By: Jeanna Probst Eastern Illinois University jrprobst@eiu.edu A Comparison of On-Task Behavior in Person-Directed VS. AAC-Directed Apraxia Therapy for Children with Autism Spectrum Disorder -name -student at EIU -in Dept. Honor’s—study is in conjunction with this -what we compared -on-task=joint attention By: Jeanna Probst Eastern Illinois University jrprobst@eiu.edu

Introduction: Autism Spectrum Disorder (ASD) Deficits in 3 areas: Social Interaction Language & Communication Repetitive & Restricted Interests (Routine) Sensory Processing Deficits Joint Attention Deficits -DSM-IV—criteria -Sensory=hypo (under responsive to stimuli) & hyper (over responsive to stimuli) -one common characteristic is the assumption that children with ASD avoid eye contact, when really just prefer peripheral over central -reason for this is because so much visual information to process with a person (make-up, jewelry, hair style, then mouth—which is what we want them to focus on for speech therapy—have trouble sorting out relevant and irrelevant information) -JA Deaficits---account then for language and communication deficits—because have to have joint attention before they can learn to make associations and learn imitation, comm., and lang.

Developmental Apraxia of Speech (DAS) Neurological disorder Difficulty sequencing movements needed to produce a clear and precise sound or utterance (Darley, Aronson & Brown, 1975; Hall, Jordan, & Robin, 2007; Tombin, Morris & Spriestersbach, 2000) “sensory integration dysfunction, which interferes with planning and executing an unfamiliar task” (Marshalla, 1994, 1995; Darley et al., 1975; Hall et al., 2007) Often associated with ASD -accounts for majority of 1/3 population in ASD that is nonverbal -can form cognitive thought of utterance—just can’t sequence and form articulators and speech muscles in the positions necessary to produce the utterance -sensory—difficulty processing where their articulators are in relative space within their mouth to know how to position their articulators for the utterance

Joint Attention Schertz & Odom, (2004) define joint attention as, “coordinating attention to an event or object with another individual, sharing interest and social engagement, and showing an understanding that the partner is sharing the same focus”(p. 42). Language delays in ASD mainly due to deficit in the area of Joint Attention

Augmentative and Alternative Communication “Augmentative and alternative communication refers to the field or area of clinical, educational, and research practice to improve, temporarily or permanently, the communication skills of individuals with little or no functional speech and/or writing” (American Speech-Language-Hearing Association, 2002). Augmentative: augment existing speech abilities Alternative: providing a substitute for ineffective speech Facilitates natural speech Consistent model Immediate reinforcement AAC devices are often used with ASD & DAS Helps the AAC users acquire functional communication and develop expressive language -alternate output mode—because cannot use speech to functionally communicate

ASD - DAS - AAC Commonalities in ASD & DAS: Neurological Disorder Routine Sensory Processing Deficits Joint Attention Deficits AAC provides a consistent model and routine Limited research that looks at joint attention in a person-directed model versus an AAC- directed model

Purpose and Research Question Limited research in area of AAC and ASD with DAS Purpose: compare on-task behavior in person-directed apraxia therapy to AAC- directed apraxia therapy in individuals diagnosed with ASD who also have apraxia of speech. Is there a difference in the length of on-task behavior when using a person-directed stimulus mode versus AAC-directed stimulus mode for individuals with co-morbid ADS and DAS? -research in area of AAC has not been used as a direct treatment approach to facilitate speech---research has just found that a result of using AAC is that speech increases

Subjects Subject Gender Age Disorder AAC System Participant 1 Female 6 ASD/DAS Dynavox V Participant 2 Dynavox MT4 Participant 3 Male 8 Dynavox V max --established AAC users –could make requests for wants & needs

