Lesson 9 Increasing Vocalizations


 Many children with Autism are unable to speak.  However, Autism is not the “cause” of this inability.  If this were true, all children with Autism would not be able to speak.   Autism is diagnostic label based on a cluster of presenting behaviors, one of which is difficulty with communication.  The nature of this difficulty varies among children. Children with difficulty speaking should have consistent sessions with a speech/language pathologist in addition to their behavioral program.

Apraxia of Speech

 It has been suggested that many children with Autism have difficulty combining movements or exhibit “motor planning disorders”.  Again, this is a diagnostic label that is used to describe difficulty producing a series of purposeful movements in a specific order.  There is typically not a weakness in the muscles or other sensory motor impairment that is causing the child to have difficulty performing the movements.  Some suggest that this term is overused to describe the difficulty with speech many children with Autism demonstrate.  As suggested earlier, there are many different types of speech difficulties in the general population that can also be found in children with Autism.


As stated earlier, it is not possible to diagnose Apraxia before a child begins speaking.  We can, however, infer that this might be the problem if the child has difficulty purposefully performing other motor movements.  Not all children who later fit into the diagnostic criteria for Apraxia of Speech have the same difficulty in other parts of their body so this isn’t always the case.  When looking at the history of children later diagnosed with Apraxia, we often see limits in the number or variety of sounds produced during vocal play.  Again, this can be an early indicator but is not enough evidence to support a diagnosis of Apraxia in a non-vocal child because other conditions may also result in the same presenting behaviors.


A speech pathologist may diagnose Apraxia if, when the child begins speaking, they often produce inconsistent errors, exhibit vowel distortions, demonstrate “groping” or struggle behaviors, and/or show an increased difficulty in producing speech in longer, more complex utterances. 


Different Terms

Oral Apraxia, Apraxia/Dyspraxia of Speech, Verbal Apraxia/Dyspraxia, are terms used to diagnose this difficulty when it pertains to speech.  Whenever an “a” is attached to a medical term, it typically means “without” and whenever the term “dys” means “partial loss or disorderd”.  So, the term “Apraxia” should be used to describe an inability to produce purposeful movement and “Dyspraxia” should be used to describe a difficulty producing purposeful movements.  Still, most professionals continue to use these terms interchangeably.  It is most common in the professional literature to see “Dyspraxia” used by occupational therapists when describing the condition in the limbs and “Apraxia” used by speech/language pathologists (SLPs) to describe the condition as related to speech production.


Oral Apraxia is often used to describe the condition when it is exhibited in movements of the oral musculature (lips, tongue, velum) with and without speech combined with the movements.  For example, they may have difficulty imitating sticking out their tongue and rounding their lips.  Some children exhibit characteristics of Apraxia when they are attempting to speak but not when they are just imitating movements without speech.  These children are often described as exhibiting “Apraxia of Speech”. 


Once children previously diagnosed with Apraxia begin communicating, it is often common in some to see difficulties with other aspects of language that require sequencing such as combining words into sentences or sentences or describing the sequence of events in an activity.  Some professionals use the term “Verbal Apraxia” to describe this difficulty.


Again, many professionals use these terms interchangeably or for different purposes than described here, so it is often best to directly ask the professional involved exactly what they are referring to when a specific term is used.

Use Chaining

It is important to remember that children can communicate (exhibit verbal behavior) with vocal productions, gestures, signs or pictures and all of these different types of verbal behavior require some series of movements.  The number of motor movements and complexity of the motor movements required vary with each type.  Movements are behaviors also and we can teach them as such.  If we wanted to teach the child to perform a series of motor movements with their arms, hands, fingers etc.  we’d determine a “starting point” or a movement the child can currently produce or can be easily taught.  We would then use either backward chaining or forward chaining to teach each of the movements required.  We’d provide whatever prompting, (imitation/modeling, physical prompts, verbal prompts, visual prompts etc.) necessary to insure the child was able to produce each of the movements in the sequence.  Once the child learned to produce each of the movements, we’d provide multiple opportunities for the child to practice the movements in correct sequence while fading any prompts needed for accurate production.


