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By Marge Blanc, M.A., CCC-SLP
A HIERARCHY OF PRACTICAL SUPPORTS FOR PART 1 |
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THE STORY THAT FOLLOWS HAPPENED EXACTLY THIS WAY... IT'S ALL TRUE, EXCEPT FOR THE NAMES. I walked through Eddie's backyard, where I had gone for a first home visit. I had just met Eddie and his sister, his mom and his dad. Eddie imitated my name quietly, almost in a whisper, saying "Mah" as we ran along. Without any signs of obvious enthusiasm, he went over to his swing set, whispering a short syllable. It was such a quiet voice that I almost missed it. But his quiet "sih" (for "swing") was unmistakable to ears that have become acutely tuned to such fleeting, subtle pronouncements. "I hope you can teach Eddie to talk," said Eddie's mother; and his father echoed an equally fervent plea. How was I going to tell them that Eddie already did talk? I had been in this situation many times before, and knew that an instant retort would be ill-timed, and seem lacking in credibility. I knew I'd have to wait until I knew Eddie, and his parents, better. PARENTS ARE CLEARLY NOT TO BLAME for not "hearing" Eddie and others like him. In fact, we are all "programmed" to think that talking comes in a certain form, with a certain loudness, with a certain rapidity, and, of course, with accompanying eye contact and referencing (pointing, gesturing, etc.). We think this is always true because it almost always is! Our phone systems expect that we will pause no longer than two seconds. If we do, they cut us off. Our voice mail systems expect us to never talk at a high frequency, or too loudly, or too softly. If we do, they cut us off. It is just "not done." And, we are programmed as parents and teachers to expect that kids will make eye contact and gesture long before they begin talking...a handy order-of-events for us, so we'll know that they are talking, that they're talking to us, what they're talking about, and that they want us to listen and to respond. But, those of us who know and love at least one child on the spectrum know we don't have the benefit of this "expected" order of events. Rather, out-of-the-blue one day, we may hear a sound, a word, even a phrase or sound contour...and never again. We think our ears have deceived us...and we are sure that we should not take it seriously. We think we can't afford to delude ourselves into thinking our child actually talked, or has the ability to use the language it would have required. We are, somehow, "bound" by our child's diagnosis to think that our child's language must be "disordered," and that since his speech doesn't sound like real words to us, that it is "babbling" or "jargon." BACK TO EDDIE... Unlike his parents, I didn't have to worry about being deluded. I had heard dozens of children like Eddie say things that were later validated by repeated, clear productions, and/or other signs of communicative intent, like independent typing. Waiting for that next time a child said a particular word or phrase, though, sometimes seemed to take forever. Usually it did not, however. I learned that if the people surrounding a child believed his words to be real, they would reappear sooner. That was the key! What if Eddie really didn't say my name, though...or didn't tell me what he wanted to do? Would it do him any harm if I thought he had and responded accordingly? Does it do infants any harm when moms hear "mamamama," and presume [read: "hope"] it means, "Mama?" No, of course not. It is this delighted parental reaction to sound that teaches kids that speech has meaning. It is how children learn to talk! Shouldn't our "non-verbal" ASD kids have the same opportunity? Of course they should! And it should be delivered with even greater regularity and "benefit of the doubt." I've witnessed, first hand, the positive results that can be achieved with our kids when we presume their communicative intent and respond accordingly. (Blanc, 2004.)
