4 key take home strategies for SLPs and OTs on Communication

Last posting: What are 4 key take home treatment strategies that SLPs and OTs can apply given the literature and discussion you provided on your blog? What is the rationale for each of these take home strategies?

             

During the last few weeks we have discussed communication and Autism; Auditory processing, motor control, learning and impairment as they relate to communication, specific word finding difficulties, and some techniques of facilitating communication.  In this last blog, four treatment strategies that SLPs and OTs can apply are discussed, along with rationale for each.

1^st strategy:

Develop Co-Treatment sessions between speech and OT

Rationale: Since communication is a social-functional occupation, it fits well under both the SLP as well as OT domain. Many of the specifics like the prosody, low tone need two professionals with slightly different focus working towards same goal, and one carrying over techniques then to their own individual sessions.

OTs can bring their expertise in sensory based techniques, vestibular, tactile and visual techniques to prepare the child, while SLP can bring their expertise of specific oral motor facilitation, and breathing techniques into the session. One can grow professionally and give the same in return.

2^nd strategy:

Use AAC for ALL non-verbal and semi-verbal ASD children

Rationale: There are many established as well as newly discovered, developing augmentative and alternative communication devices out there, so use them! When you come across any SLP, or OT that is unaware of such advanced devices, educate! Too many ASD children can not communicate to the extent they could be, due in part by unawareness of well meaning therapists of what can be done to increase desire to communicate; AAC.

The most commonly used AAC are:

-PECS

-VOCAs like “springboard”

-ipad apps like the proloque2

3^rd strategy:

Involve, collaborate, educate and empower parents, teachers.

Rationale: Systematic implementation of techniques known to SLP, OT will bring about faster changes, and reduce confusion for the child. When setting up certain treatment techniques, for ex: LIP CLOSURE AND SWALLOW to improve saliva control when speaking; it would be very important to let everyone involved know that they can be cueing the child the same way SLP would, or a certain grip on writing instrument for written communication should be known to teacher as well as parents to reinforce at home.

4^th strategy:

Use FUNCTIONAL approach when facilitating communication

Use communication during daily functional tasks. In kitchen, crawling under the table, on playground, during self care tasks in bathroom. Communication is not like handwriting that needs a t able, chair, proper lighting, pen etc. It’s everywhere; use each opportunity to facilitate it using whatever method is being trialed (PECS, Sign, PROMPT). Encourage, and give feedback to the child at each attempt to increase the desire to communicate.

After all, its only the child’s engine of desire to communicate that can get the communication train anywhere!

Facilitation of speech/communication

Describe different approaches to facilitation of speech/communication.

In Autism, Speech is one mode of communication. There are others, such as AAC, gesturing and sign language. No matter what the mode of communication may be, what is most important is that the system is internalized by the child with Autism who then feels more “in control”, and feels confident that the system works, and his or her needs are better met when the system works.

Facilitation of communication is the primary role of a speech and language pathologist, although most of us, O.T., teacher, parent must follow along and support the SLP in the method being trialed/used.

Some of the facilitation techniques are: PROMPT and NSOME.

PROMPT

The picture above demonstrates a therapist using PROMPT method to increase the oral-motor skills of a child with speech production disorder.

PROMPT (Prompts for restructuring oral musculature phonetic targets is a tactile-kinesthetic system, a philosophy that tries to integrate all aspects of communication; motor, cognitive-linguistic and social-emotional.

It can be useful in sevral speech disorders and conditions including disarthria, apraxia, hearing impaired, even non-verbal children with hearing loss.

Since children with autism respond to tactile, proprioceptive input, it can be derived that PROMPT methods are useful since they incorporate touch pressure kinesthetic tactile and proprioceptive cues and manual guidance of the clinician of the articulators.

Prompts are provided externally by touching muscles of face, under chin, mandible, nose and other structures that are involved in speech production. 