 For example, if we wanted to teach a child to swim, each of the movements involved would be taught. We’d either start and the beginning of the series of movements, teaching one, then the next in combination with the first, etc. (forward chaining) or, we’d start at the end of the series of movements, moving backward to teach each in combination with the other (backward chaining).


The same principles apply to teaching the child to produce a series of movements with their mouths.  Spoken words vary in the number and complexity of movements required to produce them.  We would not teach a child to swim by modeling the complete “stroke” (one arm forward with the other arm back and head turned then head in the water while the other arm moves forward etc.) then ask them to imitate it. And, if the child produced the sequence incorrectly, we would not show him the stroke again and again ask him to imitate it.  Why not?  Because, the child would never learn to swim!  Each time he would most likely produce the sequence of movements incorrectly.  Sometimes they would be out of order and sometimes one of the necessary movements might be missing.  Sometimes he may even add a movement that should not be included. 


 In essence, this is what we’d be doing when asking a child with behaviors consistent with a diagnosis of Apraxia to imitate a complete word if he were not able to produce the movements required to produce the sounds in the correct sequence necessary to say the word.


Pair Sounds or Single Words with Augmentative System

  It is important to pair words with reinforcement with whatever augmentative system you are using with your child.  For example, if using PECS, say the name of the item the child is asking for (reinforcer) both before giving the item, and after the child receives the item to “pair” the word with the reinforcer and to provide opportunities for automatic reinforcement.  The author advises that single words be used for all early learners rather than phrases.  For example, rather than saying, “Oh, you want a cookie?  OK, Here’s a cookie for you.” when a child requests (mands) for a cookie by signing, the adult should just say “cookie” before giving the cookie and again after the child gets the cookie.  We want hearing “cookie” (vocal stimuli) to be paired with the cookie (reinforcer).

Pair Sounds with Reinforcement

       Research indicates that a child is more likely to produce sounds/words that are presented immediately prior to delivery of a reinforcer.  Automatic reinforcement occurs and it is not unusual to hear the child begin to produce the sound after many pairings have occurred.  While this vocal behavior is not yet under instructional control, it gives us a behavior to reinforce.


      Anytime the child makes any sound, follow it immediately with one of the child’s strongest reinforcers.  Begin pairing sounds and words with the child’s favorite toys or activities.  For example, if the child likes to play with a ball, saying “b,b,b,” while bouncing the ball and before giving the ball.  If the child enjoys music, sing to him or play songs containing some isolated sounds like “Old McDonald” or the “Alphabet Song” on the Sounds Like Fun tape by Discovery Toys.  Begin leaving off the last sound in the phrase to encourage the child to produce the sound. 


Some children also enjoy playing with toys that produce sounds and will begin to spontaneously produce the sounds they hear.  For these children, toys that produce sounds may be helpful.  Be sure to choose toys that produce the isolated sounds correctly and be sure you are using the correct production of the isolated sounds when pairing.  For example the sounds for the letters “p, t, k, c, sh, f, h, s” should all be produced with no voicing (quiet/whispered) and no vowel sounds connected to them.  The sounds “m,n,z” do have voicing but should be produced in a continuious manner rather than combined with a vowel.  Your speech/language pathologist can help you learn to produce the sounds correctly so that you can model them correctly for your child.


The goal here is to increase the number and variety of sounds produced so we have a behavior to reinforce!

Imitate Sounds the Child Produces

Begin imitating the sounds the child is making during play.  If the child produces the same sound after you, reinforce heavily.  After the child is consistently imitating back and forth, add in “say” as part of your SD.


Child: mmm

Instructor: say “mmm”

Child: mmm (child is more likely to produce the same behavior under a different condition)


Another way this could be accomplished is by building “behavioral momentum”.  In other words, get a few imitation responses that the child has mastered then add in the target sound.  It is more likely that a child will produce a “difficult” behavior if it is preceded by some “easy” tasks.