WE HAVE ALL READ that, historically, nearly half the individuals with Autism Spectrum diagnoses have failed to develop useful oral language. They have been known as "non-verbal." And we have all known that motor coordination problems are prevalent across the spectrum, with Occupational Therapy leading the way towards understanding the complexity of "praxis" or motor planning. But it was not until 1997 that Speech-Language Pathologist Gail Richard reported in her book, The Source for Autism, that the 40% or so on the spectrum who are significantly challenged with Apraxia of Speech (Verbal Dyspraxia) are the same 40% who have not developed useful speech. Looking at Eddie, one can understand why. Eddie's voice was extremely quiet...not just because his confidence in being understood was so limited. His muscle tone was low, making all his movements slower and weaker, and the timing of his verbalizations seemed "random," so no one knew when to listen. Essentially, no one could hear him. Without some encouragement and feedback, Eddie was not going to become a competent speaker on his own. But kids like Eddie are not alone any more. Our kids with apraxia now stand an excellent chance of defying the odds of the past and becoming verbal! How? The rest of this article will address that. First of all, know that there are now excellent resources and many trained SLP's, OT's, and PT's to help. If your child's therapist is trained in Sensory Integration, your child will have a good start. Why? Because we now know that the sensory/motor "pieces" that challenge your child in his overall sensory and motor learning affect "praxis" as well. And what is praxis, you ask, and how does this translate into speech? PRAXIS, as defined by OT's (after the pioneering work of Jean Ayres), and now used by the rest of us, refers to motor plans...that is, formulating an idea, or an "intention" to do something unique with one's body, initiating it, following through with it, and ending it. It is important to note that dyspraxia is a disorder of motor planning, not automatic motor execution. If a motor pattern has been practiced long enough to become automatic, it is no longer a "plan." Our kids are readily able to return to familiar motor patterns. We see this is so easy, in fact, that they become "repetitive behaviors," and may risk being labeled "stereotypical movements" or "stims."
Let's look at an
example at a whole-body or gross motor level. A motor plan might be formulated
when a child sees a favorite food (a cookie) on a counter top in the kitchen and
decides to climb up to get it. Initiating the plan might mean climbing up
on the chair that's conveniently, but uncharacteristically, right in front of
the cookie. Following through with the plan would include getting over to the
chair, climbing up, reaching for the cookie and successfully getting it. Ending
the plan would mean NOT continuing to climb up higher, NOT crawling over the top
of the counter, but stopping long enough to eat. It is important to observe kids closely, since we will see kids getting 'stuck' far more often than we will have the opportunity to hear them tell us about it. This is because such kids are usually rendered speechless too. Yes, praxis can affect the coordination of any muscles of the body, including those that produce speech. An amazing array of muscles needs to coordinate before a child can talk fluently...muscles of breathing (specifically exhalation), muscles of voicing/phonation (vocal folds), and the muscles of articulation (oral speech), including those of the jaw, tongue, and lips. So, it is a rare child who can tell you that the rest of his body is "stuck." His muscles of speech are probably "stuck" too, even more so. When the "stuckedness" occurs at the level of breathing, there is insufficient air with which to produce voice. Kids might move their lips, but nothing comes out. The stuckedness can occur at the level of phonation, too, so sometimes a child can whisper, but not say something out loud or loudly enough to be heard. SLP's are quite used to another kind of stuckedness, that of the speech articulators. Kids might be able to produce a nice voice but without a coordinated flow of sounds or syllables. "Classic" apraxia of speech is like this...unintelligible, disjointed sequences of sounds, with a quality that is flat and forced. But, even kids who are typically unintelligible, or even silent, occasionally have "islands of fluency," when it all comes together perfectly...once in a blue moon. They enjoy their moment in the sun, never able to recreate it again. ALL OF THESE SCENARIOS, and dozens more, are within the rubric of apraxia, or, more accurately, dyspraxia, referring to problems with praxis, but not lack of it altogether. It all seems very confusing, I know. But, getting our kids 'unstuck' is possible, using a hierarchy of supports that we have developed in our clinic and use with our ASD kids with dyspraxia every day. We've witnessed that severely dyspraxic kids do make progress...tremendous progress...as long as the supporting levels for physical development and coordination are honored and provided. It cannot be stressed enough that "speech is movement," and, as such, "speech therapy" is movement therapy...fun movement therapy! Praxis is about figuring out how muscles move together, and, for our kids (all 40% of them) who are "stuck," we need to provide frequent and appropriate movement opportunities that give them all the feedback their growing bodies need. When provided with enough of the right supports (including the help they need to access them), kids will move (although