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By Marge Blanc, M.A., CCC-SLP
A HIERARCHY OF PRACTICAL SUPPORTS FOR DYSPRAXIA IN CHILDREN WITH ASD
PART 2 |
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In Part 1 of this article (September-October 2004), we explored the idea of developing fluent, flexible speech from “the bottom up.” This means deep breathing, helping your child coordinate breathing (exhalation) with voice production (vocalization or “phonation”), and finally, coordinating all this with more and more refined movements of the jaw, lips, cheeks, and tongue (the speech “articulators”). In Part 2, we will see how oral communication is achieved at even the most foundational level if we are well-attuned to our kids.We will revise any misconception you might have had that “speech” is just what happens with the mouth, and instead, help you to know that whenever your child is making ANY sound with exhalation, that he is speaking! And he communicates when you listen! We will then move up the eight-level hierarchy of support for dyspraxia, assured that while communication occurs at each level, its expression becomes more and more understandable (intelligible), as we move up the continuum. While the process takes many years, they are fun years, and infinitely more rewarding than remaining minimally verbal! Our goal at each level is spontaneous, fun, and fluent output, regardless of how “basic” that output seems. It all matters, and is foundational to what is to follow! By “fluent,” we mean free-flowing, unhindered and unforced production (no, “Say ...” is wanted here!) Imitation is difficult with dyspraxia on the continuum, and no matter what you read about dyspraxia off the continuum, don’t ask your child to imitate until the time is right (somewhere between levels five and seven)! We want your child’s production at each level to become so easy that it will support the next higher level. Believe me that it can be done! And your child will have fun getting there! All you need to get started is a sturdy bed to bounce on (most of us eventually get trampolines though!) and as many pillows as your family can put in one room. While you will want to pursue an OT and/or PT evaluation sometime soon, if your child is unable to bounce, or if it feels aversive to him, you should pursue that evaluation right away. Let’s start now to become familiar with the support hierarchy for speech. The first, or foundational, level is breathing, specifically deep (“diaphragmatic”) breathing and exhalation. It occurs at a whole body level, and is what happens when a child is jumping on the bed, running hard, swimming, climbing through a pillow pit, or leaning over an inner tube and swinging. This level is all about fun exertion, which promotes lots of long breaths in and long breaths out. Your child may make some noise here, and that is a plus...but it’s not necessary for success at this level. At this stage, we are primarily thinking about the middle of your child’s body (the “core”), where deep breathing takes place. Amazingly, this area also supports the trunk, shoulders, neck, and arms. The eventual support for gesture, and even the jaw, lives here, and the more the upper body can become coordinated with the lower body, and deep breathing, the better. OTs and/or PTs will be crucial at this stage of the support “game.” Knowing about this level will serve you well at all the successive levels, because as you move up the continuum, and all else fails (as it will sometimes), returning to level one is “grounding,” and restores a sense of support to the voice and speech systems. Your OT, PT, or SLP will help you find equipment that can be added to your child’s play area, and advise you about what activities can be taken on at home or at the playground. The best rule here is to “find the smile” in your child, and watch for good deep breathing from the belly area, as the muscle of deep breathing, the diaphragm, lowers to support it. The second level of the support hierarchy is voicing, or vocal production. This is what happens at the level of the larynx when adequate air flows through the throat. When the muscles of the larynx (vocal folds) vibrate, voice is produced and the child is “vocalizing.” Sometimes, a child’s first pleasant experience with voice happens during laughter (crying and screaming in pain rarely work as productive vocal experiences, since there is so little awareness of voice under such strain). Laughter elicited through joyful physical experiences such as spinning or tickling (whatever a child truly delights in) is a wonderful first voice experience. I will never forget the wise child who silently lifted up his shirt for a tickle so that he could “find” his “lost” voice when he laughed. When a child has been essentially silent all his life, this stage of supported development is magic. The child feels power and the world knows he is there! Loudness is enhanced with more air flow...more bouncing, etc., and with adequate playful experience making sound, kids have a second, solid place to return to when “all else fails” at the levels higher up. Another important part of support at the second level is shared joy in movement, fun, and vocalizing. This is where adults get to be kids again, to let go and have fun...yelling, singing, laughing, and humming on a kazoo the entire time. This not only takes the pressure off the silent child, but “models” the kind of vocal output we are supporting at this stage. Remember that dyspraxia is a disorder of “planning,” so the key here is to never have expectations for your child! The moment a child senses your expectation, he has to try, and when he has to try (or “plan”), he is rendered silent, or his sound becomes forced! The third level of the hierarchy is that of intonational support. Parents and therapists should not even think about this level until kids achieve