Autism Spectrum Disorder (ASD)

Autism Spectrum Disorder (ASD)

Treating Apraxia in Children with Autism

By

Tracy Vail, M.S., CCC-SLP

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!

© Apraxia-KIDS℠ – A program of The Childhood Apraxia of Speech Association (Apraxia Kids)
www.apraxia-kids.org

Shaping Verbal Language for Children on the Spectrum of Autism Who Also Exhibit Apraxia of Speech

By

Nancy Kaufman, M.A., CCC/SLP and Tamara S. Kasper, MS/CCC-SLP, BCBA

Many children with autism spectrum disorders are vocal, yet non-verbal. They may produce consonants, vowels and syllables, but do not use words to communicate. Though it is difficult to judge whether or not these children exhibit apraxia of speech, a specialized approach of shaping successive word approximations, combined with sign language, may help non-verbal children with autism to become verbal communicators.
There is a great deal of evidence to support that new behaviors can be established by breaking a task down into smaller units and shaping them toward the target behavior using reinforcement techniques (Skinner, l957). Utilizing these well-known techniques of Operant Conditioning, consonants and vowels can be shaped into best approximations of words to become functional vocabulary until the children are able to master the adult form of the words (Sweeney-Kerwin et al., 2005; Kasper & Goodwin, 2003; Kaufman, 1998, 2001). These techniques have been highly effective for children with apraxia of speech, as the task of verbal imitation is simplified into smaller units that can be more easily mastered and utilized immediately and functionally. For example, a child may not be able to say “apple” due to the difficulty of the final /l/, as well as the vowel /ae/, not to mention that it is a two syllable word. The child can be taught to say it as “ah-po” (using the phonological processes of vowel neutralization and vocalization (Khan, l985), thus simplifying the motor coordination of the word and making it easier to produce. Once the child can imitate the “word shell” for “apple”, he or she would be rewarded ideally by being given a piece of apple. As therapy continues, efforts would be made to assist the child to eventually be able to say “apple” accurately. The Kaufman Speech Praxis Treatment Approach follows the application of operant conditioning and is a systematic method of shaping word approximations toward target, functional vocabulary to be moved directly in expressive language. However, the Kaufman approach relies heavily upon verbal imitation, a skill that is usually lacking in non-verbal children with autism.

One solution to helping children with autism spectrum disorders to begin to verbally imitate is to first shape sign language to communicate. Often, children with autism have missed out on many opportunities to hear words during exciting and motivating situations. They have few experiences with attempting to produce words and receiving items. Sign language may be an excellent choice in these situations as the child can be physically assisted in moving his hands to make the sign. Every time the teacher or significant other helps the child produce the sign, the teacher says the word several times. Often, as the child has more experience using sign language to request specific needs and desires, which have always been paired with hearing the word, the sign itself might trigger the verbalization ”automatically” (Sundberg et al., 1986; Yoon and Bennet, 2000). The child would then be reinforced more quickly or in greater amounts when he or she produces the sign with verbalization. If the child never verbalizes anything close to how the word is produced, we would then work on achieving best word approximations through echoics (verbal imitation) of the highest level of consonant-vowel combinations toward the target word as can be obtained (Kasper & Kaufman, 2005). Signs would be chosen that represent the children’s most powerful motivators so that they will have the ability to eventually use verbal mands (requests) for their favorite foods, drinks, toys and activities.

Teaching manual signs has been found to benefit children with autism as they can be easily shaped with hand-over-hand prompting and fading (Sundberg & Partington, l998). Combining sign language with successive verbal approximations of words via the Kaufman techniques has been shown to be an effective method of helping children with autism become verbal communicators. Dr. Vincent Carbone, a Board Certified Behavior Analyst with over 25 years of experience designing learning environments for people with autism and developmental disabilities, conducted research with his colleagues comparing the use of the Kaufman approach of successive approximations to a second method of modeling whole words for imitation (Sweeney-Kerwin, et al., 2005). Dr. Carbone’s study demonstrated that providing successive approximations toward target words for two children with autism was more effective and efficient (fewer trials to criterion) in teaching production of the target words. In addition, use of the Kaufman “word shells” resulted in generalization of improved verbal imitation to untaught words. Ms. Tamara Kasper, M.S. CCC/SLP, BCBA, conducted a single subject design (Kasper and Godwin, 2003) showing the success of sign language to increase vocalizations and successive approximations using the Kaufman word shells to shape vocalizations. Their results demonstrated significant improvement in test scores and intelligibility as well as generalization of improved articulation to untaught words.