The goal of the mothod is for the client to achieve intelligible speech and functional language. Check the following links for more detailed discussion on PROMPT.

www.apraxia-kids.org

apraxiastory.wordpress.com/.../prompt-therapy/

http://www.promptinstitute.com

NSOME

Any oral motor treatment not involving speech output is typically considered to be N-SOME.

Research on NSOME was indicative of biased view existence, where those who study phonology and professors that teach speech and sound disorders seem to find NSOME ineffective, while clinicians and those giving continuing education courses have maintained that in practice they believe NSOMEs help through strengthening of oral motor musculature.

There is significant debate whether this is appropriate argument since there is much difference between the oral musculature and limb muscle system.

Following are some interesting articles that point to such unsettled dynamic that exists today for NSOMEs. All articles below are available full text at the Misericordia e-Library.

1: Watson, Maggie M.; Lof, Gregory L. Language, A survey of university professors teaching speech sound disorders: Non speech oral motor exercises and other topics,

Speech & Hearing Services in Schools, Jul2009, Vol. 40 Issue 3, p256-270

2: Forrest, Karen; Iuzzini, Jenya. A comparison of oral motor and production training for children with speech sound disorders, Seminars in Speech & Language, Nov2008, Vol. 29 Issue 4, p304-311.

3: Lof, Gregory L.; Watson, Maggie M. Language, A nationwide survey of Non speech oral motor exercise use: Implications for evidence based practice, Speech & Hearing Services in Schools, Jul2008, Vol. 39 Issue 3, p392-407.

4: Kamhi, Alan G., A Meme’s-Eye view of Non speech oral-motor exercises, Seminars in Speech & Language, Nov2008, Vol. 29 Issue 4, p331-338.

Motor learning and communication

Consider the discussion on motor planning, motor control, and motor learning – describe: The type of practice (ie: random or blocked) and the type of tasks (continuous or discrete) that may be used to promote verbal communication skills in children during social activity.

Motor Learning in Autism is approached from many different angles in past and what is becoming more evident through the literature is that children with Autism have peculiar learning needs, in this realm.

One of the considerations in motor learning in terms of practicing verbal communication is type of feedback provided. For example, adding action, tactile, visual: multi-sensory feedback would help. In practicing “CLOSE” as the word, closing a book with hand over hand action while saying “close” would help. 

Also, using random, massed as well as distributed trials is more effective. Instead of just practicing “CLOSE”, over and over, this would mean practicing other words and bringing in “CLOSE” every few times, not in a pattern. Such as 1:“Open and close”, perform book open and close act. 2:“Go and close”, go to door and close door, 3:“stand and close”, stand and close window. And so on.

Provide 2 treatment activities and how you would apply principles of task and practice to promote motor learning to help the child develop social skills with improved communicative understanding of others and expressed self-intent.

Treatment activity 1: Choosing a re-inforcer: Motivating task can be different for every child, it may be going out in sun, or playing with putty. One of my pre-school students loved holding a small flag in his hand, and I used it to get much done, he had to work to get the flag, this involved (through speech cotx) saying “FLAG”, “WANT”, and for me it was finding the flag from under the bean bags, for great sensory input!. Either way, communicative understanding was established eventually, and as soon as the kid walked into OT room, he expressed “AAG”, while jumping into the bean bag!

Treatment activity 2: Increasing cognitive/linguistic demand:

Same child was given PECS book, progressed to sentence level speech, later on, and by now had to identify the flag from multiple items very similar color combinations from a box, and at times had to choose other items such as “give me box, give me flag, give me pencil………..so now the treatment involved saying the same word with more cognitive effort and linguistic load.

Motor Impairements and effect on communication

What are the motor impairments of children which impact ability to execute the motor skill of voice onset, phonation, and articulation in autism? How do we know this? What is an application of this knowledge to a direct clinical example?

Impact of Motor skills on communication in Autism:

Children with ASD struggle with varying degree of motor impairment that affect verbal communication in general and more specifically, articulation issues, voice onset and phonation skills. This blog considers describes some of these in detail.

Like two sides of a coin, Motor skills have motor planning to be considered as well as execution/motor control.

