In honor of Autism Awareness Month, let’s talk about ways to modify apraxia therapy to be neuroaffirming and best support autistic children who have difficulties motor planning and programming speech.
Co-Occurrence
The reported rates of co-occurrence of childhood apraxia of speech (CAS) and autism vary widely, from 10% to 65% (Chenausky et al, 2023; Dawson, 2010; Tierney et al, 2015; Shriberg et al, 2011). Part of that is likely due to differences in diagnostic criteria used for both autism and CAS. Moreover, conclusively diagnose CAS, children must demonstrate multiple characteristics of CAS across speech tasks. Many autistic children who are non-verbal or minimally verbal are not able to complete the assessment tasks to diagnose CAS. It has been suggested that the reason some of these children are non- or minimally speaking is because they have significant difficulties with motor planning and programming(CAS) or other motor speech challenges. It has also been suggested that there is a sub phenotype of autism in which individuals have a motor speech disorder, similar to speech motor delay or CAS (Chenausky et al, 2023).
The bottom-line is that there is a group of autistic children who experience challenges with motor speech and may benefit from specialized motor speech intervention and support to develop speech.
The Problem
Evidence-based methodologies for CAS, such as Dynamic Temporal and Tactile Cueing (DTTC) and ReST (Rapid Syllable Transition Treatment) are based on the principles of motor learning and are typically drill-based. These treatment methods were developed through research that was based on children with CAS and few comorbidities; children with autism were excluded from the studies that developed these treatment methods. Thus, we don’t have research evidence to know if these methods are effective for autistic children with CAS. Moore et al (2024) note several challenges with motor speech therapy for autistic individuals:
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Eye contact and gaze to a person’s face may be dysregulating
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Repetitive drill-based and compliance-based
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Tactile cueing may be dysregulating
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Pre-set speech targets might not be meaningful or functional
In addition, Beiting (2022) notes that the heavily reliance on drill-based practice, verbal instruction and direct imitation of speech may be challenging for many autistic children.
Start with Regulation, Connection and Engagement
Regulation, connection and engagement are foundational for all therapy, including motor speech therapy. For autistic children, more time and/or effort may be needed to help the child obtain their best emotional and sensory regulation. Consulting with the child’s family and other professionals on the team, especially the occupational therapist (OT), can be extremely helpful to know how to best support the child’s regulation.
Building connection with a communication partner who respects their autonomy is also essential. Using trauma-informed practices that prioritize safety, bodily autonomy and boundaries (Center for Substance Abuse Treatment, 2014) helps the child to trust the therapist and maximize opportunities for engagement and growth in communication.
Move Away from the Table
In my experience, focusing on table-top activities does not promote regulation, connection and engagement for many autistic children. Of course, I suggest following the child’s lead, so if the child you are supporting is engaged in a table-top activity, by all means go with it. But generally speaking, I find that I can best support the child’s regulation, connection and engagement by following their lead for interests and activities. This often means moving around the space(s) available to us, including going outside, and engaging in a number of activities during the session, especially activities that incorporate sensory experiences and movement.
Focus on Successful Communication
I want communication to be a positive experience, which means it needs to be successful. For children who are experiencing motor speech challenges, this often means that I am introducing forms of augmentative and alternative communication (AAC) and using total communication and/or aided language stimulation so that a variety of forms of communication are available and accessible. Acknowledging a child’s communication, in whatever form, is incredibly important for regulation, connection and engagement. In my experience, the more successful communicative exchanges a child has with me, the more motivated they are to continue to engage. My goal is to provide a robust communication system that works for that child and their family. Plus, we know that AAC use does not hinder speech and for many autistic children, helps improve it (Yuan et al, 2024).
While I also want to work on improving a child’s speech, I am very careful with providing correction or feedback on speech accuracy to children who have just started attempting speech. I have found it more beneficial to acknowledge the communication and encourage it, then wait to refine the speech accuracy as the child becomes a more consistent and confident communicator.
Accept Approximations, especially for Phrases
In motor speech therapy, we are always cautious about negative practice, in which a child practices a speech target incorrectly and thus learns an inaccurate motor plan. For children with CAS, it can be more difficult to re-learn a motor plan for a word or phrase than to learn a new motor plan. If a child is not able to produce a speech target correctly, we provide more multisensory cueing so that they have accurate practice or we may re-consider that target choice if accuracy is not attained. I have found this approach to be a bit more challenging for autistic children, as in my experience, many autistic children appear to be attempting more phrases or Gestalts, especially early in their communication journey. Thus, there can be a significant mismatch between what their motor speech system is able to do with accuracy and the language forms that seem to make sense and/or be motivating to them. I take into consideration the phrases and/or Gestalts that a child is attempting and make those available with AAC but I will also include some of those in the child’s motor speech practice, with the plan of moving through successive approximations. This means I will accept and practice the child’s best approximation at that time, and then over time continue to support more accurate productions. I have found this to be more helpful than an all-or-nothing, right-or-wrong approach for keeping communication successful.
Practice Speech in Context
I have found to optimize motivation to communicate, as well as generalization, it works best to practice speech targets in context. For children that may be learning language in different ways and/or have differences in their social-pragmatic skills and interaction styles, generalization from drill-based, de-contextualized speech and language can be particularly challenging. This may mean that I obtain fewer productions/trials than a neurotypical child may do in a drill-based approach. However, for autistic children I think quality over quantity is the way to do go, and I have found the child is willing to try more and engage more when we practice in context with preferred activities or activities that make sense to them.
