmentof Communication Disorders, University of Massachusetts-Amherst, Amherst, Massachusetts.

Address for correspondence and reprint requests:Barbara Davis, Ph.D., University of Texas at Austin,Austin, TX (e-mail: [email protected]).

Controversies Surrounding Nonspeech Oral Motor

Exercises for Childhood Speech Disorders; Guest Editor,Gregory L. Lof, Ph.D.

Semin Speech Lang 2008;29:312–319. Copyright #2008 by Thieme Medical Publishers, Inc., 333 SeventhAvenue, New York, NY 10001, USA. Tel: +1(212) 584-4662.DOI 10.1055/s-0028-1103395. ISSN 0734-0478.

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LEARNER OUTCOMES: As a result of this activity, the reader will be able to (1) summarize the typical course ofvocal development in normally developing and atypical children; (2) explain how speech and language develop-ment involves the integration of means, motives and opportunities for communication, and how these can beclinically assessed and targeted for intervention; and (3) describe specic intervention strategies appropriate tochildren at various stages of vocal communicative development.

The goal of this Seminars in Speech and Language issue is to consider the tenets of oralmotor intervention,1,2 here termed nonspeechoral motor exercises (NSOMEs), for varioussubgroups of children within the large and varied population of childhood speech disor-ders. Children who function at the prelinguis-tic level of vocal development form a signicantsubgroup within this population. Thesechildren, and their level of function relativeto linguistic communication, bring uniquechallenges to the process of assessment andintervention for the achievement of optimalfunctional outcomes. As such, it is importantto consider their unique clinical needs in eval-uating the claims of NSOMEs.

The prelinguistic period generally encom-passes vocalization development across the rst12 months of life in typically developing chil-dren. Between 12 and 18 months, childrenbegin the seminal process of attaching soundsto meanings in early words. At the same time,they display dramatic growth in using recog-nizable sounds and syllable types for producingthese word forms. The children we considerin this article include both children who aredevelopmentally young and children who arechronologically older but continue to functionat the prelinguistic stage of vocal development.

Developmentally young children include in-fants and toddlers identied in the rst 3 yearsof life who begin clinical intervention very early. These children are not often capable of complying consistently with organized therapy task demands. Stimulating use of the vocalsystem for communication must, of necessity,be embedded in functional communicative rou-tines with familiar communication partners. Targets include increasing the developmentallevel of vocal forms and connecting these forms with meanings.

Chronologically older children include chil-dren with severe to profound levels of speechdelay/disorder who may have auxiliary cogni-tive, motor, social, or sensory issues underlying

the persistence of prelinguistic levels of vocalcommunication. Additionally, there may be noexpectation of normalization to age-appropri-ate use of the vocal system for linguistic com-munication. Thus maximization of availableprelinguistic vocal capacities for functionalcommunication may be an overall clinical goalfor these children.

Although these two subgroups of childrenare quite different in many ways, a generalclinical goal for both is to support acquisitionof the components of linguistic communica-tion, the sounds and sequences of sounds thatcomprise the building blocks of recognizable words. Equally important is to scaffold theirability to use these components for connectionsbetween vocal output and recognizable mean-ings. The overall goal is to support children inlearning to deploy these connections to meettheir needs.

A basic tenet of NSOMEs2 is that children will generalize nonspeech movement patterns(such as licking or feeding) to control of move-ment patterns for speech sounds and sequences.Rosenfeld-Johnson2 cautions that productionpractice should not begin until ‘‘all the respira-tory, phonatory and articulatory movementsunderlying each sound are rst learned’’(p. 7). Marshalla3 has hypothesized that those

children who do not develop age-appropriatespeech production patterns have unspecieddifculties during the sensorimotor period when neural pathways should have been devel-oped. She suggests that a child without ‘‘nor-mal’’ tactile (active or passive) experiences may not develop adequate foundations for move-ments required for development of speech.From the NSOME perspective, children withspeech sound disorders have unspecied neuraldecits in structure or function that result ina need to increase strength of peripheral oralmuscles.4 Part-whole training is suggested forintervention1 to organize and stimulate devel-opment of neural connectivity and strengthenperipheral components of the production

