Evidence based techniques for developing speech in non-verbal children Marti Weiner M.S. CCC-SLP, BCBA September, 2014

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

What is a nonverbal child? Childhood apraxia of speech Autism Cerebral palsy Developmental delay

What is a nonverbal child? Childhood apraxia of speech Autism

What is CHILDHOOD APRAXIA OF SPEECH (CAS)? (www.apraxia-kids.org) “…have great difficulty planning and producing the precise, highly refined and specific series of movements of the tongue, lips, jaw, and palate that are necessary for intelligible speech…” Can range from mild prosodic disruptions to severe lack of any speech Typically have better (though not necessarily normal) receptive language skills than expressive language skills Hypothesized to have sensorimotor impairments-difficulty processing sensory information and then producing sequences of movement; difficulty with imitation Can also have gross or fine motor apraxia

What is autism? Autism spectrum disorder (ASD) is a range of complex neurodevelopment disorders, characterized by social impairments, communication difficulties, and restricted, repetitive, and stereotyped patterns of behavior. (National Institute of Neurological Diseases and Stroke: (www.ninds.nih.gov) Speech skills in children with ASD range from verbal to nonverbal; echolalia may be present; conversely, inability to imitate speech/ initiate speech may be present

Do Children with ASD have CAS? Unknown if nonverbal children with ASD have CAS, or if they only share characteristics of the disorder Difficulty with imitation and motor planning/programing of speech

Do AAC systems promote speech in nonverbal children? Picture Exchange Communication System Training Manual, Frost and Bondy, page 27: “…we do not teach PECS as a way to speak, we teach it as a way to communicate…the acquisition of speech can be viewed as a fortunate by-product of the approach and not its direct focus.”

Do AAC systems promote speech in nonverbal children? Schwartz, I., and Garfinkle, A., “PECS: Communication Outcomes for Young Children with Disabilities”, Topics in Early Childhood Special Education, Fall, 1998, Volume 18, Issue 3: Subjects fell into two groups; “nontalkers” (56%) and “talkers” (44%); after PECS training, “…the “talkers” showed steady increase in vocabulary growth, whereas the “nontalkers”…showed little or no increase in the number of spontaneous words produced.” “…the child’s ability to verbally imitate should be analyzed to determine whether this predicts which children will acquire speech more readily…”

Treatment Protocol (apraxia-kids.org) Provide frequent and intensive practice of speech targets Focus on the actual skill being trained (i.e., accurate speech movement) Include enhanced external sensory input (not just auditory, but also visual, tactile, cognitive cues for speech production) Give careful consideration to types of practice (random vs. blocked practice of target items) Provide appropriate feedback (knowledge of results or knowledge of performance)

Current Popular Interventions for children with CAS and/or Non-verbal ASD K and K Sign and Say ($139) Kaufmann Speech Praxis Kit ($199 each for Level 1 and 2) PROMPT ($500-$700 training workshop) PECS ($395 training workshop)

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

INTERVENTION PROTOCOL Provide structured intensive program Combine evidence based principles of applied behavior analysis with therapeutic techniques used to treat CAS and nonverbal children with ASD Rather than using prepackaged programs, apply set of strategies to an individual child to develop a tailor made verbal imitation/sound sequencing program

Criterion for Success The child will learn functional communication using speech in a variety of communicative environments Augmentative modes of communication (PECS or sign language) will be used as supplemental support only as needed

Intervention Protocol 1) Establish Attending

Intervention Protocol 1) Establish Attending 2) Develop gross motor imitation

Intervention Protocol 1) Establish Attending 2) Develop gross motor imitation 3) Increase frequency of child’s vocalizations

Intervention Protocol 1) Establish Attending 2) Develop gross motor imitation 3) Increase frequency of child’s vocalizations 4) Develop imitation of a variety of individual sounds

Intervention Protocol 1) Establish Attending 2) Develop gross motor imitation 3) Increase frequency of child’s vocalizations 4) Develop imitation of a variety of individual sounds 5) As quickly as possible, combine those sounds into syllables and short words