Methodology Rapid alternating subject treatment design Randomly presented with stimuli (IV: AAC- directed & Person-directed) 5 minutes over 22 sessions AAC Device: Mercury II by Assistive Technology Inc., the Dyanvox IV, and the Dynavox V max Clinician: CDS graduate student, who was blind to the dependent variables Oral Motor Activities Blow, Kiss, Raspberry, Pat Mouth, Click Tongue, /p/, /b/, /m/ --exact set-up -subjects attended EIU speech-language-hearing clinic—2 days a week -45 minute sessions, 1st 15 minutes, 3 subjects randomly pulled out, and stimulus that was presented was also assigned in random order -explain reason for 3 devices and set-up -2 rows and 4 columns, 8 symbols -each symbol had a digital picture of graduate clinician doing the oral motor posture, with label of oral motor activity above the picture -when symbol was pressed by subject the auditory signal included the naming of the label and the sound associated with that oral motor activity -PD—clinician blind to study and told to just randomly present each of the 8 oral motor activities -prompts: name, look name, you do it, no hand-over-hand with AAC stimulus ?of why chose these oral motor activities?---natural activities that they are exposed to in real life—precursor to fine motor abilities and speech, provide that visual, tactile, and auditory input

Video Clips Person-Directed AAC-Directed Shows apraxia at work Imitation of one of the oral motor behaviors -PD-first—Participant 3= trying to click tongue (side note—he can do with immediate imitation now) -10/22=11:19-10:47 -second-Participant 1=phonemes -12/8=5:09-5:30 -AAC—Participant 1=imitating the pat mouth gesture from the AAC stimulus -11/5=1:04-1:20

Dependent Variables Dependent Variable Description Leave Work Area The subject left the identified work area (where the clinician or AAC system was). Disruptive Behavior The subject displayed behaviors that were physically or verbally disruptive and were used to block out the stimulus: closing eyes, screaming, attention focused on sensory items (e.g., string), physical disruptions (e.g., hugging). No Eye Contact The subject was within the defined work area and interacting with the stimulus, but no sustained eye contact with the stimulus or clinician was present. On-Task Behavior The subject was interacting with the stimuli or clinician within the work area.

Data Recording Sheet -Interval Recording -10 seconds observing and 5 seconds recording -No Eye contact=smaller %=more sustained eye contact with stimulus -Interjudge Reliability=96%

Results: Overall Multivariate Analysis of Variance (MANOVA) Overall significant difference, F(4,57)=5.8; p=.001 Higher occurrence of Disruptive Behavior and No Eye Contact in Condition 1 (Person- Directed) than Condition 2 (AAC-Directed) Disruptive Behavior (p=.034) No Eye Contact (p=.001)

Results: Overall Condition On-Task Leave Work Area No Eye Contact Disruptive Behavior 1-Person-Directed Mean .92 .03 .32* .42* Standard Deviation .12 .08 .18 .22 Number of Data Points Collected 30 2-AAC-Directed .98 .17* .28* .05 .07 .15 .27 32 -why we did a MANOVA—had 4 dependent variables so wanted to see if there was an overall significance and then since there was, we focused it down to the dependent variables that accounted for the overall significance -talk about overall significance—came down to no eye contact and Dis. Beh. That occurred more often in PD -so made AAC stimulus a much more clean and focused on-task behavior/joint attention with stimulus *significant difference

Results: On-Task Behavior Person-Directed 97.7%, AAC-Directed 96% -shows all 3 subjects could attend to both stimuli—so even though they may have been on-task there was a larger amount of dis. Beh. And no eye contact within the person-directed stimulus -P1-consistently on-task with both day to day -P2-largest discrepancy in on-task behavior b/w the 2 conditions -AAC-oriented—likes consistency and routine -P3-intertwined, drop in AAC on-task for session 9—but in high 90’s for on-task with both Person-Directed 94.9%, AAC-Directed 98.9% Person-Directed 84%, AAC-Directed 97% Overall On-Task: Person-Directed: 92.4% AAC-Directed: 97.6% Both IV: 95% AAC significantly higher than Person-Directed (p=.001)