Motor planning is what our brain is doing before actual start of the action, its like setting up the GPS before hitting on the gas.

When verbally responding to a question, the final voice production to relay the thought must be first based on motor planning; information processing, creating the message or thought processing, body posture recognition and preparation, oral motor structure preparation (managing the chewing gum, finishing the swallow or may be taking a long breath etc), deciding the tone, pitch, volume, and much more.

ASD population has difficulty with most of these aspects, because they have atypical perception, communication receptive prosody issues and sensory integration deficits, all required elements upon witch motor planning will be based on.

This motor plan is then followed by the execution. This is when we step on the gas and drive on to destination, controlling the car.

One must be able to hold certain balance of facial, neck and head musculature when verbalizing. Motor control is essential to effective voice production, another weak link in children with autism.

Many ASD children have poor mid range control, or core strength for even basic proper body posture.

How do we know this?

Functional MRI studies demonstrate that there may be diffused and decreased cerebellar activation, and connectivity between regions of brain, the very basis for smoothness in movements. This impacts the voice onset, and phonation as well as articulation of speech.

A research study compared very young ASD children with similar age control group, and it was shown that preverbal children with autism demonstrated higher proportion of atypical vocal quality in syllables compared to control group. They did produce however similar number of vocalizations. [i]

In other words, children with ASD produced similar amount of vocalization, canonical babbling, although they produced significantly different sound, phonation component.[ii]

Clinical relevance and application

The knowledge and understanding in the workings of the brain of someone with ASD is expanding tremendously. Such knowledge can become the basis for treatment strategies sketched out daily in clinics.

A treatment plan to improve “sentence level answering” for example, can be based on all above discussed factors

- prepare the child posturally to successfully interact

- Consider visual/auditory processing, clarify directions

- Teach differentiation of pitch, volume, tone etc

- Work on breathing (really helps with long sentences)

- Short one time instructions

- Allow increased response/reaction time

---

[i] Mostofsky, S. et. Al., Decreased connectivity and cerebellar activity in autism during motor task performance, Journal of Brain, volume 132, number 9, page 2413-2425, sept 2009

[ii] Stephen J. Sheinkopf, et al. Vocal atypicalities of preverbal autistic children, Journal of autism and developmental disorders, Volume 30, number 4, 2000.

Word Finding

Describe the word finding skills of children with autism? Describe the methods & findings of a research article on auditory processing. How will this impact ability to initiate a social exchange during a play based activity? What is 1 treatment strategy given the findings.

Word Finding Difficulty in Autism

I covered a research article on auditory processing in my last blog. In this blog, I would share my thoughts on “word finding” in autism.

Verbal communication is one of the cornerstone issues in Autism. Many children with Autism are struggling each moment as we speak to find the word, to portray the meaning they want to.

Its not as if children with autism do not want to communicate, its just that they lack the skills, and need environmental exposure, adult guidance, and reassurance in the form of gaining result/response to their “word” use.

Literature indicates that children with autism have difficulty with auditory verbal processing, and the preferred learning medium is visual. (If the “word” can be represented through a symbol, there is a better chance of expressing it. Particular difficulty arises for ASD children when attempting to express words that describe “internal feelings”, such as “I Wish”, “miss you”, or prepositions such as “After, before, yet, until”.

Such difficulty with word finding can have enormous impact on the ability to initiate a social exchange such as during a play based activity. A child may not for instance be able to convey her disinterest in the activity, or using a specific sequence of activities such as “first do this, and then do that”.

One of my middle school students with Autism had terrible time explaining to me that it’s not that he did not want OT; it’s just that he wanted me to come back “after lunch”. He is mostly non-verbal, uses “springboard”, but even with the AAC its not always easy to “find the word” one wishes to use.

We non-ASD folks, have almost unlimited vocabulary and a vast mental library to pick the best suiting word from, in contrast to our ASD children that struggle every moment to get the right word!