ESTABLISHING A BASIC SPEECH REPERTOIRE WITHOUT USING NSOME / DAVIS, VELLEMAN 313

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system before targeting a child’s motivation tocommunicate, the responsiveness of personsin the larger communication environment, orparticular sound system goals. At present,

no peer-reviewed evidence is available thatsupports any of these basic assertions.5

The general goal of this Seminars inSpeech and Language issue is to review theoriesand evidence already available from severaldisciplines relative to the neural and motordevelopment that is the stated target of NSOME intervention. For children who arefunctioning at a prelinguistic level, theseassertions are particularly critical. Cliniciansmay assume that lack of the use of the vocalsystem for communication connotes neuralcompromise and inadequate strength levels,necessitating NSOME as a critical rststep. Although neural compromise may be apresent and contributing factor in severe levelsof speech delay or disorder, we are referringhere to the assertion in the NSOME liter-ature that a broad set of children with speechdisorders have unspecied neural compromisethat will be remediated specically throughNSOMEs.

A primary goal of this particular article isto consider an alternative perspective to the useof NSOME for establishing a basic speechrepertoire in children operating at the prelin-guistic level. In our view, this goal is far moreappropriately addressed in the context of understanding communication and languagedevelopment as based on a complex suite of child capacities supported by communication

partners to guide the process of language development. The preponderance of research evi-dence over several years in widely diverseresearch disciplines supports the view thatspeech and language capacities are acquired asa process that includes learning to deploy speech forms (means of communication) toconvey intentions (motives for communication)to supportive communication partners (oppor-tunities for communication). Ideally, youngchildren have multiple interactive opportunitiesper day that help them understand the needand importance of using their vocal system toget what they want and need.

Clearly, speech and language acquisition isdriven by physical maturation and movement,

often the focus of NSOMEs, but equally importantly it is facilitated by the social andcognitive capacities of the child. Crucially,speech and language acquisition does not pro-

ceed via the decontextualized ‘‘practice’’ of component physical abilities. Children mustdeploy those physical abilities for vocalizationsconnected with meaning in multiple socialinteractions with supportive communicationpartners. To accomplish the social componentof communication, children must have thecognitive capacities for understanding why they want to communicate and for understand-ing who to communicate with. In chronolog-ically or developmentally young children whocannot consistently comply with decontextual-ized drill activities, embedding assessmentand intervention protocols in natural commu-nication contexts is crucial to building themeans (How?), motive (Why?), and opportunity (Who?) for optimizing their communicationand language capacities. Fig. 1 illustrates thetriad of components for clinical assessment andintervention with children operating at theprelinguistic vocal developmental level.

The clinical hierarchies described in con-temporary NSOME intervention guides do notconnect with this broad communication scaf-folding for developing a basic speech repertoire. The varied NSOME activities (e.g., straws,bubbles, etc.) offer decontextualized practiceon physically repetitive nonspeech movementsnot logically connected with the rapid and varied movements needed for goal-directedspeech-related behaviors. NSOME move-

ments are embedded in stimulating activities.Strategies that would help the child to bridgefrom these nonspeech actions to the planningand production of sounds needed to build words are usually not included. The implicationof NSOMEs are that children who are func-tioning at a prelinguistic communication level will somehow generalize and diversify the de-contextualized nonspeech physical movements, yielding the complex and diverse speech-related movements that must be implementedfor functional communication. They mustmake the further inference that the physicalrequirements of producing speech-relatedsounds are connected with the cognitive andsocial requirements of coding meaning to get

314 SEMINARS IN SPEECH AND LANGUAGE/VOLUME 29, NUMBER 4 2008

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what they want and need. No componentin NSOME protocols addresses these critical‘‘pieces’’ of the communication puzzle.Similarly, no NSOME protocols include goalsfor caregiver responsiveness to functionalcommunications from the child. Motivationto communicate and opportunities from theenvironment to understand the need tocommunicate are missing entirely. A recentNSOME case study 6 describes combiningNSOME with ‘‘other’’ intervention compo-nents for a nonverbal child. However, creditfor the child’s improvement is assigned tothe NSOME component of intervention. This lack of exactness in evaluating the precisecontribution of NSOMEs in the context of diverse and unspecied other interventionactivities must be addressed via the rigor

of evidence-based practice before attributingimprovement to NSOMEs.

