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AJ’s Journey: From Non-Verbal to Speech Production

December 21, 2014 By

I met AJ in April 2014, a mere 6 months ago. His story makes me realize why I do what I do, day in and day out. When I met AJ, he was 9 years old. He had a diagnosis of Autism. His family had relocated from India to Orange County a few months prior to our meeting. His mother later told me that they had made the move specifically because she wanted AJ to receive P.R.O.M.P.T therapy. His mother also revealed how AJ had been through no less than twelve speech therapists, several ABA therapists, and a few occupational therapists. They had also tried Neuro-Feedback therapy; several detox programs, and nutritional supplements, all in the hope that they would help with speech production. After all those setbacks and disappointments, it still amazes me that this family decided to move across the world to try another program. But I guess hope is a crazy thing.

During the initial evaluation, I realized that AJ was truly non-verbal. There were no vocalizations on demand. When asked to say “ah,” he would open his mouth, but there was no sound. He could imitate some lip movements with tactile prompts and cues, but again, without any vocalizations. He did spontaneously babble labial sounds like /baba/ and /mama/, but there was no intentional speech. I realized that at age 9, with little to no progress after years of speech therapy sessions, the odds were stacked against us. When I tried to explain this to his mother, she was quick to respond, “But it can’t hurt to try, right?” I knew then, I had to at least try. P.R.O.M.P.T therapy with tactile cues, in combination with Sara Johnson’s TalkTools® was definitely the way to go.

I saw AJ once a week for 45-minute sessions. His mother would sit through each session, carefully taking notes about the activities and target sounds and words. She would then practice all the activities each day during the week. This video is proof of AJ tremendous progress and his mother’s singular dedication. It was taken after merely 25 sessions of P.R.O.M.P.T. therapy. While there is clearly a long way to go, his incredible achievement so far, makes the future look bright and positive.

Filed Under: Autism, PROMPT Technique, Speech Therapy Tagged With: ,

Neurobiology of Autism

August 20, 2014 By

Neurobiology of Autism (Dr. Martha Burns, PhD, CCC-SLP)

I had the opportunity to listen to a recorded presentation “Neurobiology of Autism: Interventions that Work by Dr. Martha Burns, PhD, CCC-SLP on current research in the field of neurobiology of Autism. The original presentation was delivered in November 2013. Dr. Burns is one of the leading researchers in this field. The purpose of the presentation was to summarize the new research in the area of neurobiology as it pertains to children on the Autism Spectrum. The reason I was intrigued was because it explained autism in a way that, for me, finally made sense. Not only did it explain (in theory at least) why children on the autism spectrum demonstrate the characteristics that they do, but also why almost every autistic child presents differently from the others. The purpose of this blog isn’t to recreate Dr. Burns’ presentation, but to quickly highlight the salient points for parents and other professionals. However, I highly recommend listening to the actual presentation since there were so many details embedded within it that are beyond the scope of this blog.

The presentation was broadly divided into three major sections:

  • Etiology of autism- In summary, Dr. Burns narrows the causes of autism to genetic mutations (age of parents, environmental factors causing mutations in the fetus) and neurotoxicology (certain antibodies in the mother may enter the amniotic fluid and these can cause autism). In essence, Dr. Burns refutes theories that suggest that diet and immunizations may be possible causes of autism.
  • Neurobiology of Autism- This portion of the presentation discussed the use of “Diffusion Tensor Imaging” (an imaging technique that is more sophisticated than MRI scans). Using this technology, researchers were able to map white matter fiber tracts. These fiber tracts develop in individuals from the 3rd trimester until about 30 years of age. These are long fibers tracts that run across multiple lobes of the brain. Some of these fiber tracts in the left hemisphere of the brain impact speech development and auditory processing. Because these fibers are long, they are particularly vulnerable. According to Wass (2011), autism is a disorder of long white matter fiber tract development. A study by Wolf, et. al. (2012) also surmised that there was aberrant development of white matter fiber tracts in children with autism spectrum disorder. They also found that the fiber tracts in infants up to about 6 months of age are similar in typical children and children on the autism spectrum. After 6 months of age, they noticed a blunted development in these longitudinal fiber tracts in children with autism. This explains why often parents report that their children appeared typically developing in infancy and the autism-like symptoms were not present until later. Researchers have also found that the development of these fiber tracts is different among children with autism. Hence we see a great diversity in skills, abilities and deficits in children on the autism spectrum. In addition, since the longitudinal (long) fiber tracts are insufficiently developed, the short tracts that are overused. This results in an increase in repetitive and stereotypical behaviors, so frequently seen in children on the autism spectrum. Just as the white matter fiber tracts in the left hemisphere of the brain impact speech and language development, fiber tracts in the right hemisphere impact social skills and pragmatics (Stanley & Adolph, 2013).
  • Interventions that may prove to be beneficial- So the most crucially, how do the above findings about the neurobiology of autism impact interventions? In a crux, according to Dr. Burns, therapies that drive longitudinal white matter tract development are beneficial. Because the theory of neuroplasticity is well documented, well-designed therapy programs based on neuroscience are effective. It now appears that the combination of computerized interventions such as Fast ForWord® and individualized clinical approaches hold the greatest promise. Dr. Burns also discussed the three levels of processing:
             High Level —- Complex Problem Solving
             Mid Level —- Grammar and Vocabulary
             Low Level —- Perceptual Skills
    Researchers believe that it is the low level processing (perceptual skills) that drives the white matter tracts. These perceptual skills can be impacted effectively through computerized programs such as Fast ForWord®. However, it important to note that perceptual skills should not be addressed in isolation. The most effective interventions should therefore include computerized approaches that drive neuroplasticity and behavior interventions for functional limitations.

While new research that explains Autism is enlightening, what is truly exciting for me, is the knowledge that we can now tailor interventions and treatment programs so that they are truly effective.

Filed Under: Autism, Autism Spectrum Disorder Tagged With: ,

Treating Vowels: A Tactile Treatment Program (Part III)

April 15, 2014 By

The second part of Sam’s treatment for vowels was the speech production or articulation portion.  We began by targeting the round vowels such as /Ʊ/.  A lesson plan was created that included auditory bombardment, production of the sound in isolation with PROMPT and tactile cues, production of the sound in words using a functional or communication task, and production of the sound in a word using drills.

For the round vowels multiple tactile cues were provided to elicit the lip rounding.  The TalkTools Tactile Tubes were particularly helpful.  Since they come in different diameters, different tubes were used to elicit different sounds.  Initially the use of Renee R. Hill’s and Sara R. Johnson’s Ice Stick was also very helpful to elicit lip rounding.  The added thermal stimulation provided by the cold Ice Stick yielded some good results.  The Ice Stick placed horizontally was used to elicit lip retraction for vowels such as /i/.  In addition, two Bite Blocks placed between the molars simultaneously on both sides also assisted with stabilizing the jaw height while aiding lip retraction.

Following the principals of Hodson and Paden’s Cycle’s Approach, a vowel was targeted for a few weeks and then a new vowel was selected.  Once all the sounds were targeted, the same targets were then re-cycled.  The functional or communication tasks were the highlight of the session.  This portion is important since it gives us as therapists the opportunity to shape the sound in one phonetic context using multiple trials.  For example, when targeting the “ee” sound, I used the Honey Bee Tree game.  I worked on the words “tree” and “leaf” when Sam placed the leaves on the tree.  When he pulled the leaves out and the bees fell, I targeted the word “bee.”  I try to elicit the word at least 8-10 times per activity.  In a half hour session, I try to include at least 4-5 similar communication activities.  Apart from being able to target the same word through multiple repetitions, the communication task also gives the child an opportunity to use the sound in a meaningful way rather than simply naming pictures in a drill.

As a part of the generalization portion of the lesson, I would have Sam’s parent lead one of the activities in the clinic (so Sam can produce the target word with a person other than me) and I also provided the parents with a copy of the drill pictures to practice at home.

