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AUTISM ASSOCIATES AWARENESS CAMPAIGN
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TEACHING A NON-VERBAL CHILD WITH AUTISM SPECTRUM DISORDER TO VOCALISE AND IMATATE SOUNDS: A CASE STUDY.
By Okey-Martins N

One of the major deficits that characterize Autism Spectrum Disorders (ASD) is impaired speech and language. The development of speech and language may be deviant, delayed or absent. These deficits vary and can range from no speech at all, to complex speech with errors. Common errors may include staying on a topic of interest for too long, repeating parts of other conversations, difficulty with eye contact while speaking, changing topics rapidly, speaking in a monotonic voice and not knowing when to use particular Language (for example, a greeting, or slang).
 
therapy- Psychologist Okey Martins Nwokolo (PhD) in a therapaeutic session with an autistic child -

One of the major deficits that characterize Autism Spectrum Disorders (ASD) is impaired speech and language. The development of speech and language may be deviant, delayed or absent. These deficits vary and can range from no speech at all, to complex speech with errors. Common errors may include staying on a topic of interest for too long, repeating parts of other conversations, difficulty with eye contact while speaking, changing topics rapidly, speaking in a monotonic voice and not knowing when to use particular Language (for example, a greeting, or slang).

COMMON SPEECH AND LANGUAGE PROBLEMS IN AUTISM
v Some children with autism start to develop speech and at about age 2 begin to lose words previously acquired.
v Others may develop expressive language far in advance of their expected age. In many such cases, the children use terms that are advanced for their age, and the words are used incorrectly or out of context.
v Verbal skills are often devoid of descriptive and pragramatic language. Pragmatics is the language we use in everyday social contexts and to make our needs known. Children with autism often have difficulties with describing how or what they feel, make requests, ask questions to clarify a topic; or even realize that they have a question or reaction due to a lack of pragmatics.
v Another speech and language problems often seen in individuals with autism is pronoun reversal. Their language is often lacking in the use of personal pronouns, which are abstract forms of reference (Murray-Slutsky & Paris, 2000.)
v These children may laugh when you reprimand them, or smile when they say they are angry. Their facial expressions may not correlate with their verbal messages. Children who do not have autism but who have speech delays, actually compensate for their lack of language through gesture, body language, and facial expression. Autism, however, affect the child’s sense of how to communicate.

SOME SENSORY PROCESSING ISSUES IN AUTISM
According to Murray-Slutsky & Paris (2000), individuals with autism spectrum disorders have impaired sensory systems. They may fail to react or to register changes and things in their environment. Sensory registration is a process that occurs on a sub-conscious level within the brain and enables us to recognize changes within our environment and turn to the stimulus. Turning to stimulus or making some other type of reaction to it is known as the orienting response. A child with autism may not turn or respond when called. Some may fail to register a toy in their environment and to them such a toy is non-existent. Some others may fail to register that they are drooling and make no attempt to wipe face or react when bitten by an insect. In her view, Ayres (1979), reported that children with autism lack or at least have an inconsistent orienting response. She referred such a children’s “registration” function as capricious, citing that the brain may decide to register a sensory input one day, but not register something similar another day. If the child does not register something, how can he orient to it? (Murray - Slutsky & Paris, 2000). Ayres (1979) described two response patterns to sensory stimuli namely:
Hyporesponsive system
Hyperresponsive system
Hyporesponsive systems:- In children with hyporesponsive systems, sensory stimuli such as tactile, auditory, proprioceptive, and vestibular input may not register unless they are magnified in intensity. For example, children who can’t feel their touch on certain object may press too hard or break those objects. They may appear not to hear or tune out if they cannot perceive auditory input. If a child cannot register the information that his muscles and joints are sending to his brain, he may not know where his arms or legs are in space or how to use them in a coordinated fashion. His arm or leg placement may be awkward, his ability to sit in a chair impaired and he will appear uncoordinated or clumsy.
Hyporesponsive children are often over-active children. They remain in constant motion because they lack the balance to stay in one place; they charge ahead crashing into objects.
Hyperresponsive system: Ayres, (1973) described the hyperresponsive systems as one in which the system may overreact to stimuli. These may include intolerance of movement (a result of hyperactive response to vestibular input), tactile defensiveness (the result of overreaction to tactile stimuli, and auditory hyper sensitively as examples of hyper responsive systems.