Intervention Protocol 1) Establish Attending 2) Develop gross motor imitation 3) Increase frequency of child’s vocalizations 4) Develop imitation of a variety of individual sounds 5) As quickly as possible, combine those sounds into syllables and short words 6) Delayed Imitation

Intervention Protocol 1) Establish Attending 2) Develop gross motor imitation 3) Increase frequency of child’s vocalizations 4) Develop imitation of a variety of individual sounds 5) As quickly as possible, combine those sounds into syllables and short words 6) Delayed Imitation 7) Develop syllable grids

Intervention Protocol 1) Establish Attending 2) Develop gross motor imitation 3) Increase frequency of child’s vocalizations 4) Develop imitation of a variety of individual sounds 5) As quickly as possible, combine those sounds into syllables and short words 6) Delayed Imitation 7) Develop syllable grids 8) Run on multiple parallel tracks-set the bar at different levels for different environments

Intervention Protocol 1) Establish Attending 2) Develop gross motor imitation 3) Increase frequency of child’s vocalizations 4) Develop imitation of a variety of individual sounds 5) As quickly as possible, combine those sounds into syllables and short words 6) Delayed Imitation 7) Develop syllable grids 8) Run on multiple parallel tracks-set the bar at different levels for different environments 9) Pair meaning with sound sequences to create functional words

Establish Attending

Establishing Attending Behavior—Attending—Learning

LEARNING ATTENDING BEHAVIOR 26

Establishing Attending Behavior—Attending—Learning Work in a quiet nondistracting environment

Behavioral Disorganization Marie Anzalone “Sensory Integration Without the Gym”, Overland Park, KS, April 11, 2003) Overstimulation Behavioral Disorganization Zone of Optimum Arousal Attending Learning Understimulation

Zone of Optimum Arousal “Typical child” Overstimulation Behavioral Disorganization Zone of Optimum Arousal Attending Learning Understimulation

Child with attending challenges Overstimulation Behavioral Disorganization Zone of Optimum Arousal Attending Learning Understimulation

Establishing Attending Behavior—Attending—Learning Work in a quiet nondistracting environment Use principles of reinforcement

What is a Reinforcer? “DISC” D: Deprivation/Satiation I: Immediate S: Size C: Contingency

Establishing Attending Behavior—Attending—Learning Work in a quiet nondistracting environment Use principles of reinforcement Intersperse periods of focused work with frequent breaks

Treatment Protocol (apraxia-kids.org) Provide frequent and intensive practice of speech targets Focus on the actual skill being trained (i.e., accurate speech movement) Include enhanced external sensory input (not just auditory, but also visual, tactile, cognitive cues for speech production) Give careful consideration to types of practice (random vs. blocked practice of target items) Provide appropriate feedback (knowledge of results or knowledge of performance)

Establishing Attending Behavior—Attending—Learning Work in a quiet nondistracting environment Use principles of reinforcement Intersperse periods of focused work with frequent breaks Establish eye contact, followed by imitation

Establishing Eye Contact Hand to cheek: Cue EC Rf

Establishing Eye Contact Hand to cheek: Cue EC Rf Tracking object: Cue EC Rf

Establishing Eye Contact Hand to cheek: Cue EC Rf Tracking object: Cue EC Rf Sustained eye contact: Cue EC (pause) Rf

Establishing Eye Contact Hand to cheek: Cue EC Rf Tracking object: Cue EC Rf Sustained eye contact: Cue EC (pause) Rf Chaining Cue EC Target Rf

Develop Gross Motor Imitation

Motor & Sensory Homunculus

Gross Motor Imitation Teach without objects (clap, wave, hooray) and with objects (tap drum, roll car, shake bell) Gross motor imitation easier to teach than verbal imitation Establishes imitation chain: EC IM Rf Very important skill for later corrective feedback (i.e., should never reinforce incorrect verbal imitation, BUT can insert gross motor imitation and reinforce that)