pretty reliable, automatic “vocal access” at level two. This does not mean vocalizing whenever a child “wants” to (since “trying” makes it harder, of course). It means that kids know that they can run and get on the trampoline whenever they want to get their voices going again, and they enjoy joining you in yelling, screaming, laughing, and generally playing with the immense variety of ways voices go up and down (intonation). In our clinic, we spend lots and lots of time supporting kids at level three, because, truth be known, most of the meaning of oral communication is carried with intonation, and not with words at all! Listen to conversations at an airport, in the other room, on the bus, and hear how intonation sounds when you can’t hear the particular words. Once kids develop some intonation, we begin to understand what they know. If you are so fortunate as to have a child who is already at this stage of development, listen carefully in the next week, and see how many “intonational utterances” you can hear. Hypothesize what your child might be saying with his voice...and, over time, you will probably find out that you were right! When the clarity of “No way!” or “I know!” or “Come on!” emerges at later stages in this progression, you will be amazed at how long your child has been “talking.” The transition from level three to level four is a huge one, and one you want to make sure your child is ready for. You know that your child can enact some gross motor “plans,” and you can see that his sense of his body in space is improving. He doesn’t get “stuck” at the tops of slides or in his car seat nearly so often. He probably has plenty of automatic motor sequences that he can’t get out of, however, and this is classic level three behavior. You’ll see what I mean in the next paragraph...where we start to address stopping and starting (or “initiating”). The fourth level of support is the first where “control” starts to emerge. We do not want to rush into this stage, and you will want to have an experienced SLP listen to your child before deciding he is ready. This level is one of starting, stopping, and maintaining sound. Your child will know how to keep his voice going already, and stopping is often just a matter of running out of air. First attempts at “starting” voice, however, are another story. They often come in brief “fits and restarts,” like saying “ha ha ha,” where the pause between syllables is short. This is because true “initiating” is the hardest part of the challenge of dyspraxia, and usually, kids just have to sneak up on it. Supporting your child at this stage means knowing that momentary successes cannot, yet, be duplicated. That is fine. Let it go for the day. Return to it tomorrow.And, in between, drop back to the third level and have fun talking! A great trick here is to get your child giggling in whatever way you know will work. Then “model” (everything we say is an unintended “model”) something fun like, “Gotcha!” or “Wow!” or “Hey!” When your child “initiates” vocalization in the midst of your vocal play, it won’t be “from scratch,” but, hey...giggling is vocalizing! It is a “backdoor” technique that will feel like initiating, and will, over time, become more commonplace. The fifth level of support has often been going on for one or more levels already, but it is not until now that we give it our attention. This is the level of vowel sounds. Vowels are a result of changes in the size and shape of the oral cavity (mouth) when air flows through it and voice is produced. It’s nothing more than that, but the effect is powerful! As with all the levels, support comes from the bottom up, with play partners using the open sounds “ah” or “uh” in their play, and all the others too, such as “oh,” “uh oh,” wow, and hey. Ask your SLP to note how flexible your child’s mouth is, and include any exercises recommended to “stretch” it. Food variety and mouthing toys are helpful in your child becoming more aware of his mouth and how to move it. By this time, you have learned a trick or two from your OT and PT also, and know that how your child supports his head (especially his jaw) is critical to his success with vowels. Trunk control is as important as it ever was, so go back to some of the OT/PT “basics” as well. The sixth level of support is that of consonant sound development, even though the child may have already developed a few consonants along the way (the “m” sound is nothing more than voicing with the mouth closed). But at this stage in the hierarchy, kids are really ready to take off in their consonant sound production, usually following a developmental progression from lip sounds (m, b, p) to back-of-the-tongue sounds (g, k, ng), to front-of-the-tongue sounds (n, d, t), and then the more controlled sounds (l, r, s, sh, f, etc.). This level is the one most people think of as “speech,” and it is helpful to realize how much must happen before it can be really successful. We know that a “splinter skill” like, “Say ‘b’,” for example, fails to generalize into conversation and play. If this level is targetedwhen the child is ready, however, generalization happens readily, because all the lower levels support it. The sixth level involves the production of all the consonants of the language, in all their variations, as they precede or follow other sounds. These movement patterns involve accurate timing, pressure, and grading of all the muscles of articulation, while maintaining vowel production, intonation, and voice. Support at this level involves play with rhythm and timing, singing and chanting, coordination with motor movements such as gesturing, signing, clapping, and finger tapping, specialized oral motor “tricks” like resistance (horns, straws, etc.), and facial touch-cuing like PROMPT (Hayden, 1984). Work closely with your SLP to learn how to use supports your child likes and finds