Ex: Inst:  Do this. (touches head) R= child touches head

Inst: Do this. (touches mouth) R= child touches mouth

Inst: Do this “e”  R= child says “e”.  (This would later be transferred so the child is responding to “say “e” rather than responding to “Do this.”)

Prompt with Hand Movements and/or PROMPT

 Some children respond well to the use of visual or tactile prompting.  For example, the ­Easy Does It for Apraxia program from LinguSystems has finger cues that can be paired with isolated sounds to be used for prompting.  The “Prompt” program consists of tactile prompting strategies to be used systematically to teach children to produce specific sounds.  Or, less “formal” visual or tactile prompts can be used.  A prompt is a teaching behavior used to increase the likelihood that the child will respond correctly.  As with any other prompts used when teaching, these prompts must be faded so that the child can respond correctly without them.  A response isn’t considered “mastered” until it is produced with no prompting on a consistent basis.

If the child tolerates touch, trained instructors can use PROMPT which consist of tactile prompting strategies that increase the liklhood that the child can produce specific sounds.


Reinforce All Vocal Attempts

When children are first beginning to speak, we want to reinforce any and all vocal productions, so you would reinforce the attempt. (give the child the cookie =reinforcer, paired with social approval).  Just continue to say “cookie” before and after giving the child the cookie and give the child a bigger piece of the cookie (differential reinforcement) whenever the child said a sound in combination with the sign. 


Begin Shaping in Word Shells

Once vocalizations were consistent with the mand, begin teaching the child to produce the “k” sound in context of manding for the cookie. Wait until a vocal combined with the sign is a strong response to avoid the inadvertent extinction of the vocal.  Still, be sure the child hears “cookie” before receiving the reinforcer.


Ex: Child: (signs cookie) and says “u” (consistently)

Inst: “k”

Child: “k”

Inst:  says “cookie” and gives the child the cookie


Once the child is able to imitate the “K” sound consistently, combine it with the “u” that he already uses in combination with the sign mand for “cookie”.


Ex: Child signs cookie and says “u”

Inst: Say “Ku”

Child: “Ku”

Instructor:  says cookie and gives the child the cookie.

Next, begin teaching the child to say “ke” in the same manner as described above.  Once the child is able to produce both syllables consistently, combine them.


If, on the other hand, the child is consistently saying “e” combined with manding for the cookie, it might be more appropriate to teach the child to say “cookie” through a backward chaining procedure.  In this case, one could teach “ke”, then, “ku”, then the combined syllables. 


Children vary in the ease in which they to learn to produce sounds in different parts of words.  For example, one child might be able to produce the “K” sound but only at the end of a syllable.  In this case, one might teach the child to produce “uk”, then, “uke” then “cookie”.  The order and prompting/chaining procedures chosen should be dependent on the response or learning history of each individual child and is best determined by the child’s SLP.  The important thing is to keep the child successful by not asking him to produce sounds in a sequence that he is unable to produce in isolation and to gradually build the child’s ability to produce the movements in the correct sequence.


Provide Multiple Opportunities for Practice

Once a sequence is taught, multiple repetitions are often required before the response is fluent.  This can be achieved by giving the child small pieces of the cookie allowing multiple opportunities to “practice” or by playing with toy cookies where the child might be requesting (manding) that cookies be fed to his favorite toy characters.


Avoid Reinforcing Incorrect Productions

It is important that the child not “practice” producing the movements incorrectly.   It is not uncommon, even after a child with Apraxia has been heavily reinforced for saying “cookie” correctly, that he will not be able to produce the word correctly every time.  This is sometimes referred to as having the sequence of motor movements under “volitional control”.  Remember that one of the defining “features” of Apraxia is that it is related to difficulty with “purposeful” movement. (under volitional control)  If a person can produce a movement anytime they want to, that movement can be said to be “purposeful” or under “volitional control”.

Move Back to a Successful Production

Instead, it is recommended that the word be “broken down” to whatever level the child is able to produce correctly. 