CLINICAL ASSESSMENTFor children operating at a prelinguistic level,the clinician must assess the child’s motives ,means , and opportunities for communication toplan a comprehensive intervention program. Within the functional communication para-digm for intervention we are proposing here,there is no rationale for addressing one of the three components if the other two are notaccounted for. In the context of the presentarticle, there is no rationale for addressingmeans if motive and opportunity are not present

for the child who is using prelinguisticmeans of communicating. Additionally, means,motive , and opportunity must be assessed inthe child’s natural environment because these

developmentally young children may notbe able consistently to comply with task demands. Assessment instruments such as theCommunication and Symbolic Behavior Scales(CSBS; Brookes Publisher, Baltimore, MD)7

can be used to evaluate children across thesedimensions of functional communication. Ourgoal in this short article is not to be exhaustivein providing a template for assessment but toillustrate the kinds of questions that must beanswered to plan intervention from a functionalcommunication-embedded perspective.

The child’s motives, or pragmatic inten-tions, are related to the Why? question aboutuse of language forms and/or prelinguisticcommunication means. This assessment ques-tion is addressed through assessment of what,if any, basic communicative intents the childis using. Basic communicative intents of re-questing, giving, showing, rejecting/avoiding,greeting, and commenting are central to under-standing why the child initiates contact withhis or her environment.

Means, the How? question, must be assessedin tandem with motives . Here the clinicianmust assess how the child accomplishes his orher motive to communicate. Table 1 lists asummary of communication means.

A third aspect of the assessment triad forstimulating communication means in childrenfunctioning at a prelinguistic level isopportunity.

Responsive communication partners are repre-sentative of the Who? question for functionalcommunication assessment and intervention.Responsivity comprises a basic requirement forintervention with prelinguistic children. Theirfunctionally oriented motives and means em-ployed in communication initiations or in re-sponse to initiations by others need to be shapedtoward more mature means by responsivepartners. Ideally, responsive partners include anetwork of family members, professionals, andcaregivers that encompasses important personsin children’s environments. The clinical assess-ment question to be answered in planningintervention is ‘‘Who are the key players inthe child’s environment who can be consistently

Figure 1 The communicative triad of means,motive, and opportunity for structuring assess-

ment and intervention protocols with prelinguisticchildren.


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child focused as well as consistently responsiveto the child’s motives and immature meansto communicate?’’ Second, assessment shouldinclude the ways in which communicationpartners are responding to the child’s motivesand means for communication. These are somequestions to be asked: How often is the childsuccessful with the tools at his or her disposal? What occurs when there are communicationbreakdowns? How are communication partnerssignaling successful understanding of the child’smessage?

CLINICAL INTERVENTIONOnce we have determined the child’s currentfunctioning with respect to means, motive, andopportunity, we then have to design therapeu-tic interventions that will address areas of decit within this framework. Intervention isdesigned to target areas of decit and rely onsupport from areas of relative strength. Clearly,

neither NSOME treatment nor speech-basedmotor therapy will inspire communicationin a child without either communicative intentor supportive listeners who can respond toidiosyncratic attempts at vocal communication. Therefore, this section considers therapy approaches for all three of the priority areas.Because our primary purpose is to contrastour perspective with that of those who useNSOMEs, we focus mainly on means. But rst,a few words about motive and opportunity.