it may not be steadily) through the hierarchy, eventually achieving fluent speech that honors their drive to communicate and matches their internal intentions. This process will likely take years, which seems discouraging, I know. But, I can tell you from considerable experience that in the context of the interaction, communication, and play where most of this ‘training’ occurs, kids love it! And it's clearly better than the alternative - remaining minimally verbal. Before addressing the hierarchy in depth, it's important to review some of the foundation "pieces". These come to us from the extensive work of OT's like Jean Ayres, and are now being incorporated into the work of many SLP's. It helps to look at it this way: in the example above, if the child trying to get to the cookie can't see where the chair is in relationship to the cookie, doesn't yet know how to climb, and doesn't have the strength to hold out his arm or grasp with his fingers, the "plan" could never materialize. In other words, praxis depends on a "body schema" (Where are my knee joints? Where are my fingers?) and a sense of where one's body is in relationship to the room, the chair, and the cookie. All the senses must be working well enough to know these things. Successful praxis particularly involves the tactile (skin) sense, proprioceptive (joints and muscles) sense, and vestibular (balance) sense. WHAT SLP'S ARE REALIZING is that the same is true for the mouth - a pretty mysterious space if you can't feel and move it's parts - and the internal connections among breathing, voice, and articulation. Most of us were never faced with "planning" how to move our jaws and tongues in order to learn to talk. But for our kids, it is a truly awesome task, when you think about it. Nothing, even deep breathing, is automatic, and exercising until it becomes automatic seems to take forever. Our kids have to actually "plan" to exhale (witness the kids trying to talk on inhalation rather than exhalation). When it comes to coordination with voice (to make a sound of any kind), the "work" is intensified. That our kids want to talk so badly that they voluntarily practice each step over and over and over is a tribute to their deep intentions and will! Fortunately, we can make their practice fun and rewarding, and they can learn the power of speech early on. Amazingly, our kids tackle even more than these praxis challenges on their way to becoming fluent speakers. If the oral senses are not fully developed, or are overly sensitive, "oral motor" therapy can do for the mouth what PT/OT does for the rest of the body. Oral motor therapy can be "hands on" (Beckman) or "hands off" (Marshalla, 1999), but typically cannot be overlooked completely. Even if every sensation the mouth feels is noxious to a child (sensory defensiveness), this can be successfully addressed with the Wilbarger Protocol (Wilbarger, 1991). And, you can rest assured that oral motor therapy and praxis therapy work together and concurrently. Back to our main topic. The supports for dyspraxia begin at the level of the whole body; sensory/motor work at a gross motor level will get your child started. The hierarchy works with the knowledge that gross motor comes before fine motor development, and that speech articulation is the "finest of the fine," when it comes to the numbers of small muscles that must work together for intelligible speech to occur. As will become apparent in reading the hierarchy, speech is a multilayered phenomenon, only a part of which is movement of the muscles of the lips, tongue, and jaw. If we only view articulation as the complete definition of "speech," we risk teaching splinter skills, verbalizations that the child will not be able to access in any way other than the one in which they were learned (think of kids who can say "m" only when prompted, "say 'm'"). Such skills – usually taught before a child was developmentally ready - are limited and more importantly, limiting, because they are not a part of hierarchical, supported development. THE REASON THE HIERARCHY WORKS is because each level has been adequately practiced and developed, in the context of fun and play, before it is used to support the next higher level. While there is clearly cross-over among the levels, each successive level is targeted until it is reliable enough to support the next. Conversely, when something becomes challenging at any particular level, there is a next-lower level to fall back on to find comfortable production. We always find it helpful to talk about these forward and backward movements with kids, so they know that it is OK, even expected. It is not "regression." It is just part of the process. Part 2 of this article will start with broadening the typical concept of "speaking," so that you will be able to rejoice along with your child as you embark on the first of the eight levels that make up the hierarchy of supports for dyspraxia. You will learn that we all use our breathing and our voices to communicate, even when we never open our mouths! We’ll then share some successful tricks of the trade to help dyspraxic kids move from being 'stuck' to becoming fluent speakers!
Ayres, A. J., Sensory Integration and the Child, Los
Angeles, CA:
Beckman, Debra A.: Beckman Oral Motor
Blanc, Marge, Ask the Experts: Child-Directed
Language Therapy,
Marshalla, Pamela, Oral-Motor Techniques in
Articulation and
Richard, Gail J., The Source for Autism, East Moline,
IL:
Wilbarger, Patricia, and J. L. Wilbarger, Sensory
Defensiveness in
BIO
Click Here for Part 2 of 'When Speech Gets Stuck'
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