There is mounting evidence that sign language promotes verbal skills (speech) in children with autism, (Barrera, et al, 1980, Barrera & Sulzer-Azaroff, 1983, Carr and Dores, 1981; Layton, 1988; McIlvlane et al., 1984; Yoder and Layton, 1988) and provides an opportunity to then shape consonants and vowels to form functional words through echoics (verbal imitation). In order to provide stimulus items that would motivate children to learn, the K & K Sign and Say (Kasper & Kaufman, 2005) program was produced. Its purpose is to provide photographs of foods, drinks, toys and activities that many children, especially those on the spectrum of autism or who exhibit other developmental challenges, would be highly motivated to request. On the back of each photograph is a picture of the manual sign, a description of how the sign is produced, as well as a series of word approximations to help shape the child’s vocalizations. A complete manual is also provided as to the specific use of the K&K Sign and Say methods.

In our opinion, shaping the behavior of “speaking” can be accomplished for many children with autism and apraxia of speech, especially through initially shaping signs or sign approximations as the initial avenue toward verbal imitation. In our clinical practices, using successive approximations, cueing, fading and the effective use of reinforcement is proving to be a highly successful method to help children who otherwise have been vocal, yet non-verbal, to become functional verbal communicators.

Research on shaping new behaviors through operant conditioning has been cited in the literature since l957. The Kaufman techniques follow this behavioral shaping method with the end goal of verbal communication. These techniques have been utilized with systematic methodology since 1989. Unpublished data, pre and post videotapes as well as anecdotal successful outcome feedback from around the world provide some evidence in support of this approach. However, as with all treatment methods for childhood apraxia of speech, more scientific evidence regarding treatment efficacy is needed. In particular, we hope to see and participate in treatment research studies on this methodology with well defined subject inclusion criterion for this dually diagnosed population of children with autism spectrum disorders and possible apraxia of speech. Peer reviewed, published treatment data are greatly needed on this, as well as other, speech treatment methods for CAS and autism spectrum disorders.

Helpful Websites

Kaufman Children’s Center for Speech, Language, Sensory-Motor, and Social Connections, Inc. http://www.kidspeech.com

Tamara Kasper, MS/CCC-SLP, BCABA: http://www.kasperautism.com

Dr. Vincent Carbone http://www.drcarbone.net

Northern Speech Services http://www.nss-nrs.com

References

Barrera, R. & Sulzer-Azaroff, B. (1983). An alternating treatment comparison of oral and total communicationtraining program with echolalic autistic children. Journal of Applied Behavior Analysis, 4, 379-394.

Brady, D. O., & Smouse, A. (1992) A simultaneous comparison of three methods for Language training with anautistic child: An experimental case analysis. Journal of Autism and Childhood Schizophrenia, 8, 271-279.

Carbone, V. J. (2004). 2004 Tutorial: Clinical applications of verbal behavior research with children with autism. Proceedings of the 30th Annual International Convention Association for Behavior Analysis. Boston, Massachusetts.

Carbone, V. J. (2002) Teaching verbal behavior to children with autism and related disabilities. Unpublished Workshop Manual.

Carr, E. & Dores, P. (1981) Speech vs. sign comprehension in autistic children; analysis and
prediction. Journal of Experimental Child Psychology, 37, 587-597.

Casey, L. O. (1978) Development of communicative behavior in autistic children: A parent program using manual signs. Journal of Autism and Childhood Schizophrenia, 8, 45-59.

Fulwiler, R. & Fouts, R. (1976) Acquisition of American Sign Language by a non-communicating autistic child, Journal of Autism and Childhood Schizophrenia, 6, 43-50.