helpful, and remember that this is still play, not imitation work...yet. The seventh level is putting it all together in running speech, sequencing sounds in all the possible orders of the language, coordinating the transitions from sound to sound, and using a rate that eventually approaches “normal.” The practice work your SLP will provide at this level involves saying target utterances, while varying the emphasis and intonation, thus changing meaning. The level of practice material changes at this point, because spontaneous imitation will be pretty easy now. That’s what “fluency” is all about...imitation only when it is not “trying” any more! A word to the wise is in order here. Your child’s expressive language will start to explode now, as his consonant sounds start coming. Sounds won’t be reliable for some time to come, however, and you may not be able to understand him as well as you did! As ironic as this seems, this is classic “apraxia of speech,” where sounds get mixed up, and the sound your child intends for the end of the word, for instance, occurs at the beginning. Resist asking him to repeat himself just yet...even if he can, it requires more “planning” than it is worth at this point, and it will probably come out differently anyway! Better to teach yourself to replay his speech in your own brain...and with your own lips...and to listen closely! Remember that intonation is still your best clue, and that your child’s timing will become better! As it does, you will see the “referents” (e.g. the cookie) more often, and have more tangible clues for understanding! The eighth level involves accessing all the levels of support, under more and more purposeful conditions, within the real challenges of daily life. Remember that apraxia is a disorder of “trying.” So when trying becomes harder, so does the possibility that an individual must rely on a more foundational level of support to approach a particular situation. Specific strategies at this level will include role-play and practicing under simulated conditions (you’ll find that all those apraxia “programs” will begin to fit here), and then under a variety of supported real-life conditions. Now to summarize: one of the nice things about a hierarchy is that it has, as part of its structure, a level for everyone, whether they’re having a good day or a bad day, that provides positive support. There’s always a level to drop down to when one level is challenging. One area that will likely remain a stumbling block for months, if not years, is level four, initiating voice. Kids like the boy mentioned earlier who asked for tickles in order to start his voice, had learned that “initiating” the motor plan of speaking is often the hardest part of talking. How many kids do you know who can talk “till the cows come home” once they get started, but, if they become too sedentary, their silence can stretch long into the day? Kids will advance beyond level four, but still need to return to it (and even level two) when they have momentarily “lost” their voice. Kids realize this, and so they often want to keep talking, just so they won’t lose their voice and have to initiate getting it started again. Don’t be surprised at this, and don’t let your child become discouraged. It is a natural part of what the OTs call “alertness” or “arousal,” and when kids become too sedentary, and have lost deep breathing, support for voice is also lost. Get them up and moving, get their “engines” going, and they will learn that this is their “fail safe,” and rely on it for years to come. (DeGangi, 2000;Williams and Shellenberger, 1996) Now you know the fundamentals and how you can help your child, in a developmentally-appropriate way, alongside the treatment he is receiving from your SLP (and OT and/or PT). With this understanding available to us, we are prepared to revisit the common portrait of our children, the 40% of our ASD kids who would have remained “non-verbal” in the past, the ones we called “low functioning.” Arms at their sides, standing on the periphery of life, they appeared disinterested and perhaps intellectually limited. But now that we understand the hierarchy of supports for dyspraxia, we can ask one crucial, informed question, “Can this child initiate action...of any kind?” If he cannot motor plan with his legs...or his arms...or his voice, he is “stuck.” But, what if we started him running, or climbing, or sliding, or jumping...what could he do then? And then where could he go next? Try it yourself...again and again and again...remembering the hierarchy...and you will find out!
References
Agin,
Marilyn C., L. F. Geng, and M. J. Nicholl, The Late Talker: What to do if your
Blanc,
Marge, Autism and Verbal Dyspraxia: What We Are Learning from Our
Childhood Apraxia of Speech Association of North America: Apraxia Kids Web Site:
DeGangi,
Georgia, Pediatric Disorders of Regulation in Affect and Behavior, San
Hayden,
Deborah, “The PROMPT System of Therapy: Theoretical Framework and
Williams, Mary Sue and S. Shellenberger, How Does Your Engine Run? A Leader’s BIO Marge Blanc, Speech-Language Pathologist, is the founder and director of the Communication Development Center in Madison, WI. CDC specializes in communication services to children on the autism spectrum and others who benefit from sensory-motor supports. Versions of the opening story have occurred regularly over the years, and in working with numerous kids who have been termed "non-verbal" and "low functioning," CDC has developed a local reputation in helping kids get "unstuck." Contact her and her associates at the Communication Development Center, 700 Rayovac Drive, Suite 200,Madison, WI 53711; TEL (608) 278-9161; email lyonblanc@aol.com
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Version of the Articles November - December 2004 Autism n Asperger’s Digest
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