Patti Hamaguchi, MA, CCC-SLP
What is the role of speech therapy in my child’s program? What does good speech therapy look like? How does it interface with other therapies? These are questions I am often asked. In particular, for parents of children with autism, it is often confusing to understand how all the therapies a child receives work together, and what speech therapy can and cannot do. Is speech therapy the same as ABA? Does a child need speech therapy if he/she is getting Floortime? Is it worth paying for speech therapy if my child is resistant or non-compliant? With mounting bills and the logistics of trying to schedule so many therapies, these are very good questions to ask. Since every child is different, bear in mind that these are generalities and may or may not apply to your individual child’s case. The main thing to remember is that there is no singular way to treat autism. We still have a long way to go in order to understand the best combination of interventions to help children with ASD achieve their maximum potential, but the good news is we are making great strides on that score!
ABA (Applied Behavioral Analysis) is designed to help your child attend, follow directions, learn concepts, develop functional communication, work within an adult-directed structure, and understand the idea of working for a reward. It is typically done in the home and on an intensive basis, with many repetitions of certain tasks. Many children with moderate-severe autism do well with ABA (although not all SLPs will agree with me on this) and are better able to tolerate direct teaching/therapy in other settings as a result. It serves as a foundation for the learning process. Children with milder forms of autism may not need ABA.
Floortime is used as an intervention ideally with very young children who are resistant to direct adult intervention and interaction. Many families choose Floortime instead of ABA, but it can also be used in concert with ABA, although schools generally tend to provide ABA only. Floortime is a child-led intervention designed to facilitate interaction and connection between the adult and child. It too serves as a way to bring the child into “our world” and thus the motivation to interact and communicate.
Occupational Therapy is a therapy that works on fine motor, self-help, and sensory integration and processing. Good occupational therapy can be extremely helpful for children with ASD in that it addresses the core deficits that often get in the way. By addressing the underlying sensory issues, children are often less agitated, more able to focus and move within the world, and even sleep better. I can’t recall meeting a child with ASD who wouldn’t benefit from at least an OT consultation.
Special Day Classes provide structure and a place to work on academic skills, integrating language and motor skills, social opportunities, and listening. A good special day class can be invaluable, especially for children with moderate-severe autism who cannot thrive well in a full-time regular education placement. It is often used in conjunction with opportunities for mainstreaming.
So why add speech therapy into the equation?
Speech therapy’s long-term goal is to help the child develop natural, dynamic language, and a truer understanding of when/how to use words and sentences in novel settings, and how to interact and play. In some cases, that may initially look somewhat like ABA for part of the session, especially if the child is highly resistant and used to an ABA-style of learning. It may also look a little more like Floortime, if the SLP favors a child-led approach, and if the child is not responding to direct instruction. What sets speech therapy apart is – there, the professional is not limited to a specific program. The SLP (speech-language pathologist) should be versed in a host of intervention strategies and can tailor the speech-language intervention piece accordingly. In many cases, a combination of approaches will be used such as (RDI—Relationship Development Intervention), Prompt (apraxia/speech tactile cueing system) Hanen (Parent-training) TalkTools (for oral-placement and articulation) Social Thinking (Garcia-Winner), Social Stories (Carole Gray) Kauffman (word shells) PECS (Picture Exchange) and signing, to name but a few, while integrating play, games, individual and group work, as necessary.
In an ideal world, many children, especially children with moderate-severe autism, benefit from a carefully coordinated combination of interventions, with the professionals involved all working together to achieve a set of well-defined goals. It is often a dynamic process, where at one point, a child may need a heavy dose of ABA and some speech and occupational therapy, and over time require a heavier dose of speech therapy and less of the ABA and OT, with a greater emphasis on the social piece. All of these may also be happening within a special education self-contained class or in conjunction with regular ed. The “right combination” is a moving target! Good, solid intensive speech therapy can help the child function better in all environments, socialize, and be less frustrated.
The clinician should be engaged and enjoy what he/she is doing. At the same time, he/she will likely need to be firm and set clear boundaries. This is often a tricky combination to have within one clinician. But children with ASD need strong boundaries and rules if adult-directed therapy is going to be successful. If the clinician is noticeably unnerved by a little fussing, the child will pick up on it and push even harder. Managing, understanding, and responding to behaviors such as grabbing, screaming, resisting, etc., especially in the context of sensory, anxiety, and language deficits requires a very large bag of tricks, patience and creativity.
Techniques should be varied and extensive. A child should have a number of cuing strategies and supports available. A good clinician should know if initial sound cues (“It starts with sssss…”) will elicit a word, a carrier phrase (“open the ____?”), a sign or gestural cue, or visual support will help. A good clinician should also use pause cues– pausing and giving the child time to process the information and attempt to answer it before using one of the other strategies. Children may need support to respond the “first time” or ask for repetition by saying/signing, “again” so he/she doesn’t get used to expecting the question to be repeated many times. How many choices? How can the lesson be made easier or more challenging? How can we integrate this new knowledge into the child’s everyday world?