Kasper, T., & Godwin, J. (2004). Teaching verbal behavior: Hands on training for tutors and therapists. Unpublished Workshop Manual.

Kasper, T., & Godwin, J. (2003). Improving vocal verbal behavior via tutor-modeled successive approximations. Proceedings of the 29th Annual International Convention Association for Behavior Analysis. San Francisco, California.

Kasper, T. & Kaufman, N. (2005). K&K Sign & Say: Shaping Verbal Language for Individuals with Autism an d Other Developmental Challenge. Gaylord, MI: Northern Speech Services, Inc.

Kaufman, N. (1995). Kaufman speech praxis test for children. Detroit: Wayne State University Press.

Kaufman, N. (1998). Kaufman speech praxis treatment kit for children. Gaylord, MI: Northern Speech Services.

Kaufman, N. (2001). Kaufman speech praxis treatment kit for children-2. Gaylord, MI: Northern Speech Services.

Kaufman, N. (2005). Kaufman speech praxis workout book for children. Gaylord, MI:Northern Speech Services.

Layton, T. (1988) Language Training with autistic children using four different modes of presentation. Journal of Communication Disorders, 21, 333-350.

Layton, T. & Watson l. (1995) Enhancing communication in non-verbal children with autism. In K. A. Quill (Ed) Teaching Children with autism: Strategies to enhance communication and socialization. (pp 73-101) New York: Delmar Publishers.

Miguel, C.F, Carr, J. E. & Michael, J. (2002). The effects of a stimulus-stimulus pairing procedure on the vocal behavior of children diagnosed with autism. The Analysis of Verbal Behavior, 18, 3-13.

Palmer, D.C. (1996). Achieving parity: The role of automatic reinforcement. Journal of the Experimental Analysis of Verbal Behavior, 65, 289-290.

Schaeffer, B., Kollinzas, G., Musil, A., & McDowell, P. (1978). Spontaneous verbal language for autistic children through signed speech. Sign Language Studies, 21, 317-352.

Skinner, B. F. (1957). Verbal Behavior. Englewood Cliffs, NY: Prentice Hall.

Sundberg, M.L., Michael, J., Partington, J. W., & Sundberg, G.A. (1996). The role of automatic reinforcement in early language acquisition. The Analysis of Verbal Behavior, 13, 21-27.

Sundberg, M.L., & Partington, J.W. (1998). Teaching language to children with autism or other developmental disabilities. Pleasant Hill, CA: Behavior Analysts, Inc.

Sweeney-Kerwin, E., Zecchin-Tirri, G., Carbone, V.J.; Janeckey, M.; Murrary, D. & McCarthy, K. (2005). Improving the Speech Production of Children with Autism. Proceedings of the 31st Annual International Convention Association for Behavior Analysis. Atlanta, Georgia.

Yoder, P. & Layton, T. (1989) Speech following sign language training in autistic children with minimal verbal language. Journal of Autism and Developmental Disorders, 18,217-229.

Yoon, S.Y., & Bennett, G. M. (2000). Effects of a stimulus-stimulus pairing procedure on conditioning vocal sounds as reinforcers. The Analysis of Verbal Behavior, 17, 75-88.


[Nancy R. Kaufman, M.A., CCC/SLP is the director of the Kaufman Children’s Center for Speech, Language, Sensory-Motor and Social Connections, Inc. She has specialized in the area of Apraxia of Speech in Children since l979. An experienced clinician, diagnostician, author, presenter and clinical service award winner, Nancy presents The Kaufman Speech Praxis Treatment Approach nationally and internationally. Nancy works with children, professionals and families daily, providing video consultations as well.

Tamara S. Kasper, MS/CCC-SLP, BCBA, has practiced as a pediatric speech/language pathologist with emphasis on treatment of children with challenging behaviors for over 16 years. She has specialized in treatment of children within the autism spectrum for the last 10 years. In her pursuit of effective treatment methods, she became a Board Certified Behavior Analyst under the mentorship of Dr. Vincent Carbone. She has advanced training in application of Skinner’s analysis of verbal behavior, Greenspan’s DIR approach, and Kaufman’s strategies for apraxia of speech. She is co-author of the K&K Sign and Say kit. Currently, Ms. Kasper provides consulting services, training, and workshops to treatment teams who serve children with autism in the United States, Canada, and Europe.]

