Evidence based techniques for
developing speech in non-verbal
children
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 Analysis
by 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
Establish Attending
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)
Overstimulation
Behavioral Disorganization
Zone of Optimum Arousal
Attending
Learning
Understimulation
“Typical child”
Overstimulation
Behavioral Disorganization
Zone of Optimum Arousal
Attending
Learning
Understimulation
Child with attending challenges
Overstimulation
Behavioral Disorganization
Zone of Optimum Arousal
Attending
Learning
Understimulation
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
Tracking object: Cue
EC
EC
Rf
Rf
Establishing Eye Contact



Hand to cheek: Cue
EC
Tracking object: Cue
EC
Sustained eye contact:
Cue
EC (pause)
Rf
Rf
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

Develop Gross Motor
Imitation
Motor & Sensory
Homunculus
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
•
Very important skill for later corrective feedback
(i.e., should never reinforce incorrect verbal
imitation, BUT can insert gross motor imitation
and reinforce that)
IM
Rf
Increase Frequency of
Child’s Vocalization
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…”
“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
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”
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”
“The vast majority of the legitimate research
shows no changes in speech sound
productions because of non-speech oral
motor exercises.” Gregory L. Lof, Ph.D.
www.apraxia-kids.org
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”
Always Reinforce a Correct
Response






Adult “Get ready”
Child: EC
Adult “k”
Child “d”
Adult (pause), “mmm”
Child “mmm”
Rf
OR



Adult “do this”, claps hands
Child claps hands
Adult “Good clapping hands!”
Rf
Combining Individual
Sounds into Syllables and
Short Words
Combining Sounds into
Syllable and Short Words

Shortest sequence of connected speech is the
syllable

Want to practice CVs and VCs that can:
Immediately be turned into functional words
(“go”, “up”, “eat”) OR
Become the building blocks for CVC, CVCV, and
increasingly longer sequences



Want to practice each consonant with a variety
of vowels, both CV and VC
Combining Sounds Into Syllables and Words:
Some : “Tips and Tricks”
• Consonants easiest to combine with vowels:
/m,n,w,f,v,s,z,sh,l,r,th/, because you can
“hang on to them”
Combining Sounds Into Syllables and Words:
Some : “Tips and Tricks”
• Imitating 2 distinct sounds: Say
/mmm/……say /ahahah/
• Blending: Say /mmm/..hold onto the sound,
and as soon as the child starts to say /m/, you
blend into /ahahah/
 Say /mmmmahahah/
 Say /mah/
Combining Sounds Into Syllables and Words:
Some
“Tips and Tricks”
• If child doesn’t have many vowels when you do your
sounds probe, start with ah/ee/oo
• They are very visible
• They can be combined for other sounds
 /ah/ + /ee/= “kite”
 /ee/ + /oo/= “cute”
 /oo/ + /ee/= “we”
Combining Sounds Into Syllables and Words:
Some
“Tips and Tricks”
 When teaching voiceless consonants, teach
imitation of /p/, not /puh/; when teaching
“plosives” (p,b,t,d,k,g), sometimes easier to
start with VC syllables
 Voiced plosives will have a little vowel sound
after them called a “schwa”: /duh/ is
acceptable, but not /duh/
Delayed Imitation
Delayed Imitation
Delayed imitation is often taken as a
more complex form of imitation since it
involves remembering the modeled
stimulus, rather than direct stimulus
control (www.termwiki.com)
Teaching Delayed Imitation

Cue “Get Ready”
EC
Teaching Delayed Imitation
Cue “Get Ready”
 Adult “Say (sound)

EC
Child imitates
Teaching Delayed Imitation
Cue “Get Ready”
EC
 Adult “Say (sound)
Child imitates
 Adult “AGAIN (sound)
Child
Imitates
Rf

Teaching Delayed Imitation
Cue “Get Ready”
EC
 Adult “Say (sound)
Child imitates
 Adult “AGAIN (sound)
Child
Imitates
Rf
After multiple trials of practice, PROBE
 Adult “AGAIN(pause)”
Child Imitates
Rf

Develop Syllable Grids
CV
m
n
p
b
t
d
s
z
k
g
ah(pot) Ee(me) oo(too) uh(up)
-------- -------- -------- --------
VC
m
n
p
b
t
d
s
z
k
g
CV
m
n
p
b
t
d
s
z
k
g
ah(pot) Ee(me) oo(too) uh(up)
-------- -------- -------- --------
5-20-14
VC
m
n
p
b
t
d
s
z
k
g
CV
m
n
p
b
t
d
s
z
k
g
ah(pot) Ee(me) oo(too) uh(up)
-------- -------- -------- --------
5-20-14
6-10-14
VC
m
n
p
b
t
d
s
z
k
g
CV
m
n
p
b
t
d
s
z
k
g
ah(pot) Ee(me) oo(too) uh(up)
-------- -------- -------- -------7-12-14
7-16-14
VC
m
n
p
5-20-14
6-10-14
b
t
d
s
z
k
g
CV
m
n
p
b
t
d
s
z
k
g
ah(pot) Ee(me) oo(too) uh(up)
-------- -------- -------- -------7-12-14
8-04-14
7-16-14
VC
m
n
p
5-20-14
6-10-14
b
t
d
s
z
k
g
CV
m
n
p
b
t
d
s
z
k
g
ah(pot) Ee(me) oo(too) uh(up)
-------- -------- -------- -------7-12-14
8-04-14
7-16-14
9-01-14
VC
m
n
p
5-20-14
6-10-14
b
t
d
s
z
k
g
Multiple Parallel Tracks:
Setting the Bar at Different
Levels for Different
Environments
Run On Multiple Parallel Tracks: Setting the Bar at
Different Levels for Different Environments
•Simultaneously work on imitation of new individual
sounds, syllables of mastered single sounds, new word
approximations, new target words
Run On Multiple Parallel Tracks: Setting the Bar at
Different Levels for Different Environments
•Simultaneously work on imitation of new individual
sounds, syllables of mastered single sounds, new word
approximations, new target words
•/m/ can mean “more”, “mom”, “mine” in functional
environment before the child has learned to imitate
syllables in structured imitation practice
Run On Multiple Parallel Tracks: Setting the Bar at
Different Levels for Different Environments
•Simultaneously work on imitation of new individual
sounds, syllables of mastered single sounds, new word
approximations, new target words
•/m/ can mean “more”, “mom”, “mine” in functional
environment before the child has learned to imitate
syllables in structured imitation practice
•Generalize imitation practice to functional settings
Run On Multiple Parallel Tracks: Setting the Bar at
Different Levels for Different Environments
•Simultaneously work on imitation of new individual
sounds, syllables of mastered single sounds, new word
approximations, new target words
•/m/ can mean “more”, “mom”, “mine” in functional
environment before the child has learned to imitate
syllables in structured imitation practice
•Generalize imitation practice to functional settings
•Accept word approximations in functional environment
until child can easily imitate target word in structured
practice, then raise the level of expectation
Pair Meaning with Sound
Sequences to Create
Functional Words
Pair Meaning with Sound Sequences to Create
Functional Words
“Reception precedes expression”- continue to work on
receptive language acquisition
Requesting items- first way to teach meaning
Expressive picture labeling-flashcards, favorite books
Setting up opportunities for commenting in functional
environment
Directing another’s behavior: “go, up, out, on”
Singing songs with selected word approximations
Remember: You may need to provide a reinforcer for
communication until your child understands its intrinsic
value
Video: Tyler