Activities should change up within a session, sometimes very often! Children with ASD typically have a limited attention span and low frustration threshold. A single session should move along and switch up activities to eliminate boredom and keep the child from getting too frustrated. The ability to “read” a child’s mood, anxiety and frustration threshold—which often change moment to moment—is critical.
Sessions should attempt to tackle several goals. A good SLP should always have “the big picture” in mind. This requires a constant juggling of receptive, expressive, articulation, and social-cognitive goals, while facilitating the core attending and behavior issues that need ongoing support.
Activities should be varied and creative. Sometimes using picture cards is necessary but rote learning and pointing should be only part of the session. Likewise having a structure and routine is often advisable, but a good clinician will know how to keep expanding and pushing the envelope for a child so new concepts are introduced and practiced as often as the child can handle. The child should not be doing the same activities day after day if at all possible, unless learning that skill can’t be accomplished otherwise. In many cases, multiple repetitions are critical, and so finding a balance between drill and novel learning, requires a savvy and patient clinician.
Materials should be varied and creative. Good therapy should extend beyond picture cards and worksheets. It should embrace a host of materials including storybooks, games, toys, arts and crafts, apps/software, fingerplays, role-playing, puppets, dollhouses and dress-up to name a few. For some very rigid children with severe delays, the introduction of “new” toys may need to be slower to avoid meltdowns and confusion. Knowing how and when to change out toys and materials is important.
Communication with the family/other service providers is important. Therapy for children with ASD requires planning, coordination and ongoing communication between all the members of the child’s team. Teaching skills in isolation so that the child can “perform it” in a specific setting is missing the bigger goal of transference across settings.
Goals should be clear, but with flexibility. Goals should be clearly defined and therapy should be geared to it. That said, intervention should also be fluid enough to integrate the needs of a child “within the moment”. For example, if a child comes in with a cut and is preoccupied with it, it may be a great opportunity to talk about “what happened”, personal pronouns (“my” knee) or “ouch”. It may not have been on the plan for the day, but a good clinician should be able to capitalize on events and situations that present themselves.
Data collection is not the point of therapy. While data tracking for pre-post measurement is important, it would concern me if a clinician’s focus during a session was on data collection and not interaction, spontaneous learning and cueing. Good therapy requires using strategies to help the child “get” to the right response. Holding back these strategies in order to get a data count for the session is not productive and unnecessarily frustrating for the child. Think about how frustrating it would be to only be successful 2 out of 10 responses with no change in approach or help, and what a waste of precious time—the SLPs job is to the child learn the skills not count and hope the child figures it out.
Progress should be observable in the real world. The goal of therapy should not be to do better on a standardized test or be successful with a discrete, isolated task. The goal is to communicate, speak and comprehend better, as well as interact and play. Many—if not most– of these skills cannot be measured on a standardized test. “Teaching to the test” is never a good idea, especially with children on the autism spectrum disorders.
What if my child is completely resistant to therapy?
In these situations, there are many variables to consider. Is the therapy style a good fit? Some children, especially toddlers, are not ready for structured, adult-directed sessions and do better with a Floortime, child-led approach. Some really need a strong ABA approach for a period of time before having success with more traditional “speech therapy”. Another option is an occupational therapy/speech therapy co-treatment. This is often a good fit for the child who needs “room to move” and is not ready for a structured speech therapy setting.
If you are willing and are not squeamish about having your child fuss, sometimes there is an initial “warming up” period that can include acting out, resistance, and even screaming. The speech pathologist, setting and activities are all new and for many children with ASD, this alone can be a huge hurdle. You may need to leave the room so your child can properly bond with the SLP and avoid running to you for cover. With time and patience, many children work through their initial resistance over 4-6 weeks and settle in to a happy routine. But if there is little productive work going on at that point, it’s time to rethink the therapy approach and/or therapist for your child—at least for the time being and consider other models of service delivery.
Patti Hamaguchi, M.A., CCC-SLP is a licensed speech-language pathologist and the Director at Hamaguchi & Associates Pediatric Speech-Language Pathologists Inc., (Cupertino) and the CEO of Hamaguchi Apps for Speech, Language & Auditory Development. She is the author of Childhood Speech, Language & Listening Problems: What Every Parent Should Know, A Metacognitive Program for Treating Auditory Processing Problems and It’s Time to Listen as well as an expert on speech topics for BabyCenter.com. Currently, she and her colleague, Dr. Deborah Swain (Swain Center in Santa Rosa), are working with a major publisher to develop a standardized language assessment for children on the autism spectrum.
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