Two practical strategies in such circumstances would be co treatment sessions with Speech and language pathologists (drawing on the expertise), and having the availability of “visual forms” of communication devices. Using PECS system for basic level communication and the more advanced alternative communication devices such as the Dynavox, or other voice output devices (to be discussed in details in later postings). In any case, keeping “total communication approach” is the key, making sure we put play, socialization and language all fostered at the same time. There are no words to describe the feeling you get when you have helped a child find the right word!

Reference:

Lecture Notes, class material (Amy Lynch, Anne Van Zelst), 2011.

Book reading, Miller-Kuhaneck, 2^nd edition, 2004, chapters 12, 8, and 3.

Communication- Auditory Processing in children with Autism

8        Communication: Consider communication with respect to the functional occupation of social interactions with others during a play based activity. Describe the auditory processing challenges in children with autism that you see clinically.  Describe the methods & findings of a research article on auditory processing.  What is 1 treatment strategy given the findings?

We have heard through different discussions and readings, that ASD population may have auditory Processing Challenges.

AP issues can have great impact on functional communication during play based activities for children with autism. I found an interesting article on this very same topic but first let me go over what I see in the clinical setting.

Anna is a verbal 8 year old child with autism on my caseload who is “Lost”-unable to excel during group interaction or activity, and yet when seen individually, her tolerance, attitude and performance on specific understanding questions is much better.

The more I think of it, the more I remember using visual information presentation during our one to one sessions, and she performs better. Is it the background noise that’s cut off? Is it the proximity to another adult and ability to lip read, basically using visual cues instead of “auditory” that helps her make sense of things?

Anna always appeared shy and avoided joining fun play groups, until one day during the class Valentines’ dance party, when I trialed my ipod Nano with her with children’s songs! Anna was dancing with quite elaborate moves, right in the middle of the dance floor, not at all shy, looking rather confident. Is it the pitch changes and rhythm of music she is comfortable with rather than the decoding of speech sounds of people around?

In my search for answer to “What is exactly different in Anna’s auditory processing?” I found this great article in the journal of developmental science that compared group of children with ASD to group of normally developing “control group” with similar IQ.

I particularly like the methodology used since it seemed very simple. At first they tested each subject on visual Pairs of shape and color differences, the child had to look at the two cards with similar or different “color” or “shape” and say “Different”, or “similar”. This was just to get them acclimated to understanding how to answer.

After achieving 80% accuracy on the visual “pair- difference” recognition, now they were then given the “Pair of sounds”, and asked if they could tell if the sound bite is similar or different. “Music-Music”, “Speech-Speech”, and “Music-Speech” were the different categories.

What the study found is to me ALARMING! ASD children had a hard time differentiating between “Music” and “speech” sound, or speech –speech sounds! The control group children not on the spectrum were pretty comparable to ASD on “Music-music” category, but significantly better in recognizing differences on “Music-Speech” category.

Interestingly ASD children seem to be able to catch the “difference” in the PITCH changes, within “Music-Music” sound bites, demonstrating evidence that ASD children hold similar perceptual processing ability as the control group.

Could it be then this focus on detail of difference between pitch, is probably what is keeping them away from identifying the overall difference of the two sound bites? (Complementing the Weak Central Coherence theory findings.)

Now looking back, I can see that the reason ANNA avoided group was not because she was shy, rather she was overwhelmed with multiple verbal interactions, unable to categorize witch ones to take notice of. Anna looked lost because she could not process what some one said to her, given her difficulty filtering the background verbal input.

She enjoyed the Music pitch changes because she could differentiate, and did not HAVE to even make meaning out of it, just had to coordinate spatial body movements resonating with the music.

As a treatment strategy, I would recommend presenting same information in visual form, if possible or giving one SHORT verbal instruction at a time, speaking in slow speed.

Would love to blog more on “Communication and autism” topic, look for the next weeks posting if you are interested!

The reference for the article is:

Anna Jarvinen-P., Heaton, P., Evidence for reduced domain specificity in auditory processing in autism. Developmental science, 10:6 (2007), pp786-793, UK.

Test Blog

Test blog.