Ex: Child says “toge” while reaching for the cookie

Instructor: say “ku”

Child: Ku (child said the syllable correctly so there is no need to go to isolation)

Inst: say “kuke”

Child: “kuku” (child was unable to imitate both syllables)

Inst: Say “key”

Child: key

Inst:  Say “ku   Ke” (slight separation between the syllables)

Child:  “Ku  ke”

Instructor says cookie and gives child cookie

Keep the Child Successful

The strength of the EO and the learning history of the child are important considerations in determining how many trials you should attempt before reinforcement.  It is important to keep the child successful.  If at anytime, the child demonstrates a decrease in manding or reverts back to behaviors previously used to get desired items (tantrums etc.), it is likely that the demands are too high and the teaching should be adjusted accordingly.


It is highly recommended that the sign or PECS continue to be reinforced even after the child begins to use vocal requests (mands).  It may take quite awhile for everyone in the child’s life to understand his vocal requests and we want to be sure the child continues to have a way to communicate when he’s not understood by others.

Determine Best Possible Production

There are many words that require so many complex movements that it might be a long time before the child is able to produce them correctly. Instead, teams can and should decide on which approximations will be accepted.  Your SLP will be able to help you determine appropriate target approximations for your individual child but the following includes a few general guidelines to consider:

Factors to Consider

  1. Vowels carry the most meaning and greatly affect intelligibility to begin shaping vocal productions with vowels.
  2. It is easier to add movements to a sequence than it is to remove them.  So, avoid reinforcing any approximations where sounds are added.  For example, if a child were unable to say “green” but could say, “gee” this would be a better target approximation than “guwee”.
  3. Sounds produced in the same location (place) increase intelligibility so choose target approximations with sounds produced in the same place whenever possible.  For example, if a child were unable to say “popcorn” but could say “bobun”, this would be a better target approximation than “cocun”.
  4. Avoid stressing final consonants too early.  When final consonants are stressed in speech, it is typical to add a bit of a vowel sound or “schwa” to the end of the word. This often results in children adding entire syllables to the ends of words that further reduces intelligibility.  It is preferable to continue with open syllables (no ending sounds) or build syllables in consonant vowel (CV) patterns before working on ending sounds.  For example, if a child were able to say “do” for “dog”, the open syllable would be easier to understand than “dogu” resulting from an overemphasis on the final sound.  Teaching “doggie” next to teach a new sequence of movements containing the target sound would be preferable to trying to teach the CVC pattern resulting in “dogu”. The author typically begins teaching the child to produce the vowel + consonant (VC) pattern after the child is able to imitate voiceless consonants in isolation to avoid this tendency to add the “schwa” sound.  For example, some of the first VC patterns taught might include “eat”, “out”, and “up”.  The first consonant + vowel + consonant patterns typically taught include words where continuant sounds are at the end such as “mom” or “bus” to reduce the tendency to add a “schwa” or vowel sound at the end.
  5. If the child is unable to produce “l,r,w” sounds, vowels can be substituted with little effect on intelligibility.  For example, if the child is unable to produce ending “l” sounds, “buboo” (oo as in boot) would be an acceptable target approximation.
  6. Duplicated syllables (repeating the same syllable twice) are easier to produce than two different syllables.  So, if the child were unable to say “cookie”, “kuku” would be an acceptable target approximation.
  7. Producing voiceless consonant sounds and moving to a vowel sound adds complexity to a movement to the sequence. Therefore, saying “bye” is an easier response than saying “pie”.  In order to say “pie”, the child must have his voice off, put his lips together, release air, then turn his voice back on for the vowel sound.  In order to say “bye”, the step requiring the voice onset at the correct time is removed since the voice is on from the beginning.  All other movements are the same.  Therefore, it is typically easier to produce words containing voiced sounds than voiceless.  “dop” would be an acceptable approximation for “top” since the only error is in voicing.
  8. Moving from nasal sounds (m,n,ng) to oral sounds (all other sounds) requires an additional movement of the soft palate (flap on the back of your mouth) to direct the air from the nose to the mouth.  Therefore, saying, “mama” requires more movements than saying “dada” and is therefore a more difficult response for a child with Apraxia. (That explains it!!) While this is helpful information to have when determining the difficultly of targets selected, it is not recommended that target approximations be chosen that consistently result in oral productions of nasal sounds because intelligibility is compromised too greatly.  For example, it would not be recommended that “baba” be taught instead of “mama” even though the only difference is in the nasal vs. oral air flow. 
  9. It is typically more difficult to produce movements that go from the front of the mouth to the back of the mouth such as required to produce “kite” or “dog”.  So, these types of words should be avoided as early targets.