Increase Frequency of Child’s Vocalization

Increase Frequency of Child’s Vocalizations If child can imitate at least two sounds, this step is not necessary Use high preference reinforcers EC Cue: “TALK” Rf any sound May have to wait as long as a minute at first, but eventually child will vocalize faster to get reinforcer Goal is to get vocalization on request within 1-2 seconds

“This is still too hard…”

“This is still too hard…” Set aside time period Use high preference edible reinforcer; Every sound that child incidentally spontaneously makes, reward with praise “Good talking!” and edible reinforcer

Develop Imitation of a Variety of Sounds

Develop Imitation of a Variety of Sounds Probe to see which vowels and consonants a child can imitate- will not follow developmental hierarchy of acquisition Always have child attend to your face Constantly probe to see what sounds child can imitate on request-may change over time Imitation of nonverbal oral movements (e.g., blowing, lip smacking) not a necessary prerequisite, but these movements may be shaped into speech sounds Never reinforce incorrect imitation- no “nice try”

Develop Imitation of a Variety of Sounds Probe to see which vowels and consonants a child can imitate- will not follow developmental hierarchy of acquisition Always have child attend to your face Constantly probe to see what sounds child can imitate on request-may change over time Imitation of nonverbal oral movements (e.g., blowing, lip smacking) not a necessary prerequisite, but these movements may be shaped into speech sounds Never reinforce incorrect imitation- no “nice try”

Develop Imitation of a Variety of Sounds Probe to see which vowels and consonants a child can imitate- will not follow developmental hierarchy of acquisition Always have child attend to your face Constantly probe to see what sounds child can imitate on request-may change over time Imitation of nonverbal oral movements (e.g., blowing, lip smacking) not a necessary prerequisite, but these movements may be shaped into speech sounds Never reinforce incorrect imitation- no “nice try”

Develop Imitation of a Variety of Sounds Probe to see which vowels and consonants a child can imitate- will not follow developmental hierarchy of acquisition Always have child attend to your face Constantly probe to see what sounds child can imitate on request-may change over time Imitation of nonverbal oral movements (e.g., blowing, lip smacking) not a necessary prerequisite, but these movements may be shaped into speech sounds Never reinforce incorrect imitation- no “nice try”

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

Develop Imitation of a Variety of Sounds Probe to see which vowels and consonants a child can imitate- will not follow developmental hierarchy of acquisition Always have child attend to your face Constantly probe to see what sounds child can imitate on request-may change over time Imitation of nonverbal oral movements (e.g., blowing, lip smacking) not a necessary prerequisite, but these movements may be shaped into speech sounds Never reinforce incorrect imitation- no “nice try”

Always Reinforce a Correct Response Adult “Get ready” Child: EC Adult “k” Child “d” Adult (pause), “mmm” Child “mmm” Rf OR Adult “do this”, claps hands Child claps hands Adult “Good clapping hands!” Rf

Combining Individual Sounds into Syllables and Short Words

Combining Sounds into Syllable and Short Words Shortest sequence of connected speech is the syllable Want to practice CVs and VCs that can: Immediately be turned into functional words (“go”, “up”, “eat”) OR Become the building blocks for CVC, CVCV, and increasingly longer sequences Want to practice each consonant with a variety of vowels, both CV and VC

Combining Sounds Into Syllables and Words: Some : “Tips and Tricks” Consonants easiest to combine with vowels: /m,n,w,f,v,s,z,sh,l,r,th/, because you can “hang on to them”

Imitating 2 distinct sounds: Say /mmm/……say /ahahah/ Combining Sounds Into Syllables and Words: Some : “Tips and Tricks” Imitating 2 distinct sounds: Say /mmm/……say /ahahah/ Blending: Say /mmm/..hold onto the sound, and as soon as the child starts to say /m/, you blend into /ahahah/ Say /mmmmahahah/ Say /mah/