© Apraxia-KIDS℠ – A program of The Childhood Apraxia of Speech Association (Apraxia Kids)
www.apraxia-kids.org

Similarities and Differences in Young Children with Autism and Those Children with Apraxia of Speech

By

Tracy Vail, M.S., CCC-SLP

I primarily serve very young children and specialize in treating children with Autism. My clinical experience has been that about possibly 20% of children with autism who I see also have apraxia of speech. These disorders can occur in isolation or in combination. Physicians and early intervention case coordinators often refer children for speech-language services when they see a child has “autistic tendencies” and often well before a diagnosis has been confirmed.

After 22 years I have noted that there appear to be a group of children who demonstrate autistic tendencies when they are very young but later are instead diagnosed with apraxia of speech. Many of these children have sensory issues and are not very social. (It is difficult to be social when no one understands you!) Some very young children with apraxia can even exhibit some perseverative play behaviors early on, but typically outgrow these pretty quickly. Both disorders are often described as having a neurological basis.

Since I have four children of my own, I know how desperately parents want to know exactly what is going on with their child. It’s terrifying to get either diagnosis for your child, especially when you begin gathering information and hear so many mixed reports of progress and prognosis for improvement. This is true with both Apraxia and Autism. It is very normal to go through a grieving process anytime you are told your child has a disability and I understand the need for parents to progress through the stages of grieving. They need to talk and get support from other people.

Still, when a child is very, very young I do not even discuss a diagnosis and instead choose to focus on identifying and treating current symptoms. My reasoning is that first, diagnosing autism requires a team of professionals with expertise in a variety of areas of development. A speech-language pathologist cannot ethically diagnose autism independently even if she or he were confident about the diagnosis for a particular child. Second, I’ve seen too many children with a diagnosis of autism come into the clinic at two years old and have the diagnosis removed later on. (Please be clear that I mean to indicate the child was incorrectly diagnosed rather than that we “cured” them). I’ve also seen children who have the diagnosis ruled out at two years of age but later autism is confirmed. It’s just not an exact enough science to say with certainty with many young children. The same thing can be said of very young children with apraxia of speech.

I don’t want to appear uncaring or unsupportive of parents when they feel they need me to validate their impressions of their child’s diagnosis. I want parents to be supported and consoled and strongly recommend support groups and counseling if needed. I just feel that my role as the SLP has to focus on helping parents learn how to teach specific skills to their child. We have limited time and must prioritize how we spend it.

We determine the needs of services for each child based on the severity of presenting symptoms. If we see motor planning problems, we address those. If we see sensory problems, we address those. If we see social problems, we address those. It really doesn’t matter what the “reason” is as long as the problem areas are being treated. I think we can waste a great deal of time and energy both as parents and professionals by focusing on specific behaviors to “prove”…. is he or isn’t he?? The true answer will come in time as the child teaches us how he learns best and moves through developmental stages. We can deal with it when the time comes and know that either way, progress will continue. Neither diagnosis gives a picture of what the child will “look like” in twenty years. The best we can do for all the children is to give them the best and most intensive early intervention possible.

We also need to continue to work together as parents and professionals to advocate to our legislators that money be earmarked for intensive early interventions services for all children with significant developmental delays and disorders no matter what the diagnosis. There are many research findings indicating that intensive early intervention provides children with the best possible outcome as well as saving our society millions of dollars over the life of the child.


[Tracy Vail, M.S., CCC-SLP, has been a speech-language pathologist for over 25 years, practicing in both the public school and private clinical settings. She has a specific interest in children with autism and childhood apraxia of speech. She currently owns a private practice, Lets Talk, in Raleigh, NC, where she provides both direct and consultative services. She is also a past president of the North Carolina Speech, Hearing and Language Association. In addition, she has contributed articles for the Apraxia-Kids web site.]

