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Evidence based techniques for developing speech in non-verbal children. Marti Weiner M.S. CCC-SLP, BCBA September, 2014. What are evidence based techniques?.
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Evidence based techniques for developing speech in non-verbalchildren 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 Analysisby 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
Establishing Attending • Behavior—Attending—Learning
LEARNING ATTENDING BEHAVIOR
Establishing Attending • Behavior—Attending—Learning • Work in a quiet nondistracting environment
Marie Anzalone “Sensory Integration Without the Gym”, Overland Park, KS, April 11, 2003)
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
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 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…” • 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 • 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”