Filed Under: Apraxia of Speech, Autism, Autism Spectrum Disorder, Speech Therapy Tagged With: , , , , ,

Treating Vowels: A Tactile Treatment Program (Part II)

April 1, 2014 By

When Sam began therapy he had difficulty tolerating any sensory input in or near is mouth. Bringing a toothette close to his mouth would lead to an involuntary tongue protrusion to resist any stimulation. Placing a bite block between his molars would lead to gag reflex. My first goal therefore was to decrease his tactile defensiveness, while building his proprioceptive awareness (knowing where his lips, tongue and jaw are in space) of his oral structures. The first step of course, was to build his trust and comfort level with me and the tools I would use. We named the toothette with the vibrator “Mr. Tickles.” Mr. Tickles would always start the session. Sam could tell Mr. Tickles where he wanted to be tickled. We would usually start with the palm of his hand or his arm and gradually work our way to his mouth. Within a few sessions, Sam could tolerate several minutes of stimulation with a toothette without any negative reactions.

vibrator-tootethOnce Sam’s tactile defensiveness was significantly reduced, my next goal was to stabilize his jaw and increase jaw grading (i.e. opening and closing of his mouth to various jaw heights without jaw sliding or jerking). Since Sam tended to “fix” his jaw at jaw height 1 (closed mouth position) during speech, my objective was to move him gradually through Sara R. Johnson’s Bite Block hierarchy. Unless Sam was able to lower his jaw to jaw height 3 or 4, production of vowels such as /Ɔ/ would be challenging. We started with Bite Block #2 and within several weeks were able to move to Bite Block #6, which requires considerable jaw opening. Sam can now hold a lower jaw position without sliding. As a part of a comprehensive oral motor or oral placement program, we also worked on lip rounding, lip seal and tongue retraction. Sara R. Johnson’s Horn and Straw Hierarchy’s were employed for this purpose. In addition, a tongue depressor with added “weights” (pennies taped to both ends) were used to build lip strength and lip closure.

Filed Under: Apraxia of Speech, Autism, Autism Spectrum Disorder, Speech Therapy Tagged With: , , , , ,

Treating Vowels: A Tactile Treatment Program (Part I)

March 18, 2014 By

Sam came in with a diagnosis of Autism Spectrum Disorder and Apraxia of Speech. During the initial intake over the phone, his mother informed me that her main concern for Sam’s speech was his vowel production. And sure enough, all of Sam’s vowels were substituted by a neutral /Ʌ/. There was no discrimination even for round vowels like /Ʊ/ or /Ɔ/. On further observation, it was evident that Sam had oral motor deficits. There was limited if any jaw grading. He tended keep his jaw height at 1 for all his words. His lips did not appear to dissociate from his jaw with no rounding or retraction. Similarly, tongue and jaw dissociation was also limited. Basically, he used his jaw to elevate his tongue. For vowels, the tongue stayed at the floor of his mouth with little to no tongue elevation. Sam had difficulty imitating non-speech oral postures such as a lip pucker, smile, a wide open mouth, even with visual cues like a mirror. It was clear that using purely auditory and visual models to increase his vowel repertoire was a path to frustration and limited success. I therefore planned a unique treatment program that used a two pronged approach:

  • Building sensory awareness, increasing strength, coordination, grading and dissociation skills,
  • Using tactile approaches (P.R.O.M.P.T, TalkTools Therapy Tactile Tools for Apraxia of Speech and TalkTools Ice Stick) to build speech production for vowels.
tactile-tubes-apraxia

TACTILE TUBES FOR APRAXIA

ice-stick

ICE STICK

 

Filed Under: Apraxia of Speech, Autism, Autism Spectrum Disorder, Speech Therapy Tagged With: , , , , ,

You are a Social Detective!

October 15, 2013 By

Review of “You are a Social Detective! Explaining Social Thinking to Kids” written by Michelle Garcia Winner and Pamela Crooke, illustrated by Kelly Knopp

You Are A Social DetectiveGetting started with the Social Thinking Curriculum by Michelle Garcia Winner is always a challenge. Most of us, Speech-Language Pathologists, fall under two distinct categories: 1) “Read first Therapists” that like to read and study a program until it we can recite it in our sleep before we will begin to implement it on our students, 2) “Try it out first Therapists” that will try to figure out the program while we implement it on our students.