Autism Spectrum Disorder (ASD)

Treating Apraxia in Children with Autism

By

Tracy Vail, M.S., CCC-SLP

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!

© Apraxia-KIDS℠ – A program of The Childhood Apraxia of Speech Association (Apraxia Kids)
www.apraxia-kids.org

Shaping Verbal Language for Children on the Spectrum of Autism Who Also Exhibit Apraxia of Speech

By

Nancy Kaufman, M.A., CCC/SLP and Tamara S. Kasper, MS/CCC-SLP, BCBA

Many children with autism spectrum disorders are vocal, yet non-verbal. They may produce consonants, vowels and syllables, but do not use words to communicate. Though it is difficult to judge whether or not these children exhibit apraxia of speech, a specialized approach of shaping successive word approximations, combined with sign language, may help non-verbal children with autism to become verbal communicators.
There is a great deal of evidence to support that new behaviors can be established by breaking a task down into smaller units and shaping them toward the target behavior using reinforcement techniques (Skinner, l957). Utilizing these well-known techniques of Operant Conditioning, consonants and vowels can be shaped into best approximations of words to become functional vocabulary until the children are able to master the adult form of the words (Sweeney-Kerwin et al., 2005; Kasper & Goodwin, 2003; Kaufman, 1998, 2001). These techniques have been highly effective for children with apraxia of speech, as the task of verbal imitation is simplified into smaller units that can be more easily mastered and utilized immediately and functionally. For example, a child may not be able to say “apple” due to the difficulty of the final /l/, as well as the vowel /ae/, not to mention that it is a two syllable word. The child can be taught to say it as “ah-po” (using the phonological processes of vowel neutralization and vocalization (Khan, l985), thus simplifying the motor coordination of the word and making it easier to produce. Once the child can imitate the “word shell” for “apple”, he or she would be rewarded ideally by being given a piece of apple. As therapy continues, efforts would be made to assist the child to eventually be able to say “apple” accurately. The Kaufman Speech Praxis Treatment Approach follows the application of operant conditioning and is a systematic method of shaping word approximations toward target, functional vocabulary to be moved directly in expressive language. However, the Kaufman approach relies heavily upon verbal imitation, a skill that is usually lacking in non-verbal children with autism.

One solution to helping children with autism spectrum disorders to begin to verbally imitate is to first shape sign language to communicate. Often, children with autism have missed out on many opportunities to hear words during exciting and motivating situations. They have few experiences with attempting to produce words and receiving items. Sign language may be an excellent choice in these situations as the child can be physically assisted in moving his hands to make the sign. Every time the teacher or significant other helps the child produce the sign, the teacher says the word several times. Often, as the child has more experience using sign language to request specific needs and desires, which have always been paired with hearing the word, the sign itself might trigger the verbalization ”automatically” (Sundberg et al., 1986; Yoon and Bennet, 2000). The child would then be reinforced more quickly or in greater amounts when he or she produces the sign with verbalization. If the child never verbalizes anything close to how the word is produced, we would then work on achieving best word approximations through echoics (verbal imitation) of the highest level of consonant-vowel combinations toward the target word as can be obtained (Kasper & Kaufman, 2005). Signs would be chosen that represent the children’s most powerful motivators so that they will have the ability to eventually use verbal mands (requests) for their favorite foods, drinks, toys and activities.

Teaching manual signs has been found to benefit children with autism as they can be easily shaped with hand-over-hand prompting and fading (Sundberg & Partington, l998). Combining sign language with successive verbal approximations of words via the Kaufman techniques has been shown to be an effective method of helping children with autism become verbal communicators. Dr. Vincent Carbone, a Board Certified Behavior Analyst with over 25 years of experience designing learning environments for people with autism and developmental disabilities, conducted research with his colleagues comparing the use of the Kaufman approach of successive approximations to a second method of modeling whole words for imitation (Sweeney-Kerwin, et al., 2005). Dr. Carbone’s study demonstrated that providing successive approximations toward target words for two children with autism was more effective and efficient (fewer trials to criterion) in teaching production of the target words. In addition, use of the Kaufman “word shells” resulted in generalization of improved verbal imitation to untaught words. Ms. Tamara Kasper, M.S. CCC/SLP, BCBA, conducted a single subject design (Kasper and Godwin, 2003) showing the success of sign language to increase vocalizations and successive approximations using the Kaufman word shells to shape vocalizations. Their results demonstrated significant improvement in test scores and intelligibility as well as generalization of improved articulation to untaught words.

