Occupational and Speech Therapy: Treating children with ASD

1. Occupational and Speech Therapy: Treating children with ASD Emily Rasco, OTR Mindy Granberry, MA, CCC-SLP June 12, 2010

2. Pediatric Speech Language Pathologists: • Evaluate and treat children for speech, language, cognitive, social communication and feeding or swallowing deficits. • American Speech Language and Hearing Association (www.ASHA.org)

3. Autism: Implications for Language Intervention • Therapy attempts to adapt input and support output to accommodate information-processing differences. • Therapists’ call is to determine specific information-processing limits, interferences with learning, and most helpful input/output modalities for each individual with ASD. Williams, D. & Minshew, N. (2010, April 27)

4. Speech-Language Evaluation • Standardized assessments: • Language assessments (e.g. Preschool Language Scales – 4th Edition, Clinical Evaluation of Language Fundemantals, etc.) • Pragmatics/Social interaction (Communication Symbolic Behavior Scales) • Speech/articulation/oral motor (e.g. Goldman-Fristoe Test of Articulation-2) • Clinical Observation • Spontaneous Language Use (language sampling) • Spontaneous Speech Use (speech sampling) • Verbal and nonverbal communication assessment • Joint attention, eye contact, reciprocity, turn taking, initiation • Language-based cognition: play skills, problem solving

5. Evaluation cont. • Parent Interview • Behavior • Play • Social Relationships • Checklists of behaviors/language observed at home • Goal setting • Developmental • Short term goals • Long term goals

6. Treatment Models • Individualized sessions • Group Therapy • Co-treatments

7. Treatment Overview • Social Communication • Speech • Language • Language-based cognition • Play skills

8. Social Communication • For children with ASD, challenges in orienting to social stimuli and acquiring joint attention skills are evident from a very early age and provide barriers to the development of early communicative intent, social functions of communication, and language acquisition. ASHA, 2006

9. Hierarchy of Social Communication Goals – Floortime Approach • Attention • Engagement • Intentionality • Initiation • Circle of communication • Problem solving • Generalization Greenspan & Wieder, 2006

10. Social Communication - Treatment “Because difficulty with attention and engagement are the first core deficits of autism, working with the child on these should be the first goal of parents, educators, and other caregivers.” (Greenspan & Wieder, 2006)

11. Social Communication Treatment - Attention • Joint attention • social orienting • recognizing another’s visual line of regard • establishing shared attention • monitoring emotional states • considering another’s intentions ASHA, 2006

12. Social Communication Treatment - Attention • Attend to the child’s • Slow down and observe where their attention • Why? • Guide them into a more functional task

13. Social Communication Treatment - Engagement • Engagement: “entering the child’s world and helping her enter into a shared world with others.” • social and emotional development • self-regulation • purpose or direction in actions • leads to shared problem solving Greenspan & Wieder, 2006

14. Social Communication Treatment - Engagement • Join • Observe • Attend • Follow • Respond • Distress? • Relevant toys Greenspan & Wieder, 2006

15. Social Communication Treatment - Intentionality, Initiation, Social Reciprocity • Intentionality • Initiation: Initiating bids for interaction • Maintaining interactions by taking turns • Providing appropriate responses to communication initiated by others • Circle of communication: • Child initiates/Caregiver initiates • Caregiver responds/Child responds • Child responds/Caregiver responds Greenspan & Wieder, 2006

16. Social Communication Treatment – Problem Solving • Small changes to the play interactions. • Communication and language intentionally to seek emotional responses from others • Gauge social impact ASHA, 2006

17. Social Communication - Treatment • Social Stories • Needs based • Visual picture story • How event “should” go • Review story • Execute story • Group therapy • Practice for success • Generalizations of skills

19. Speech • Speech: the faculty of expressing thought by spoken words or sound symbols that are understood by another. • Speech Disorder: unacceptable variations from the common form of speech creating negative impressions on the listener, lowered intelligibility, and personal disturbance in the speaker. Palmer & Yantis, 1990

20. Speech Approximately one-third to one-half of individuals with ASD present with significant difficulty using speech as a functional and effective means of communication.

21. Speech Disorders • Articulation • Delays in developmental acquisition of sounds (common in ASD) • Phonology: the rules and customs of phoneme use • Apraxia/Dyspraxia of speech: a disturbance in normal volitional muscle movement patterns (common in ASD) • Fluency and prosody Palmer & Yantis, 1990; ASHA, 2006

22. Speech: Treatment • Speech analysis • Target errors • Therapy techniques • auditory bombardment • modeling • imitation • tactile cues • Therapy • structured tasks • free play

23. Speech Treatment Single sound production Consonant-vowel (syllable shape) Increase complexity of syllable shapes Transference to meaningful words Words in sentences Multi-sentence production Conversational speech

24. Language • Language and related cognitive skills: underlying capacity to symbolize and learn a rule-governed system, enable an individual to request, protest, share experiences, and exchange ideas with others through modalities of communication that have shared meanings. • Language Disorder: a problem involving the linguistic aspects of oral communication. Meaning, communicative intent, and linguistic code of an utterance may not be conveyed successfully. Palmer & Yantis, 1990; ASHA, 2006