I belong to the former category. I spent months after my first Social Thinking conference buying various books and studying them. After all that extensive reading, I concluded that, “You are a Social Detective!” was arguably one of the best programs to initiate the Social Thinking curriculum. This is possibly also because a majority of my caseload includes pre-school and early elementary students. It uses a comic book form and introduces many of the social thinking vocabulary in a clear and systematic way.

The first section points out how we all have school smarts, sports smarts, Lego smarts, etc. but we also have social smarts. It explains that social smarts means understanding that others have thoughts about us and we have thoughts about others. We use social smarts everywhere.

You Are A Social Detective

Some of the social thinking vocabulary that is explained using simple but age appropriate illustrations include “being a part of a group,” “thinking with our eyes,” “expected and unexpected behaviors.” The program uses the same social situation to contrast expected and unexpected behaviors, making it easier for children to grasp the concept.

You Are A Social Detective Versus You Are A Social Detective

The book introduces the concept of “having uncomfortable thoughts,” which, in my opinion is more appropriate and specific than using “feeling mad or angry,” especially for children on the spectrum. Feeling angry is so broad and vague and encompasses so many different scenarios and situations, that it makes it challenging for children on the Autism Spectrum. “Having uncomfortable thoughts” directly links the person’s thoughts to the student’s behavior.

You Are A Social DetectiveThe book also explains “being upset” in explicit physical terms (mean sounding voice, angry face, body gets tight) so children can identify their own states when they get upset.

The book then goes on to explain the process of being a social detective, i.e. using eyes and ears along with what they know in their brains. The authors talk about how we use our eyes, ears and brain to make “Smart Guesses” about how to behave. The contrast (Whacky Guess) is also illustrated.

You Are A Social DetectiveAnother challenge a lot of my little ones have is identifying and differentiating between peers who are nice and friendly and others who say or do mean things. The book has tables (page 44 and 45) to help the child identify and list characteristics of a “nice person” and a person who is “not nice to talk to.” In addition, the book also has a glossary with definitions of the Social Thinking vocabulary for quick reference. The book also includes three lesson plans at the end of the book for “Expected Vs Unexpected Behaviors,” “Social Spy,” and “Social Detective.”

Pros:

  • Illustrates in a simple and clear manner what it means to be a social detective.
  • Appropriate for early to late elementary aged students.
  • Contains three lesson plans that require little to no preparation.

Cons:

  • The illustrations may not be appropriate for older students.
  • Wish it included more lesson plans.
  • Some of the concepts may be challenging for low functioning students.

For me, “Being a Social Detective” forms the crux of the Social Thinking curriculum. Unless our students understand that their “unexpected behaviors” cause others to have “uncomfortable thoughts” about them, they are unlikely to change their behaviors. Concrete reinforcers such as prizes will only go so far.

Filed Under: Autism, Social Communication DIsorders, Social Stories, Social Thinking Tagged With: , , , , , ,

We Can Make it Better

October 7, 2013 By

Review of “We Can Make it Better: A Strategy to Motivate and Engage Young Learners in Social Problem Solving Through Flexible Stories” By Elizabeth M. Delsandro.

we can make it betterA majority of my caseload includes preschool and early elementary aged students. Many of them are diagnosed with Autism or demonstrate social skill deficits. If you’re like me and work with the younger students, you know how hard it is to find social skill programs that are structured, but still age appropriate. For the last year or so, the Social Thinking Curriculum has been the go-to program for many therapists to build social skills. However, finding materials that are appropriate for this age group has always been a challenge. In many settings including the public schools the Social Thinking curriculum isn’t incorporated until upper elementary or middle school years. Does that mean that the Social Thinking Curriculum isn’t appropriate for the preschool age group? In my opinion the preschool and early elementary age group is ideal to begin teaching the Social Thinking Curriculum. Introducing the Social Thinking vocabulary and concepts early on makes them a part of their everyday lives and routine. It does present unique challenges though: 1) teaching the vocabulary in ways that makes sense to younger students and 2) preparing lessons that are age appropriate, engaging and flexible.