There is mounting evidence that sign language promotes verbal skills (speech) in children with autism, (Barrera, et al, 1980, Barrera & Sulzer-Azaroff, 1983, Carr and Dores, 1981; Layton, 1988; McIlvlane et al., 1984; Yoder and Layton, 1988) and provides an opportunity to then shape consonants and vowels to form functional words through echoics (verbal imitation). In order to provide stimulus items that would motivate children to learn, the K & K Sign and Say (Kasper & Kaufman, 2005) program was produced. Its purpose is to provide photographs of foods, drinks, toys and activities that many children, especially those on the spectrum of autism or who exhibit other developmental challenges, would be highly motivated to request. On the back of each photograph is a picture of the manual sign, a description of how the sign is produced, as well as a series of word approximations to help shape the child’s vocalizations. A complete manual is also provided as to the specific use of the K&K Sign and Say methods.

In our opinion, shaping the behavior of “speaking” can be accomplished for many children with autism and apraxia of speech, especially through initially shaping signs or sign approximations as the initial avenue toward verbal imitation. In our clinical practices, using successive approximations, cueing, fading and the effective use of reinforcement is proving to be a highly successful method to help children who otherwise have been vocal, yet non-verbal, to become functional verbal communicators.

Research on shaping new behaviors through operant conditioning has been cited in the literature since l957. The Kaufman techniques follow this behavioral shaping method with the end goal of verbal communication. These techniques have been utilized with systematic methodology since 1989. Unpublished data, pre and post videotapes as well as anecdotal successful outcome feedback from around the world provide some evidence in support of this approach. However, as with all treatment methods for childhood apraxia of speech, more scientific evidence regarding treatment efficacy is needed. In particular, we hope to see and participate in treatment research studies on this methodology with well defined subject inclusion criterion for this dually diagnosed population of children with autism spectrum disorders and possible apraxia of speech. Peer reviewed, published treatment data are greatly needed on this, as well as other, speech treatment methods for CAS and autism spectrum disorders.

Helpful Websites

Kaufman Children’s Center for Speech, Language, Sensory-Motor, and Social Connections, Inc. http://www.kidspeech.com

Tamara Kasper, MS/CCC-SLP, BCABA: http://www.kasperautism.com

Dr. Vincent Carbone http://www.drcarbone.net

Northern Speech Services http://www.nss-nrs.com

References

Barrera, R. & Sulzer-Azaroff, B. (1983). An alternating treatment comparison of oral and total communicationtraining program with echolalic autistic children. Journal of Applied Behavior Analysis, 4, 379-394.

Brady, D. O., & Smouse, A. (1992) A simultaneous comparison of three methods for Language training with anautistic child: An experimental case analysis. Journal of Autism and Childhood Schizophrenia, 8, 271-279.

Carbone, V. J. (2004). 2004 Tutorial: Clinical applications of verbal behavior research with children with autism. Proceedings of the 30th Annual International Convention Association for Behavior Analysis. Boston, Massachusetts.

Carbone, V. J. (2002) Teaching verbal behavior to children with autism and related disabilities. Unpublished Workshop Manual.

Carr, E. & Dores, P. (1981) Speech vs. sign comprehension in autistic children; analysis and
prediction. Journal of Experimental Child Psychology, 37, 587-597.

Casey, L. O. (1978) Development of communicative behavior in autistic children: A parent program using manual signs. Journal of Autism and Childhood Schizophrenia, 8, 45-59.

Fulwiler, R. & Fouts, R. (1976) Acquisition of American Sign Language by a non-communicating autistic child, Journal of Autism and Childhood Schizophrenia, 6, 43-50.