Motive and OpportunitySeveral intervention approaches have been de- veloped to address motives and opportunities

that are key to supporting communicationdevelopment in prelinguistic children. All of these approaches focus on connecting thechildren’s communicative means, which may not be in the vocal modality, to functionalcommunication. These include the Hanentraining programs for parents, caregivers, andprofessionals,8 Picture Exchange Communica-tion Systems (PECS),9 Prelinguistic Milieu Therapy (PMT),10 the Social PartnershipModel (SPM),11 and Functional Communica-tion Training (FCT). 12 Researchers have docu-mented the progress in means that childrenmake when their motives and opportunities areaddressed in these programs. Interventionsdesigned to increase communication duringthe prelinguistic stage result in better linguisticoutcomes.8,13–16 Thus addressing motive andopportunity is inseparable from addressingmeans .

MeansBecause our purpose is to present an alternativeto NSOMEs for developing a basic speechrepertoire in prelinguistic children, the remain-der of the article focuses specically on means.However, as we have noted in assessment, acore principle underlying this information isthat motive and opportunity are critical compo-nents for diversifying communicative means indevelopmentally young children.

For many children who have both motivesand opportunities to communicate, vocal development may still be slow. Varied modesof nonvocal communication will likely need tobe established rst to decrease frustrationand facilitate aspects of cognitive and social

Table 1 Communication Means for Clinical Assessment

Gestural/Sign Vocalizations Nonverbal

Presymbolic No vocalizations Eye gazePointing Pitch or loudness changes Physical manipulationReaching Vowels only Other idiosyncraticOther idiosyncratic Consonants onlySymbolic Nonrhythmic syllablesSingle gestures Repetitive syllablesCombined gestures Diverse syllablesLinguistic signs


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development dependent on interactions withothers. It is well established that providingan alternative means of communication, suchas basic signs, picture exchange (PECS), or

simple electronic devices, does not decreasethe likelihood that a child will establish oralcommunication. Strong evidence suggests thatenhancing a child’s overall communicative ef-fectiveness may instead increase oral commu-nication capacities17 . Thus augmentative andalternative communication (AAC) training orusing other augmentative devices does notconstitute ‘‘giving up’’ on oral communication.Speech remains a goal even for children whose primary means of interacting is likely to continue to depend on nonvocal means.

The backlash against nonspeech motortreatment has been interpreted as a claim thatmotor decits should not be directly addressedin intervention.1 This assertion is far fromaccurate. As discussed elsewhere in this series,many successful intervention approaches arebased on principles of motor learning. The key distinction is whether the intervention targetsspeech-related movements. For chronologically young or developmentally young children, as with other children with speech sound delay ordisorder, it is necessary to practice on activitiesthat are as complex and as hierarchically organ-ized as speech to improve speech.18,19

Children with little or no vocal outputhave few or no practiced speech movementpatterns to draw on for the production of real words. To make oral communication effectivefor such children, intervention approaches that

build on existing motor representations andautomatize new motor schemas will be mostefcient and successful. Building on existingmotor synergies involves what has been termed‘‘shaping,’’ which involves beginning with a vocalization that the child already producesand supporting gradual evolution into a morespecic rened, useful utterance.

How can these new motor synergies beautomatized? Here the principles of motorlearning20–22 come into play. Despite their focuson muscle strength, NSOME approaches typ-ically focus on peripheral aspects of the speechproduction system only. Principles of motorlearning go deeper, into the planning and pro-gramming of speech production, as well as its

execution. Planning and programming incorpo-rates a cognitive processing component into theconsideration of how to pursue intervention.

The motor learning literature indicates

that enough practice has to be provided sothe motor schema will be available for plan-ning, programming, and executing furtherutterances. Developmentally and chronologi-cally young children can be encouraged torespond more consistently in natural play con-texts where motive and opportunity are presentto stimulate use of available means. Therefore,to maximize the number of uses of targetedforms per session, activities that incorporaterepetition in a meaningful and playful way should be used. For example, one can point toone’s toes while repeating ‘‘toe, toe, toe, toe’’ tentimes or point to the M&M’s inThe M&M’s Brand Counting Book while saying ‘‘m, m, m.’’