Combining Sounds Into Syllables and Words: Some “Tips and Tricks” If child doesn’t have many vowels when you do your sounds probe, start with ah/ee/oo They are very visible They can be combined for other sounds /ah/ + /ee/= “kite” /ee/ + /oo/= “cute” /oo/ + /ee/= “we”

Combining Sounds Into Syllables and Words: Some “Tips and Tricks” When teaching voiceless consonants, teach imitation of /p/, not /puh/; when teaching “plosives” (p,b,t,d,k,g), sometimes easier to start with VC syllables Voiced plosives will have a little vowel sound after them called a “schwa”: /duh/ is acceptable, but not /duh/

Delayed Imitation

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

Teaching Delayed Imitation Cue “Get Ready” EC

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

Teaching Delayed Imitation Cue “Get Ready” EC Adult “Say (sound) Child imitates Adult “AGAIN (sound) Child Imitates Rf

Teaching Delayed Imitation Cue “Get Ready” EC Adult “Say (sound) Child imitates Adult “AGAIN (sound) Child Imitates Rf After multiple trials of practice, PROBE Adult “AGAIN(pause)” Child Imitates Rf

Develop Syllable Grids

CV ah(pot) Ee(me) oo(too) uh(up) VC m -------- n p b t d s z k g

CV VC m n p b t d s z k g -------- ah(pot) Ee(me) oo(too) uh(up) 5-20-14 d s z k g

CV VC m n p b t d s z k g -------- ah(pot) Ee(me) oo(too) uh(up) 5-20-14 6-10-14 d s z k g

CV VC m n p b t d s z k g -------- ah(pot) Ee(me) oo(too) uh(up) 7-12-14 p 7-16-14 b t 5-20-14 6-10-14 d s z k g

CV VC m n p b t d s z k g -------- ah(pot) Ee(me) oo(too) uh(up) 7-12-14 8-04-14 p 7-16-14 b t 5-20-14 6-10-14 d s z k g

CV VC m n p b t d s z k g -------- ah(pot) Ee(me) oo(too) uh(up) 7-12-14 8-04-14 p 7-16-14 9-01-14 b t 5-20-14 6-10-14 d s z k g

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

Run On Multiple Parallel Tracks: Setting the Bar at Different Levels for Different Environments Simultaneously work on imitation of new individual sounds, syllables of mastered single sounds, new word approximations, new target words

Run On Multiple Parallel Tracks: Setting the Bar at Different Levels for Different Environments Simultaneously work on imitation of new individual sounds, syllables of mastered single sounds, new word approximations, new target words /m/ can mean “more”, “mom”, “mine” in functional environment before the child has learned to imitate syllables in structured imitation practice

Run On Multiple Parallel Tracks: Setting the Bar at Different Levels for Different Environments Simultaneously work on imitation of new individual sounds, syllables of mastered single sounds, new word approximations, new target words /m/ can mean “more”, “mom”, “mine” in functional environment before the child has learned to imitate syllables in structured imitation practice Generalize imitation practice to functional settings

Run On Multiple Parallel Tracks: Setting the Bar at Different Levels for Different Environments Simultaneously work on imitation of new individual sounds, syllables of mastered single sounds, new word approximations, new target words /m/ can mean “more”, “mom”, “mine” in functional environment before the child has learned to imitate syllables in structured imitation practice Generalize imitation practice to functional settings Accept word approximations in functional environment until child can easily imitate target word in structured practice, then raise the level of expectation

Pair Meaning with Sound Sequences to Create Functional Words

Pair Meaning with Sound Sequences to Create Functional Words “Reception precedes expression”- continue to work on receptive language acquisition Requesting items- first way to teach meaning Expressive picture labeling-flashcards, favorite books Setting up opportunities for commenting in functional environment Directing another’s behavior: “go, up, out, on” Singing songs with selected word approximations Remember: You may need to provide a reinforcer for communication until your child understands its intrinsic value

Video: Tyler