25. Language • Receptive Language: the understanding of spoken or written messages • Expressive Language: communication through spoken or written form, or other forms • Verbal and Nonverbal

26. Language • Children with ASD’s ability to recall detail information (often non-relevant) is really a failure to form schemata or paradigms spontaneously to organize information into categories that make information meaningful. • Language in ASD often involves holistic storage of information with a failure of analysis and integration. • Most children with ASD capable of verbal communication but significantly limited for some. Williams, D. & Minshew, N. (2010, April 27)

27. Language • It is common for children with ASD to develop problem behaviors to communicate (e.g., screeching, hitting, and/or fleeing from an undesired activity) in lieu of acquiring more conventional gestures or symbolic communication as effective strategies for protesting, exerting social control, and emotional regulation. ASHA, 2006

28. Language Treatment Children with ASD: • Limited range of conventional gestures (showing, waving, pointing, shaking head) and vocalizations in early stages of communication development. • A reliance on presymbolic gestures (leading, pulling another’s hand) ASHA, 2006

29. Language Treatment • Language therapy with nonverbal children may include teaching of conventional gestures to: • Help get basic needs met • Expand underlying cognitive concepts of symbolic communication which is required for meaningful word development

30. Language Treatment - Picture Exchange Communication (PECS)

31. Language Treatment • Children with ASD may have difficulty with any component of language development: • Semantics: system of meaning • Morphology: rules of word formation • Syntax: rules of sentence formation • Pragmatics: use of language • Literacy

32. Language Treatment - Semantics • Children with ASD: • Restricted semantic development and difficulties with development of more creative and generative language • Emerging language: often limited to nouns or object labels • Delays in developing word form referents other than nouns: action words, modifiers, and relational words. ASHA, 2006

33. Language Treatment - Semantics • Total vocabulary • Variety of classes word forms • Semantic roles • Multi-word relations • Wh- questions (What? Where? Why? When?) • Use of conjunctions

34. Language Treatment - Morphology • Children with ASD may hear a word or “chunk” of language and associate it with a specific experience or event rather than understanding the conventional meaning of a word or phrase and how it may be applicable across similar contexts. ASHA, 2006. • Children with ASD may have difficulty understanding and using morphemes (smallest units of language that carry meaning).

35. Language Treatment - Morphology • Morphemes: • plurals (e.g. dogs) • possessives (e.g. “the dog’s”) • verb tenses (e.g. “the dog jumped", “the dog is jumping”) • verb contractions (e.g. “it’s”, “he’s”)

36. Language Treatment - Syntax • Grammatical concepts: • modulation of simple sentences (e.g. verb tensing: present, past, future, regular vs irregular; subject-verb agreement) • embedded and complex sentences (e.g. prepositional clauses, infinitives)

37. Language - Pragmatics • Using Language • Changing Language • Following Rules for conversation www.asha.org

38. Language Treatment - Pragmatics • Using language for different purposes • greeting (e.g., hello, goodbye) • informing (e.g., I'm going to get a cookie) • demanding (e.g., Give me a cookie) • promising (e.g., I'm going to get you a cookie) • requesting (e.g., I would like a cookie, please) www.asha.org

39. Language Treatment - Pragmatics • Changing language according to the needs of a listener or situation: • talking differently to a baby than to an adult • giving background information to an unfamiliar listener • speaking differently in a classroom than on a playground www.asha.org

40. Language Treatment - Pragmatics • Following rules for conversations and storytelling: • taking turns in conversation • introducing topics of conversation • staying on topic • rephrasing when misunderstood • how to use verbal and nonverbal signals • how close to stand to someone when speaking • how to use facial expressions and eye contact www.asha.org

41. Language - Literacy • Due to strengths in visuospatial perception and rote episodic associations, individuals with ASD may learn phonological rules and detect patterns in words, thereby allowing for the acquisition of a sight word vocabulary, often without comprehension of the printed words: hyperlexia. ASHA, 2006

42. Language Treatment - Literacy • Language therapy may address: • Figurative language • Mental states in written narratives • Varying grammatical forms to clarify their intentions to an unfamiliar reader • Inferences ASHA, 2006

43. Cognition: Language-based • Impact across cognitive domains including • difficulty managing complex information • difficulty deriving new problem-solving strategies within novel situations. • manifested in day-to-day functioning ASHA, 2006

44. Cognition: Language-based treatment • Functional and symbolic play • Problem solving in play • Formulation of thoughts or ideas • Executive functions • Planning • Preparing • Executing • Negotiating

45. Treatment Modalities • Relevant information obvious/explicit. • Words paired with environmental referent • Large number of examples • Extreme examples for abstract concepts. • Limit amount of information Williams, D. & Minshew, N. (2010, April 27)

46. Treatment Modalities • Platform of routine/structure • Multimodality input: • Visual: picture schedules and cues • Tactile: sensory input based on child’s needs • Auditory: concrete; repetition • Structured tasks and free play • Behavioral considerations

47. Treatment Modalities

48. Treatment Modalities

49. Augmentative/Assistive Communication

50. Overview • What is Occupational Therapy? • Occupational therapy services focus on enhancing participation in and performance of activities of daily living (ex. Feeding, dressing), instrumental activities of daily living, education, work, leisure, play and social participation.