10.  Some vowels require more than one movement to be produced (dipthongs).  Most “long vowels” “a, “i”, “o” “u” as well as “ou” as in “house”, and vocalic “r” sounds require more than one movement and these movements have no “contact” point where one part of the mouth touches another.  As a result, these sounds are typically much harder to teach than short vowels or consonants that do have a “contact point”.  This should be considered when choosing targets.

  1. When teaching children to say words, keep in mind that we don’t often produce words phonetically as they are spelled.  For example, the word “bottle” is typically produced with a “d” sound rather than a “t” sound in the middle and there is very little movement between the “d” and the “l” resulting in what sometimes is referred to as a “dark L”.  If we teach the child to say “bottle” by producing a “t” sound in the middle and an “ul” sound at the end, the result would sound very unusual, giving the child a “robotic” or unnatural sounding speech.  The author has experienced children who were taught to produce words in this manner rather than taking into account the normal changes that occur to sounds as a result of co-articulation (producing sounds differently depending on other sounds in the words).  This should be avoided if at all possible.

Desensitize Mouth

As we know, children with Autism often respond differently to sensations than other people (atypical responses to environmental stimuli).  Some children are so sensitive to touch that they may find the feeling of their own tongue, teeth, lips touching each other to be aversive!  For these children, it is important to desensitize them to touch.  It will be difficult to teach him to say “mama” if he can’t stand to have his lips touch together!


Desensitization should be approached very slowly.  Applying touch to other parts of the body that may be less sensitive should be conducted first with the touch paired with established reinforcers.  For example, if a child enjoys looking at books, touch during this activity.  If he enjoys watching videos, cuddle up and touch during as you watch the video with him.


  Typically deep pressure using the palm of the hand is preferable and more easily tolerated than light touches.  Since a gloved hand will eventually be used to desensitize the mouth, a gloved hand is introduced as soon as the child is able to tolerate touch with a bare hand.  A face is drawn on the glove and he is identified as “Mr. Tickle Guy” so that he can be removed and thrown away rather than having the therapist’s own hand paired with any aversiveness the child may experience.


The cheeks and external oral musculature are desensitized first.  Once the child is able to tolerate having his cheeks and lips massaged, small swipes can be taken into the mouth.  This should be done slowly and carefully.  It is sometimes best to have parents perform the initial desensitization procedures under the guidance of an SLP since the parent is more heavily paired with reinforcement. 


Once “in” the SLP may use a wide variety of textures and flavors on different parts of the mouth as part of the desensitization procedures.  For children who will only eat certain textures of foods, chewing different textures can be added to the desensitization procedures.

Address Rate and Volume Issues

Many children with Apraxia tend to have a very rapid rate of speech that further reduces their intelligibility.  Vowels are distorted and shortened.  Once a child is able to produce many consonant sounds, vowels should be targeted.  These are often difficult to target since they have no “contact” points and instead depending on the positioning of the tongue as well as the degree of opening of the mouth.  Use of bite blocks or sticks of varying width can sometimes be helpful in prompting the correct degree of mouth opening.


For children who speak quickly, a slowed rate should be modeled.  Rate can be slowed by increasing the duration (stretching out) the vowel sounds.  Remember that when learning any new sequence of movements, we tend to produce them more slowly at the beginning.  Once the sequence of movements is mastered, we can “pick up the pace” approximating more normal rates.


