By Patti Hamaguchi, MA, CCC-SLP
Q. My child has pronunciation difficulties as well as a speech delay. He’s four and is sometimes hard to understand. When should speech therapy work on that? What are some of the challenges associated with articulation problems with children on the autism spectrum?
A. When a child has a speech delay, we will actually expect to see developmental articulation patterns persist a bit later than usual. Why? Children who start talking later are often delayed across many areas, and that would also include articulation development. Also, articulation requires practice, and the less a child talks, the less practice they get to develop clear speech. For children on the autism spectrum, there is an added challenge – the natural process of articulation improvement relies on the child wanting to be understood. Children with autism often are not attending to the facial expressions of their peer (Huh? What did you say?) to get the necessary feedback about their productions to inspire them to fix up their speech errors. They also can struggle with transferring new skills across settings so sometimes they are successful learning the pronunciation of new words in one context, but don’t use that pronunciation in another.
So what to do? The speech pathologist will likely target words that are used often, such as family member names, labels for favorite foods and toys, etc. The goal will be on production across settings and improving the child’s attention to his or her own productions. Articulation errors are often a secondary focus of therapy because of the pressing need to work on receptive/expressive language and social interaction and play. Weaving the articulation piece into these activities is often a good way to target pronunciation issues. For example, when introducing a new word or concept (behind/she/jumped) the speech pathologist may want to make sure that the pronunciation is as clear as possible right from the start for this new concept so it isn’t habituated incorrectly. That said, if the child is not ready to pronounce a certain sound or word, it may be very appropriate to let it go, and accept whatever approximation possible until the child is further along in their development. If there are oral-motor weaknesses (such as drooling, tongue protrusion, etc.) it may also be helpful to incorporate some oral-motor and/or feeding goals, which can help provide a stronger foundation for speech clarity.
Q. My child is still non-verbal. When can I expect him to say his first words? And how can we get him there faster?
A. Unfortunately, it is not always easy to predict when a child will begin talking. Some of the behaviors that generally precipitate talking include a willingness to imitate sounds, frequent babbling/jargoning, trying to get the attention of those around him, the use of signs or gestures to communicate, making specific sounds that animals make (“rrrr!”) knowledge and understanding of basic object words, and a growing frustration when those around him cannot understand what he wants– a desire and need to communicate! Therefore, these are often the skills we target in therapy when we are trying to move towards those “first words”. The specific words are often just a syllable (“dah”, “muh”) but the difference being that it is directly linked to something concrete and used consistently—usually a person, favorite toy, or something functional (“eat”) along with a purpose to use it, such as asking for it or showing it to you. It is always a very exciting time when a child makes the leap to functional speech!
For children on the autism spectrum, we sometimes need to introduce external rewards to get to that place because the process doesn’t always come naturally. An experienced speech pathologist who can connect with your child can help make that happen, but sometimes the pace is slower than we all hope for. Remember that communication of any kind is worth celebrating, even if it isn’t specifically speech, although we all are doing our best to make that happen.
Q.We speak more than one language at home. Should we try to speak only one language for our child’s sake? He is severely speech-delayed.
A. This is a question I am often asked. Certainly we know that raising a child in a bilingual house does not cause a child to be speech-delayed. For many of our families in the Bay Area, having more than one language spoken in the home is the norm. Your child will benefit from interacting with other family members here or during visits overseas in the “family language”. Sometimes that may mean understanding some basic phrases or knowing the names of familiar native foods. For other children, it may be in the form of conversation and more advanced language development. Ways to support bilingual learning include playing music CDs, showing videos in the native tongue, and socializing with friends and family who speak the language. This helps the child hear the intonation, rhythm and sounds of the language.
That said, the language of the speech pathologist and ABA/Behavior team/classroom is likely English if they are in the Bay Area. Since your child is making slow progress, it will be critical to provide more exposure to this language because your child needs to have the repetitions to hear and use the language in order for it to “sink in”. Keeping the two languages separate is key so the child can learn the conventions of both and not get confused. I often suggest speaking English during the school week (Monday-Friday) and native tongue on the weekend, when speaking directly to your child.
