Many young children with Autism are unable to speak. When we observe their attempts at verbalizations, it is clear that some of these children exhibit characteristics of Verbal Apraxia/Dyspraxia. Vowels are distorted, searching behaviors are exhibited and inconsistent errors are present. Other children are completely silent or just produce occasional vowel sounds in a repetitive pattern.
While our first and foremost goal should be to provide these children with a means to communicate, we must not forget that we need to teach them to talk! Working with children with Autism often compounds the therapeutic difficulties inherent in dealing with Apraxia, but this article will supply some suggestions the author has found effective. This is not to suggest that these are the only techniques that work or that they will work with every child. It is my hope that therapists and parents can add these ideas to their “bag of tricks” to use as necessary.
The first, and perhaps most important step is to gain the trust of the child and create an environment in which the child enjoys having you around. Behaviorists might call it “pairing yourself with reinforcers”. Hanen or Greenspan trained therapists might call it “following the child’s lead in order to make emotional connections and close circles of communication”. I call it “getting to know the child and playing with him/her in a way that makes him/her feel good”. Start by observing the child for clues to sensory issues. What kind of sounds do they like? How do they like to be touched? What kinds of things are fun for them to look at? What foods do they like? Use this information to choose activities to introduce to the child and follow the child’s lead in participating in the activities. Be silly! Be expressive! You’ll know it’s working when you get lots of smiles and good eye contact!
As soon as the relationship is established, introduce “Mr. Tickle Guy” (A gloved hand with a face drawn on the palm). Be sure to check with the child’s parent to see if the child is on any diet that may preclude the use of latex, flavorings or powder. The rate at which you move to the mouth with “Mr. Tickle Guy” will depend on the sensory defensiveness of the child. It’s important not to move too fast and risk losing the relationship you’ve built. “Mr. Tickle Guy” might just talk to the child, tickle their legs, arms etc., or he may be able to jump right into the mouth! Some kids I see crave that oral input! I personally start with Beckman’s passive oral motor exercises to check out strength and range of motion of the oral musculature and to improve proprioceptive awareness. I also attempt to introduce a variety of flavors and textures to the mouth. If the child has little volitional control over his articulators, we work on blowing, licking and generally imitating nonspeech oral movements.
In the meantime, I have the parents play a sound song repeatedly to their child. Many children I work with love music and have a special interest in the alphabet, so I use the “Alphabet Sounds” song from the Discovery Toys tape named “Sounds Like Fun”. This song presents a word and it’s beginning sound repeated 3 times for each letter of the alphabet. My kids love it! I enlarged the hand/finger cue pictures from the “Easy Does It for Apraxia” program and made them into cards. Additionally, I added a Boardmaker icon of the words from the song in the corner of each card. I then put all the cards in a small photo album so the pictures and finger cues can be seen while singing the song. The opposite page is a good place to write the level at which the child should be practicing at home. I might write syllables or words to work on and it’s a good place to keep track of mastered words to incorporate into other training paradigms in which the child might be working. I’ve found the finger cues to be quite helpful as a visual prompt. As we work on each sound production in isolation, I use oral motor exercises and tactile prompts as necessary. I occasionally use bite blocks to assist in jaw stabilization for vowels, as these are often the most difficult. Many children will not stop “working” until the entire song is over! I use token boards to build up the number of responses required for each verse. The next verse actually becomes the reinforcer! However, it’s important not to move too fast, especially when combining sounds to keep the level of frustration low.
Typically, our goal with children who have apraxia is to move into “real words” as soon as possible. While this is important for children with Autism too, I’ve often found it necessary to work with nonsense syllables much longer. Many of my clients have a terrific ability to “match” what they’re hearing to a word they already know. For example, if they know how to say “mom”, as soon as they hear an ‘m’ sound, they say “mom”. It’s important to teach them to repeat exactly what they hear and I’ve found working on syllable formations as nonsense words combined with the finger cues to be the best way to do that.
As soon as a word is mastered, we put it into functional settings. The best “first words” to teach are things the child likes so you know they will have a desire to ask for the items. Of course you have to choose words carefully, especially if his favorite food is spaghetti! These words are also probably the first signs or PECS you introduced so now comes the tricky part. When do you stop “accepting” signs or pictures as communication and start requiring sounds? My opinion is NEVER. It’s important to always accept the communicative attempt. I’ve seen many children stop initiating any type of communication because each time they did, they were asked to say a word that they were incapable of saying. The child will stop using the sign or picture when he is able to say the word easily. To help this process along and get the words functional you might try this approach. Example: The child comes to you and gives you a picture of his juice. Give him just a little juice while verbally saying “juice”. Notice when he’s finished then prompt with a fill-in such as “you want more “. If he does not fill in the response, fill it in for him and see if he will echo it then try again. Once he can fill-in the word, give him a little of what he requested then just look at him expectantly. Again, if he doesn’t say the word, see if he will echo it. This procedure can also be used for just getting the initial sound in the correct context.
What if the child does say the word but says it incorrectly? Again, my opinion is that you honor the communicative intent and then ask the child to say the word again with you providing a model. Only do this for words that you know the child has mastered in the “drill/song” setting. All children with Apraxia have difficulty retrieving motor plans for specific words on occasion. What if you provide a model and he still says the word incorrectly? I would drop back to a syllable or even an isolated sound to be sure the child is successful. It’s very important not to “practice” incorrect motor plans by having the child repeat words over and over incorrectly.
If everybody involved gets so sick of the song that they want to throw the tape recorder across the room, you can use other types of reinforcers for practicing. Unfortunately, children with motor planning issues require a great many repetitions of sounds or words before the motor plan becomes automatic and it’s difficult, if not impossible, to get a large number of repetitions in the natural environment alone. Some children will practice in a game type format; others will practice for a video. The specific reinforcers will depend on the child. For children who don’t mind talking toys, “Little Leap” is one of the few phonics toys that I’ve found to be phonetically accurate. He’s a stuffed frog made by “Leap Frog” that sings the letter sounds when you touch the letters on his tummy. Some children will stim on pressing the letters but the voice doesn’t sound too bad and they would provide lots of auditory bombardment! One parent tapes the speech sessions and the child practices willingly while watching the tape!
Another important issue to consider is the status of the child’s nervous system at the beginning of therapy. If he appears very active with lots of stimming, you may want to do some calming activities before starting your oral motor work. If he appears more withdrawn, you may want to do some gross motor activities to rev him up before you start. It the child is working with an occupational therapist, they should be able to provide good activities for the particular child’s sensory needs. In addition, parents are often the most in-tune with what their child needs at any given moment. Ask them what you think the child needs before getting started.
It’s important when working with all children with motor planning difficulties that the work on speech be done on a consistent basis. My most successful cases have been those in which the parents take an active role, practicing daily and learning the finger cues to model words throughout the day. In addition, if the child is involved in other treatment setting, whether they be home-based or school-based, it is critical that all those working with the child work together to establish targets and determine effective strategies to incorporate new words into the child’s daily life.
While many different professionals work with children with Autism and do a tremendous job, it’s important not to leave the speech language pathologist out of the team, especially for children who are not verbal. These children have so many important things to learn. We shouldn’t leave teaching them to talk as the least important goal!