“We Can Make it Better: A Strategy to Motivate and Engage Young Learners in Social Problem Solving Through Flexible Stories,” by Elizabeth Delsandro is an excellent starting point in terms of meeting both these challenges. This program essentially uses short stories to identify a problem situation and then encourages the students to express ideas that would “make the problem better.” It follows the core concepts of Michele Garcia Winner’s social thinking curriculum. The lessons are based on how ones behavior can alter the thoughts other people have about them (good or uncomfortable thoughts). Thus, it makes an important initial connection between people’s thoughts and their feelings. The stories follow a predictable pattern:

  • Introduction of a familiar social event,
  • A social problem, and
  • The undesirable conclusion.

Each story contains a lesson plan or pathway for the children to discover “how to make it better.” This involves active verbal problem solving to yield a preferred ending to the story. So the structure of the lesson basically involves reading the story with the social problems, then brainstorming together for ideas regarding what the characters should have done instead. Each story comes with two endings. The first one is the undesired ending and the second is the preferred ending. So, after the brainstorming, you would read the story once again, but incorporate the children’s suggestions and then use the alternate ending. Together, you have “made it better.”

I like that it uses a narrative approach similar to Carol Gray’s Comic Strip conversations. What I like to do is use Post It notes with speech bubbles and write in the suggestions made by the students and place them on the printed copy of the story. In addition, it allows children to view familiar social situations without being in it and therefore actively engaging in problem solving in a safe and non-threatening environment. All of the lessons:

  • Are structured and predictable,
  • Use illustrations instead of just auditory information, and
  • Use illustrations that are simple and free of distractions.

The program therefore caters to the strengths of children on the autism spectrum (and I have to admit, mine too. After all, which Speech-Language Pathologist doesn’t like structured, organized and predictable).

A typical lesson takes about 30-40 minutes, although it could easily be extended to encompass an hour-long session.

We Can Make It BetterAppendix A describes the story structure. The first edition contains the social dilemmas, while the second provides solutions so the ending is a preferred ending.

We Can Make It BetterAppendix C provides a visual script for the lesson.

We Can Make It BetterAppendix G provides a visual link between people’s thoughts and their feelings. This could be a very powerful and versatile tool. It could be used for far more activities than just the lessons in this program.

Pros:

  • The scripts for the lessons are provided making it easy to plan and run the session.
  • The illustrations are suitable for a wide age group.
  • It includes a CD with lots of printable worksheets and materials.
  • It incorporates strong visual supports for students that are predominantly visual learners. The visual supports could be used for so much more than just this program.
  • It also works on a variety of skills ranging from greeting and turn taking to making predictions.
  • The “thinking and feeling” board helps make the connection between our actions and what people think and how they feel because of their thoughts about us.
  • It includes goal ideas, which would be helpful for IEPs.

Cons:

  • It would be hard to make up your own stories and illustrate them (at least for someone like me who can’t draw). This means you are restricted to the story bank that is included in the program. While the stories are varied and fairly extensive (21 stories), there are several situations and scenarios I would have liked to be included.

Disclaimer: I (Sonali Shah) was provided with a copy of this program to review. However, all the opinions and thoughts are mine.

Filed Under: Autism, Social Communication DIsorders, Social Stories, Social Thinking Tagged With: , , , ,

Hello world!

February 19, 2011 By

I am so excited to finally launch my website. I want to officially thank everyone who helped make my vision a reality. I thought I’d write this blog to share ideas and techniques with parents and other speech language therapists. Thank you for reading and I can’t wait to hear your comments.

Filed Under: Apraxia of Speech, Articulation Disorder, Auditory Processing Disorder, Autism, Autism Spectrum Disorder, Cycles Approach, Expressive Language Disorders, Fluency Disorders, It Takes Two To Talk, Learning Disabilities, Oral Motor Disorders, Oral Motor Therapy, Phonological Disorder, Picture Communication Symbols, Picture Exchange Communication System, PROMPT Technique, Receptive Language Disorders, Social Stories, Stuttering, Therapeutic Listening Program Tagged With: , , , , , , , , , , , , , , , , , , ,