Kasper, T., & Godwin, J. (2004). Teaching verbal behavior: Hands on training for tutors and therapists. Unpublished Workshop Manual.

Kasper, T., & Godwin, J. (2003). Improving vocal verbal behavior via tutor-modeled successive approximations. Proceedings of the 29th Annual International Convention Association for Behavior Analysis. San Francisco, California.

Kasper, T. & Kaufman, N. (2005). K&K Sign & Say: Shaping Verbal Language for Individuals with Autism an d Other Developmental Challenge. Gaylord, MI: Northern Speech Services, Inc.

Kaufman, N. (1995). Kaufman speech praxis test for children. Detroit: Wayne State University Press.

Kaufman, N. (1998). Kaufman speech praxis treatment kit for children. Gaylord, MI: Northern Speech Services.

Kaufman, N. (2001). Kaufman speech praxis treatment kit for children-2. Gaylord, MI: Northern Speech Services.

Kaufman, N. (2005). Kaufman speech praxis workout book for children. Gaylord, MI:Northern Speech Services.

Layton, T. (1988) Language Training with autistic children using four different modes of presentation. Journal of Communication Disorders, 21, 333-350.

Layton, T. & Watson l. (1995) Enhancing communication in non-verbal children with autism. In K. A. Quill (Ed) Teaching Children with autism: Strategies to enhance communication and socialization. (pp 73-101) New York: Delmar Publishers.

Miguel, C.F, Carr, J. E. & Michael, J. (2002). The effects of a stimulus-stimulus pairing procedure on the vocal behavior of children diagnosed with autism. The Analysis of Verbal Behavior, 18, 3-13.

Palmer, D.C. (1996). Achieving parity: The role of automatic reinforcement. Journal of the Experimental Analysis of Verbal Behavior, 65, 289-290.

Schaeffer, B., Kollinzas, G., Musil, A., & McDowell, P. (1978). Spontaneous verbal language for autistic children through signed speech. Sign Language Studies, 21, 317-352.

Skinner, B. F. (1957). Verbal Behavior. Englewood Cliffs, NY: Prentice Hall.

Sundberg, M.L., Michael, J., Partington, J. W., & Sundberg, G.A. (1996). The role of automatic reinforcement in early language acquisition. The Analysis of Verbal Behavior, 13, 21-27.

Sundberg, M.L., & Partington, J.W. (1998). Teaching language to children with autism or other developmental disabilities. Pleasant Hill, CA: Behavior Analysts, Inc.

Sweeney-Kerwin, E., Zecchin-Tirri, G., Carbone, V.J.; Janeckey, M.; Murrary, D. & McCarthy, K. (2005). Improving the Speech Production of Children with Autism. Proceedings of the 31st Annual International Convention Association for Behavior Analysis. Atlanta, Georgia.

Yoder, P. & Layton, T. (1989) Speech following sign language training in autistic children with minimal verbal language. Journal of Autism and Developmental Disorders, 18,217-229.

Yoon, S.Y., & Bennett, G. M. (2000). Effects of a stimulus-stimulus pairing procedure on conditioning vocal sounds as reinforcers. The Analysis of Verbal Behavior, 17, 75-88.


[Nancy R. Kaufman, M.A., CCC/SLP is the director of the Kaufman Children’s Center for Speech, Language, Sensory-Motor and Social Connections, Inc. She has specialized in the area of Apraxia of Speech in Children since l979. An experienced clinician, diagnostician, author, presenter and clinical service award winner, Nancy presents The Kaufman Speech Praxis Treatment Approach nationally and internationally. Nancy works with children, professionals and families daily, providing video consultations as well.

Tamara S. Kasper, MS/CCC-SLP, BCBA, has practiced as a pediatric speech/language pathologist with emphasis on treatment of children with challenging behaviors for over 16 years. She has specialized in treatment of children within the autism spectrum for the last 10 years. In her pursuit of effective treatment methods, she became a Board Certified Behavior Analyst under the mentorship of Dr. Vincent Carbone. She has advanced training in application of Skinner’s analysis of verbal behavior, Greenspan’s DIR approach, and Kaufman’s strategies for apraxia of speech. She is co-author of the K&K Sign and Say kit. Currently, Ms. Kasper provides consulting services, training, and workshops to treatment teams who serve children with autism in the United States, Canada, and Europe.]