It is evident from the above theory that children with hyporesponsive and or hyper responsive systems have inconsistent responses to sensory input and therefore have a modulation disorder (Ayres and Tickle, 1980). Similarly, knickerbockers, (1980) proposed that the oral defensiveness often seen in these children may be another example of a sensory system that is not only hyporesponsive to oral input, but lacking in the ability to process the sensory input bombarding it. Lovaas and Colleagues (1971) observed that when presented with multiple stimuli, children with autism tend to overfocus on one mode of sensory input rather than integrate all of the presenting stimuli. He proposed that these children may fail to manage multiple stimuli in their environment.
Murray-slutsky and Paris (2000) therefore suggested that for a child to benefit from any teaching or learning effort, such a child should be helped to function within a window called calm-alert state. They defined the calm-alert as a window in which a person’s ability to function is maximized. In this state, the child has a balance between the ability to attend to a stimulus or task, and the level of arousal within his brains and bodies to prepare him to respond.
A child with a problem in registering and modulating sensory input will exhibit problems in learning, language, and purposeful interaction; and also will have difficulty with ideation or concept formation, initiation, motor planning, and organization of behaviours (Ayres and Tickle, 1980). Hence learning, language and purposeful interactions depend upon registering information, filtering extraneous input, and having an optimal state of arousal to attend to a task, a child with a sensory modulation disorder will be hampered in all of these areas.
Many children with autism are in a state of either underarousal or overarousal. The underarousal child will miss much input and therefore, fail to register and respond to it. The overaroused child is bombarded by a constant stream of unfiltered input and the intense stress posed by changing and unpredictable situations. The stress from this overwhelming stimulation may easily lead to sensory over load, shutdown, over focusing, disorganized and disruptive behavior.
 
THE CASE OF MAJE
At 2 years of age Maje had started to vocalize and develop speech. Suddenly, at about his 29th month, parents observed that Maje began to lose the words he had previously acquired. Though his vocabulary bank at the time contained only 5 words (bye “bei”, Mama “maama”, Dad “Da-da-daaa”, Me “Mii” and Oh-oh “Oh-o”), 2 of which are only sounds that sounded like real words, they were often non-spontaneous. He would drag parents or siblings hands toward a desired object; or throw tantrums when he wants something. Parents were quite displeased about Maje’s regression. Maje babbled with a variety of sounds, but he had none of the words expected of a 2-year old. His disruptive behaviours increased, with lots of fleeting eye contact, inattention and hyperactivivity. Communication was extremely difficult with siblings; parents and other adults. He had very poor receptive language and did not follow simple instructions such as sit, go, come, give, take, wave and so on). In addition to his language and communication problems, Maje also has low muscle tone and several sensory issues
 
VERBAL IMITATION TRANINING TECHNIQUE
Verbal imitation is an effort directed at teaching a child how to talk by teaching him how to imitate speech, beginning with sounds and words. Most children with ASD who are either mute or non-verbal find it extremely difficult to imitate speech. Majority of them find it easier to imitate gestures and actions (for example clapping, waving)
This technique was popularized by Lovaas, (1981) and uses behaviour modification principles to train children to develop speech. The greater the amount of time spent on this exercise the better the outcome. According to Lovaas (1981), the amount of time you put into verbal imitation training depends on how important you feel it is for the child to talk, relative to other skills he needs to acquire.
In Lovaas’s technique, half of the teaching time is spent on language programmes, which in the beginning means an upward of 4 hours a day spent teaching the non-verbal child to imitate speech. To avoid monotony, therapists intersperse verbal imitation training with non-verbal imitation and other drills. Some children will learn to talk using the Lovaas method of verbal imitation while some may not. Lovaas (1981) warns therapists to note that not all children will learn to talk using this technique. Unfortunately, it is difficult to say beforehand which child will benefit from this technique and which will not. Nevertheless, Lovaas suggested the following:
v If the child is over 6 years old, and if he is not making some sounds or words involving “difficult” consonants (such as k, g, p), but merely gives an occasional (“ooh,” “ah”), then he is likely to progress very slowly. He will progress quickly if he is less than 6 years and already using complicated vowel – consonants corroborations.
v Consider dropping the programme if after 2 or 3 months on verbal imitation training and your child cannot imitate 5 or more succinct sounds. You may want to come back to it later.
 