Volume difficulties can be addressed through the use of imitation and/or visual prompting.  If a child has a strong echoic (imitates easily), teach him to imitate various volumes with isolated sounds and then words.  Sometime a drawn stairway or ladder used as a prompt can help.  Place a toy or token on the lower rungs or steps as you model a low volume and on a higher rung or step as you model a louder volume.  First teach the child to discriminate and produce volumes at the lowest and highest point you want to teach.  Whenever teaching a new skill, it is often helpful to begin at a level of greatest discrimination.  Then, as the child is able to imitate these, move to more subtle discriminations toward the center of the continuum.


Avoid Increasing Lenght and Complexity Too Quickly

A common characteristic of children with Apraxia is that their ability to produce mastered movement sequences is greatly reduced when the length or complexity of what they are saying increases.  The author suggests that it is more valuable to the child to be able to say shorter utterances in a manner in which people can understand him than it is to produce longer utterances.  When you do increase the length of utterance, do so in a way that will add functional value to the utterance.  For example, it would be more functional for a child to be able to request a “big cookie” when given the choice between a big and little cookie than it would for him to be able to request using “I want a cookie”.  In addition to being more functional, “big cookie” would be shorter and less complex and therefore easier for the child to produce. 


When “carrier phrases” such as “I want”, “give me” or “can I have” have been added and the child is no longer able to produce previously mastered words, it is recommended that the carrier phrases be dropped and instead there be a concentration on adding more objects/actions (reinforcers) to the list of things the child can spontaneously request and/or increasing 2 word combinations that will allow the child to specify his requests more clearly.


Articulation and Phonological Disorders

As stated earlier, children with Autism can exhibit as many different types of speech disorders as are found in the general population.  In addition, it is developmentally “appropriate” for children to have difficulty producing certain sounds depending on their age and developmental level.  Your SLP can advise you if the sounds your child is unable to produce are developmentally appropriate.  If so, just model the correct production after the child but don’t attempt to “teach” the child to produce it correctly at this point in time.  For example, “J” is one of the later developing sounds in typically developing children so if your 3 year old says “duice” instead of “juice”, just repeat “juice” after his approximation and before giving him the juice.  It is likely that this “automatic reinforcement” inherent in hearing the correct production of the word just prior to reinforcement will result in correct productions as he matures.   


Minor articulation difficulties can often be gradually changed to more accurate productions (shaped) when the child is requesting (manding).  This can be accomplished by presenting a model for the child to imitate (echoic prompt). 

Ex:  Child: mi

Inst: say “milk”

Child: milk

It is recommended that no more than 3 attempts be made to improve the production and that the best approximation be reinforced. (The child gets the milk when he says the word better)


Muscle Strength Difficulties

These are often characteristics of children with weak oral musculature.  If your SLP has determined that this is the case, he/she may suggest exercises that can be combined with therapy designed to increase the strength and mobility of the oral musculature.  Mobility and strengthening exercises can also be helpful for children who exhibit limited or little movement in their oral musculature when speaking even though the strength of the muscles appears adequate.


Oral exercises, both passive (the SLP performing the movement) and active (the child performing the movement, blowing horns, whistles etc.) have often been found to be helpful for children with speech difficulties although there is no empirical evidence proving their efficacy.  These exercises can be used as prompts to help children learn to produce specific movements but should not be the only activities involved in treatment.  For example, if a child is unable to round his lips, he may be taught to move his mouth in this manner while blowing bubbles or blowing a whistle with a rounded opening.  The movements produced should be transferred to sound productions as quickly as possible.

Work with an SLP with Experience with Autism

In general, it is important to remember that talking should be fun!  Producing speech can be very difficult for some children but it is less difficult if those working with the child understand the characteristics of their disorder and know how to prompt them effectively to “build” responses that the child can produce easily.  An SLP who is experienced in working with children with Autism is an important and necessary part of the “team”.

Tracy Vail,MS,CCC/SLP

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