Reduce Instructions
I try to be sensitive and cognizant of a child’s sensory needs and language levels and not overwhelm them. For this reason, I often reduce or simplify my instructions for the child. I find that using visuals, such as gestures, can be effective. I often use hand cues for sounds (such as the hand cues that go with the Bjorem Speech Sound cues) and/or sign language associated with words to help cue children, rather than providing as much placement instruction.
Alter Cueing
Along the same lines, I alter visual and tactile cueing to meet the sensory needs of the children I am supporting. Some children are not comfortable being touched, and I respect their autonomy and refrain from tactile cueing. I also seek the child’s assent before providing touch cueing. If the child appears apprehensive or moves themselves away during tactile cueing, I respect that and will use other cueing methods that are more comfortable for the child. Sometimes a child is comfortable with tactile cueing, but I need to change the amount of pressure, to either more or less pressure, depending on the child’s sensory needs (Moore et al, 2024).
Many autistic children find eye contact dysregulating, and even gazing toward another person’s face can be uncomfortable. Typically during apraxia therapy I encourage children to watch my mouth, but for children that find this dysregulating, I will wear sunglasses, cover my eyes, look away from them, position myself next to them so that we are not face-to-face and/or use a screen in selfie-mode so that they can see my mouth for cues without eye contact.
Provide an Exact Model
I model exactly what is appropriate for the child to say, so that they can imitate what I say and it will be accurate. For example, I will model pronouns from their perspective (e.g. “I wanna do it”). I also use a lot of collaborative language, such as “let’s do it” that the child can imitate directly and that is functional in a variety of situations. I also avoid providing an instruction such as “say” as many autistic children will imitate that exactly and will then say “Say let’s do it.” Also, if a child has a PDA (persistent demand for autonomy or pathological demand avoidance) profile, then they will sometimes perceive this as a demand, whereas I have found more collaborative language is not typically perceived that way.
Use More Cloze Phrases
Another way that I have found I can elicit more productions is by using familiar books, songs or phrases and Gestalts as a cloze phrase for the child’s speech targets. This way, I avoid placing a demand on the child and the speech is practiced in a meaningful context to the child. In my experience, it is often also easy to build in a lot of repetition and trials, if we are practicing speech targets that are within these familiar contexts and routines that the child enjoys.
Decrease Feedback
Along the lines of reducing instructions and altering tactile cueing, I have found that providing less verbal feedback is also beneficial. By reducing verbal feedback, I hope to avoid overwhelming the child from a sensory or motor perspective. I have also worked with some children who will shutdown and stop trying if given feedback that their attempt was not accurate. In some cases, I have found that sound effects or a visual are a better way to provide feedback on accuracy.
Summary
Autistic children who experience challenges with speech often benefit from the implementation of AAC, as well as motor-based speech therapy. However, I suggest modifying motor speech therapy to be more neuroaffirming, so that the child feels safe and is regulated and engaged.
References
Beiting M. (2022). Diagnosis and Treatment of Childhood Apraxia of Speech Among Children With Autism: Narrative Review and Clinical Recommendations. Language, speech, and hearing services in schools, 53(4), 947–968. https://doi.org/10.1044/2022_LSHSS-21-00162
Center for Substance Abuse Treatment (US). Trauma-Informed Care in Behavioral Health Services. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2014. (Treatment Improvement Protocol (TIP) Series, No. 57.) Chapter 1, Trauma-Informed Care: A Sociocultural Perspective. Available from: https://www.ncbi.nlm.nih.gov/books/NBK207195/
Chenausky, K., Brignell, A., Morgan, A., & Tager-Flusberg, H. (2019). Motor speech impairment predicts expressive language in minimally verbal, but not low verbal, individuals with autism spectrum disorder. Autism & developmental language impairments, 4, 10.1177/2396941519856333. https://doi.org/10.1177/2396941519856333
Dawson EJ (2010). Current assessment and treatment practices for children with autism and suspected childhood apraxia of speech: A survey of speech-language pathologists. Doctoral Thesis, Portland State University, Portland, Oregon.
Moore J, Boyle J, Namasivayam AK (2024). Neurodiversity-Affirming Motor speech Intervention for Autistic Individuals with Co-Existing Childhood Apraxia of Speech: A Tutorial. Int J Autism & Relat Disabil 7: 168. DOI: 10.29011/2642-3227.100068
Shriberg LD, Paul R, Black LM, van Santen JP. (2011). The hypothesis of apraxia of speech in children with autism spectrum disorder. J Autism Dev Disord. (4):405-26. doi: 10.1007/s10803-010-1117-5. PMID: 20972615; PMCID: PMC3033475.
Tierney C, Mayes S, Lohs SR, Black A, Gisin E, Veglia M. How Valid Is the Checklist for Autism Spectrum Disorder When a Child Has Apraxia of Speech? J Dev Behav Pediatr. 2015 Oct;36(8):569-74. doi: 10.1097/DBP.0000000000000189. PMID: 26114615.
Yuan W, Dunn M, Kennedy J, Hsiao YJ. (2024). Impact of Speech Generating Device Interventions on Vocalizations of Individuals with autism and severe communication impairment: a systematic review of the research. Education and Training in Autism and Developmental Disabilities, v59, n3, p 233-256
