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

2. 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:

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

4. What is a nonverbal child?
Childhood apraxia of speech
Autism

5. What is CHILDHOOD APRAXIA OF SPEECH (CAS)?(
“…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

6. 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: (
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

7. 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

8. 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.”

9. 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…”

10. 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)

11. 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)

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

13. 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

14. 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

15. Intervention Protocol
1) Establish Attending

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

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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. Establish Attending

25. Establishing Attending
Behavior—Attending—Learning

26. LEARNING
ATTENDING
BEHAVIOR 26

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

28. 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

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

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

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

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

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

34. 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)

35. 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

36. Establishing Eye Contact
Hand to cheek: Cue EC Rf

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

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

39. 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

40. Develop Gross Motor Imitation

41. Motor & Sensory Homunculus

42. 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)

43. Increase Frequency of Child’s Vocalization

44. 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

45. “This is still too hard…”

46. “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

47. Develop Imitation of a Variety of Sounds

48. 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”

49. 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”

50. 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”

51. 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”

52. “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.

53. 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”

54. 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

55. Combining Individual Sounds into Syllables and Short Words

56. 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

57. 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”

58. 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/

59. 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”

60. 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/

61. Delayed Imitation

62. 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 (

63. Teaching Delayed Imitation
Cue “Get Ready” EC

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

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

66. 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

67. Develop Syllable Grids

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

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

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

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

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

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

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

75. 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

76. 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

77. 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

78. 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

79. Pair Meaning with Sound Sequences to Create Functional Words

80. 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

81. Video: Tyler