PROCEDURE USED TO TEACH MAJE TO VOCALISE AND IMITATE SOUNDS
v We scheduled Maje for an 8 hour per day one-one-one therapy in his natural environment ( home).
v We worked on his attending behaviours (such as learning correct responses to simple instructions like, sit, give, take, come, go and look). Other pre-requisite skills developed include focusing/eye contact, motor imitation (he progressed from one step to 2 step instructions) and gesture imitation.
v We assessed and identified effective reinforcers to be used to reward Maje
v We designed a clutter and noise free work area where distraction is highly minimal. Extraneous stimuli were kept under maximum control.
v Because of his sensory issues which included overarousal and hyperresponsivity, we applied sensory integration exercises to get Maje to a calm alert state.

The integration exercises included –
>- Brushing (Wilbarger protocol)
> Joint compression
> Deep pressure
> Brain Buttons
> Cross crawl
> Brain Gym
> Drink water
> Hook ups
> Handle exercise
These exercises were done routinely and consistently with songs which are repeatedly sung every session. Once this procedure is completed, Maje is certainly in relaxed, calm-alert and ready to work.

HOW MAJE WAS TAUGHT TO VOCALISE
AIM: The goal of the vocalization training is to increase the frequency of his vocalizations. A vocalization is any sound made with the vocal cords, including grunts, laughter, babbling, “ahs “and “ee’s (Lovaas, 1981).
We wanted Maje to learn that verbalizing will be rewarded with food (banana, pineapple), and praise, and that he can control the supply of these rewards by making sounds.
 
PHASE 1: INCREASING VOCALISATIONS
STEP 1a: Get child to feel calm, released and motivated to work. Create a friendly atmosphere.
STEP 1b: Seat with child face to face
STEP 2: Say, “Talk” and immediately reward each vocal response with food and praise. If you are doing it right, your pleasant, happy manner, your timing of “Talk”, and the nature of your rewards should help prompt vocalizations which you can reward.
STEP 3: If child does not make any sounds, wet get creative. Prompt him physically by finger prompts, mouth prompt. Tickle, caress the child or sing a song as you make him to jump or swing.
Immediately reinforce any sound that your child makes. When that didn’t work, we step down and teach imitation of facial expressions.
 
PHASE 11: CONTROLLING VOCALISATIONS
Our aim in phase one was to teach Maje that he could control the supply of banana/pineapple. In phase 11, we aim to get him to respond upon command; when asked to “Talk”. The goal is to teach him to make vocalization within 3 seconds after the therapist says ‘TALK”. He will only be rewarded if he first listens to the therapist vocalize. There are four steps:

STEP 1: Sit face to face with child, and about 1 – 2 feet apart.
STEP 2: Say “Talk”, and reinforce each vocal response that occurs within about 3 seconds after your demand with praise and food. Continue trials until the child makes a vocal response to your instruction within about 3 seconds for 10 consecutive trials.
STEP 3: Reduce the interval between your instruction and his response to about 2 seconds.
STEP 4: When the child has successded at a 2 second interval for about 10 consecutive trials, the interval is further reduced to 1 second. When the child has made vocal responses within 1 second after you say “Talk” for 10 consecutive trials, go on to phase 3. Be consistent in data collection.
 