However, if a parent or caregiver is not fluent in English, he/she should speak to the child in the language in which they are most comfortable regardless. Having the child exposed to the native language by overhearing your adult conversations keeps the language alive. As your child progresses in English, targeting the same concepts in your native tongue is helpful. For example, if you are working on the concept of “drinking”, practice the English word during the workweek, but also demonstrate/speak it in your native tongue on the weekend to make the connections clear. In some cases, the child may persist in speaking English, but will at least understand your native tongue and pick it up easier later when his language is more developed and he can learn a second language more explicitly.
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My child has problems with the pitch and tone of her voice. It sounds monotone. Is there anything that can be done to help that?
We often find that children on the autism spectrum have a “different” sounding cadence or pitch when speaking. The clinical term is “prosody”, that is the rising and falling our voice does, the flow, and melodic contours. Interestingly, we know that many of these same children have difficulty interpreting these very same elements in the voices of others, which makes interpreting sarcasm, emotion, and meaning challenging. (“You went WHERE? In an angry voice vs. “You went where?” Such as in “I can’t hear you.”)
Sometimes the child will sound monotonic and sometimes the voice is more sing-songy than a typical child or choppy. These difficulties can be extremely challenging to change, and many times it is best to incorporate work on them as the child learns. For example, if the speech pathologist is working on asking a question to a peer such as, “Where should I stand?” we will want to incorporate work on pitch at the same time we work on sentence structure, articulation and gaining someone’s attention.
Using visual supports to provide feedback—to show the voice rising and falling—is helpful, but often a challenge. Sometimes software programs that address pitch and sustaining voice can be used, as well as some apps. Frequently, this is an area that is addressed for children who have more advanced language skills and are very high-functioning.
Some people also report that using therapeutic listening programs or programs such as Fast ForWord also train the ear to hear pitch and indirectly provide some improvement in this area, but research is sparse on their effectiveness in this area.
Why is it so difficult for my child to talk about what happened at school, on our vacation or why he’s upset? He’s got verbal skills but having conversations about things that are not in front of him is a challenge. Is there anything we can do to work on that?
What you are observing is a common issue for children who struggle with language. In particular, they can look at something and ask for it or sometimes say something about it, but once it’s gone, it becomes much more difficult to do. Why is that? For one thing, most children on the autism spectrum have difficulty staying focused, and their visual sense (letters, puzzles) is often more developed than their auditory sense (listening, comprehending what people say). When trying to have a conversation with you and react to your questions, your child has to tune out all of the visual input he sees (posters, a fly on the wall, his shoelaces, his hands) and focus on something—words—that are invisible. Without something to “see”, talking about it becomes more demanding.
So start small. Use toys or things in sight and talk about them. Cover them up with a towel or something and try to repeat it. Set a timer and let your child know you’ll be talking about it again in 5 minutes (or 1 minute, if you need to start here). Over time, try to stretch out the time between the visual exposure and the conversation about it. When you go out and about to stores, doctor’s visits, etc., take a quick snapshot on your cellphone. When you get home, try to elicit language without looking at the pictures, but pull them out if needed. (“What did we eat at the yogurt place? I had strawberry frozen yogurt. What did you have?”) Provide the first sound if needed to help with word retrieval (“You had some chooo…?”) and if that doesn’t help, pull out the picture, and then repeat the conversation a short time later.
The IEP season is quickly approaching and I know my daughter is going to do poorly on the speech tests. It’s a stressful process for her and I don’t think it really captures all of her strengths and weaknesses. Should we decline to have her tested?
In a word, no. Schools and private practices, hospitals, etc. are required to show progress—that the therapy is in fact working—as part of the therapeutic process. The difficulty with children on the autism spectrum is that their performance is so variable. It really depends on what moment in time you do it, what mood they’re in, and who is doing the testing.
A good clinician knows that formal assessment is only a small piece of the assessment plan for children on the autism spectrum. Much of the important information will be gained from interviewing the parents and teachers, watching the child in a number of settings—especially with peers, and engaging in play and conversation.
When you find that formal testing and school observations don’t match your own impressions of your child, it can be helpful to bring a video of your child, talking and interacting with you or family members, so the professional staff can see the difference in how your child functions across environments. Formal tests do give us a quick snapshot of how your child performs the exact same tasks from year to year but it should not be the only measure of your child’s progress.
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 (Wily & Sons, 2010 3rd ed.), A Metacognitive Program for Treating Auditory Processing Problems (Pro-Ed, 2003) and It’s Time to Listen (Pro-Ed, 2002) as well as an expert on speech topics for BabyCenter.com.
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