© Apraxia-KIDS℠ – A program of The Childhood Apraxia of Speech Association (Apraxia Kids)
www.apraxia-kids.org

Similarities and Differences in Young Children with Autism and Those Children with Apraxia of Speech

By

Tracy Vail, M.S., CCC-SLP

I primarily serve very young children and specialize in treating children with Autism. My clinical experience has been that about possibly 20% of children with autism who I see also have apraxia of speech. These disorders can occur in isolation or in combination. Physicians and early intervention case coordinators often refer children for speech-language services when they see a child has “autistic tendencies” and often well before a diagnosis has been confirmed.

After 22 years I have noted that there appear to be a group of children who demonstrate autistic tendencies when they are very young but later are instead diagnosed with apraxia of speech. Many of these children have sensory issues and are not very social. (It is difficult to be social when no one understands you!) Some very young children with apraxia can even exhibit some perseverative play behaviors early on, but typically outgrow these pretty quickly. Both disorders are often described as having a neurological basis.

Since I have four children of my own, I know how desperately parents want to know exactly what is going on with their child. It’s terrifying to get either diagnosis for your child, especially when you begin gathering information and hear so many mixed reports of progress and prognosis for improvement. This is true with both Apraxia and Autism. It is very normal to go through a grieving process anytime you are told your child has a disability and I understand the need for parents to progress through the stages of grieving. They need to talk and get support from other people.

Still, when a child is very, very young I do not even discuss a diagnosis and instead choose to focus on identifying and treating current symptoms. My reasoning is that first, diagnosing autism requires a team of professionals with expertise in a variety of areas of development. A speech-language pathologist cannot ethically diagnose autism independently even if she or he were confident about the diagnosis for a particular child. Second, I’ve seen too many children with a diagnosis of autism come into the clinic at two years old and have the diagnosis removed later on. (Please be clear that I mean to indicate the child was incorrectly diagnosed rather than that we “cured” them). I’ve also seen children who have the diagnosis ruled out at two years of age but later autism is confirmed. It’s just not an exact enough science to say with certainty with many young children. The same thing can be said of very young children with apraxia of speech.

I don’t want to appear uncaring or unsupportive of parents when they feel they need me to validate their impressions of their child’s diagnosis. I want parents to be supported and consoled and strongly recommend support groups and counseling if needed. I just feel that my role as the SLP has to focus on helping parents learn how to teach specific skills to their child. We have limited time and must prioritize how we spend it.

We determine the needs of services for each child based on the severity of presenting symptoms. If we see motor planning problems, we address those. If we see sensory problems, we address those. If we see social problems, we address those. It really doesn’t matter what the “reason” is as long as the problem areas are being treated. I think we can waste a great deal of time and energy both as parents and professionals by focusing on specific behaviors to “prove”…. is he or isn’t he?? The true answer will come in time as the child teaches us how he learns best and moves through developmental stages. We can deal with it when the time comes and know that either way, progress will continue. Neither diagnosis gives a picture of what the child will “look like” in twenty years. The best we can do for all the children is to give them the best and most intensive early intervention possible.

We also need to continue to work together as parents and professionals to advocate to our legislators that money be earmarked for intensive early interventions services for all children with significant developmental delays and disorders no matter what the diagnosis. There are many research findings indicating that intensive early intervention provides children with the best possible outcome as well as saving our society millions of dollars over the life of the child.


[Tracy Vail, M.S., CCC-SLP, has been a speech-language pathologist for over 25 years, practicing in both the public school and private clinical settings. She has a specific interest in children with autism and childhood apraxia of speech. She currently owns a private practice, Lets Talk, in Raleigh, NC, where she provides both direct and consultative services. She is also a past president of the North Carolina Speech, Hearing and Language Association. In addition, she has contributed articles for the Apraxia-Kids web site.]



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