If a child has communicative intents(motives) and only produces nonspeech vocal-izations, the clinician can begin by attributingmeaning to reexive or other nonspeech vocal-izations. Clearly associating physiologically based sounds with meaning, such as a grunt when moving a heavy object,

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a sharp intakeof breath while pretending to touch a toy knife,or snoring while pretending to sleep, can sup-port the child in connecting communication with vocal output that is within his or hercapacities. Stimulating the child to use availablenonspeech vocalization capacities to communi-cate is conceptually different from the practiceof NSOMEs. These stimulations are used ina meaningful context and incorporate means,

motive, and opportunity for the purpose of encouraging meaningful oral communication.Encouragement to attribute meaning to non-speech behaviors does not pursue the NSOMEgoals of strengthening muscles that are already strong enough for speech purposes, organizingan oral action that is not useful for talking, orstimulating a neural connection for nonspeechthat is different from the neural connectivity associated with speech production. Instead, itfurthers the goal of connecting oral sounds tomeanings.

For children with nonmeaningful pre-rhythmic or semirhythmic (i.e., marginalbabble) vocalizations, it’s helpful to pair vocalizations with rhythmic movement (e.g.,


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bounce on ball) and model canonical babble(highly rhythmic, with nonspeech rhythm).Songs and rhymes can be sung/recited usingconsonant vowel (CV) syllables in place of

words. Meaning can be introduced by pairingreal-word vocalizations as close to canonicalsyllables as possible (CV, vowel consonant[VC], etc.; e.g., ‘‘go go go,’’ ‘‘up up up’’) withaction and speech rhythm.

For children with meaningful but vowel-only vocalizations, clinicians could start by modeling meaningful consonant-alone vocal-izations (e.g., ‘‘shhh,’’ ‘‘mmmm’’), sound effects(animal noises, vroom, pouring sounds, etc.),and words with emotional content and early emerging consonants, such as glottals andglides (‘‘uh-oh,’’ ‘‘yeah!,’’ ‘‘wow,’’ ‘‘whee,’’‘‘haha’’). Tactile cues can help cue for lipclosures. Labial cues are especially easy andtransparent. Once the child is able to approx-imate some of these, then clinicians can moveon to modeling other words illustrating mean-ingful CV and VC syllables with early occur-ring consonants (e.g., [b], [p], [m],[n], [w]).

Homonymy and variability may be charac-teristic of children who are emerging into therst use of meaningful word forms. For a childusing homonymy (i.e., the same production formany different words), there may be a pattern(template) that the child imposes on words,such as reduplication or an alternation of alveo-lar and labial consonants.23 Once a pattern hasbeen identied, the goal is to make the child’scommunicative means more effective by diver-sifying: shaping his or her vocalizations into

more diverse patterns (e.g., labial-alveolar in-stead of alveolar-labial) or introducing differentpatterns (e.g., CVC for a child who is producingonly CV and CVCV words). For excessive variability (i.e., many different productions forthe same word), in contrast, the goal is to makethe child’s communicative means more effectiveby stabilizing vocalization output. Here oppor-tunity is paramount. A major goal is to system-atize adult interpretations of child-initiatedattempts by modeling and selective responding. The message is that consistency matters . This is aprinciple that encourages a clinician to considermeans, motive, and opportunity for increasingthe success of communication and movingtoward linguistically based output in children

who are operating at the prelinguistic level of vocal development.

CONCLUSION We have presented a functional communicationalternative to using NSOMEs for children whoare operating at a prelinguistic level of vocalcommunication. Many speech-language path-ologists feel at a loss when it comes to stimulat-ing language in children with severe speech-language disorders, especially those who haveno preexisting communicative intent or nospeech-like vocalizations. For these clinicians,consideration of implementation of NSOMEs versus communicatively embedded communica-tion is of critical importance as they seek todeliver efcient and effective services to thisgroup of children within the larger populationof speech-disordered clients. For researchers,studying the claims and effectiveness of NSOMEs provides vital support to understand-ing the basic nature of speech disorders as wellas supporting best clinical practices. One auxil-iary goal of this series of articles may be topoint out areas where researchers need to acceptthe charge of evaluating NSOMEs as wellas proposed clinical intervention alternativesfollowing evidence-based practice guidelines.24

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Pre Linguistic Kids

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