Results: No Eye Contact Person-Directed: 33.9% AAC-Directed: 19% Overall: 26% P=.001 Person-Directed 38.6%, AAC-Directed 10% -P1-no eye contact variation—could be because of the overload of visual processing that is required with the person-directed stimulus---had a lot more direct eye contact with AAC stimulus (PD was always higher) -P2-more no eye contact with PD -P3—less direct eye contact with the AAC stimulus because appeared to show greater interest in PD—received more input with various senses Person-Directed 27.7%, AAC-Directed 33.5% Person-Directed 37.8%, AAC-Directed 11.5%

Results: Disruptive Behavior Person-Directed 44.8%, AAC-Directed 41% Disruptive Behavior: Person-Directed: 41.5% AAC-Directed: 27% Overall: 34% P=.034 -P1—slightly more dis. Beh. With PD, but can see it intertwined across the study -P2--dis. Beh—tried to manipulate clinician with her behavior because she did not want to attend to the PD stimulus as much as she did the AAC---can see this through the increase of PD dis. Beh. Line and decrease in AAC line -P3—showed quite a bit of variation across the study but there was quite a bit more dis. Beh. With the PD condition Person-Directed 41%, AAC-Directed 28.9% Person-Directed 38.9%, AAC-Directed 11%

Results: Leave Work Area Person-Directed 3%, AAC-Directed 9.5% Leave Work Area: Person-Directed: 3.4% AAC-Directed: 3.7% Overall: 3.6% -P1---routine-oriented=could account for why like clock work she would get up at 4:30 to leave because she knew the time was close to being done -P2---intertwined quite a bit across the study and no real discrepancy -P3---only obvious discrepancy is in the leaving the work area—could be because PD is more interactive and variable where as AAC, the subjects knew what was expected of them—to sit in chair and interact with device Person-Directed 4.1%, AAC-Directed 0% Person-Directed 2.7%, AAC-Directed 1.5%

Discussion Variables to account for results ASD is an individual disorder AAC was more routine orientation; PD involved more variability Disruptive behaviors Clear focus with AAC PD provided a richer multimodality learning experience compared to the AAC device with flat 2-dimensional picture and auditory feedback --just want to highlight again –very unfavorable conditions for this study and yet these children were in the 90 percentile for on-task behavior and being able to attend to both stimuli—very extraordinary for the conditions at hand and the characteristics of ASD --AAC—sense of control over environment and able to make own choice of which symbol to press

Discussion Strengths Limitations Routine Design Limited time frame Focused/Controlled sensory input Limitations Small subject size Technology Difficulties -technology difficulties—not favorable for study—but gave us a real life insight to what the parents and users of AAC devices often go through

Discussion Future Research Broader Sample (different severity levels of ASD and DAS) Lower and higher emerging level of AAC users Evaluate emerging imitation in Person-Directed vs. AAC- Directed conditions Evaluate if either of these conditions help develop joint attention Use of a video model instead of a static picture on the AAC device Replication to determine generalization of the present study -did begin to see imitation with each of the subjects—which is why our next study is going to look emerging imitation and how many imitation behaviors are there

References American Speech-Language-Hearing Association (2002). Augmentative and Alternative Communication: Knowledge and Skills for Service Delivery. [Knowledge and Skills]. Available from http://www.asha.org/policy Darley, F. L., Aronson, A. E., Brown, J. R. (1975). Motor Speech Disorders. W. B. Saunders Company. Hall, P. K., Jordan, L. S., & Robin, D. A. (2007). Developmental Apraxia of Speech: Theory and Clinical Practice (2nd ed.). PRO-ED Inc. Marshalla, P. (1994). The non-verbal apraxic child: speech-language techniques. 1-19. Marshalla, P. (1995). Developmental apraxia of speech: facilitating vocal and verbal expression. Speech Dynamics Incorporated, 1-25. Schertz, H. H. & Odom, S. L. (2004). Joint attention and early intervention with autism: a conceptual framework and promising approaches. Journal of Early  Intervention, 21, 1, 42-54. Tombin, J. B., Morris, H., & Spriestersbach, D.C. (2000). Diagnosis in Speech- Language Pathology (2nd ed.). Singular Publishing Group, Inc.

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