Evidence based techniques for developing speech in non-verbal children

1. Evidence based techniques for developing speech in non-verbalchildren 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: www.asha.org)

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)? (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

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: (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

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 Analysisby 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

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

28. Marie Anzalone “Sensory Integration Without the Gym”, Overland Park, KS, April 11, 2003)

29. “Typical child”

30. Child with attending challenges

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”