PHASE 111: IMITATION OF SOUNDS
Here we are ready to teach the child to imitate specific sounds which he will later use in saying words. The child should initially learn to imitate about 10 sounds, including at least 3 consonants.
The first sounds to train were sounds that the child frequently emitted while we tried to increase vocalization or just some easy sounds.
a (“ah”)
o (“oh”)
d (“duh”)
m (“mm”)
f (“ef”)
e (“ee”)
k (“kuh”)
t (“tuh”)
Teaching the first sounds
STEP 1: You and your child should not face to face 1 -2 face apart
STEP 2: On each trial, say one sound, such as “ah” using an echo mic
STEP 3: On the first five trials, any sound that the child makes within 3 seconds of your sound is to be reinforced even if it is just a rough approximation of the sound you made. For example, “eh” would be acceptable for “ah” at the early stage.
STEP 4: If the child fails to match the sounds roughly or correctly, use visual /physical prompting. Use mouth prompt – e.g. when saying “ah” open your mouth very wide. Re ward the child for imitating the shape of your mouth, whether or not he vocalizes. You may even finger prompt by opening his mouth for him. Continue visual prompting procedure until the child has roughly approximated the sound you made for 5 consecutive trials.

In the manual prompting procedure, you hold the child’s mouth in the appropriate shape where the child vocalizes. For example, you can manually prompt the labial sounds (p, b, m) by holding the child’s lips together when he vocalizes. Gradually fade the prompt until the child has roughly approximated your vocalization without any prompting for 5 consecutive trials.

STEP 5: Shape the child’s response to more closely match your vocalization. On successive trials reinforce responses that closely match yours. Continue to shape this until the child can correctly imitate the sound that you make. When the child has correctly imitated the first sound for 10 consecutive trials, imitation of the second sound can begin.

TEACHING MAJE THE SECOND SOUND
The second sound “oh” that Maje learnt is quite different from the first sound. We repeated steps1 through 6, used in teaching the first sound.
In addition, we did random rotation with the two sounds “mm”, “oh”, “mm”, “oh” “oh” “mm”. We continued to present trials in random rotation until the child imitated correctly to criterion. In this fashion, we continued up to the tenth sound.
After he acquired each new sound, presentation of the new sounds were mixed with presentations of the sounds learned earlier.
When he learnt to imitate 6 – 10 sounds, we began a next phase of building syllabus and words. For example we worked on consonant – vowel combinations such as CV and CVCV forms.

C V
A E I O U
B Ba Be bi bo bu
C ka ke ki ko ku
D da de di do du

…..up to letter Z
CV CV
Baba bebe bi,bi bobo bubu
etc
 
PHASE IV: TEACHING IMITATION OF WORDS
We made a word list chosen from sounds that Maje could readily imitate. The words include:
Papa banana down wee wee
Mummy apple we toilet
Bye bye water go me

TEACHING THE FIRST WORD
STEP 1: For the first 20 – 50 trials the therapists says a word, such as “bye bye” and reinforce any approximations that include the main sounds in the word.

STEP 2: Reward approximations and shape the words until they sound closely with yours and consistently so.
Therapist: “Bai bai”
Child: Ba
Therapist: Good...bai bai
Child: “ba” ba”
Therapist: Well done

Continue shaping and adding new words from the word list. As the child learns to imitate his first words, he may show problems in the areas of pitch, volume, and overall speed with which he says his first words. These problems can be remedied using shaping and imitation.

When Maje learnt to articulate sounds, a new challenge set in – the challenge of meaning and programtics. So we used similar reinforcement procedures to teach him how to mand (request) e.g. Maje says “water” and gets water; Tact (label) e.g. show him a glass of water and ask “Maje what is this?”.

Today Maje is mainstreamed and attends a regular school. Because of his behaviour and attention issues a facilitator shadows him at school.

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Related Links: Blue Ridge Autism Centre , Autism South Africa,  Autism Today Cure Autism Now  ,  Autism Speaks Talk Autism Autism Genetic Resource Exchange (AGRE) Autism Treatment Network (ATN) Combat Autism AUTISM SOCIETY OF AMERICA  ,COMMONWEALTH AUTISM SERVICE (formerly The Autism Program of Virginia - TAP-VA) , UNLOCKING AUTISM, AUTISM RESOURCES , PROJECT LIFESAVER, POLICE AND AUTISM: AVOIDING UNFORTUNATE SITUATIONS

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