225. Under the Iceberg: Why Isn't Speech Developing in Autism with Dr. Karen Chenausky
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Speaker 6: [00:00:00] Today's guest is Dr. Karen Chenausky. Dr. Chenausky is an associate professor from the MGH Institute of Health Professions in Boston. Dr. Chenausky there directs the Speech and Autism and Neurodevelopmental Disorders Lab, known as the SPAN Lab. Dr. Chenausky has also worked for numerous years specializing in treating children with autism as a speech language pathologist. Dr. Chenausky has numerous NIH grants and publications as a result of her research. She is a speech scientist, as well as a speech language pathologist.
So today, she is going to give us insight as to why it is that an estimated 30% of children with autism do not develop functional fluent speech within their lifetimes. We're gonna know better and do better. Today, we're gonna talk about how we can apply that research to Monday morning practice in closing the gap.
Thank you so much for being here, Dr. Chenausky. We are so fortunate to have [00:01:00] you.
Speaker 7: Oh, thank you for having me, Kelly. I'm really excited to talk about one of my favorite topics.
Speaker 6: The first question I'm gonna ask you are what are the differences that you're seeing for children with autism compared to their neurotypical peers that could be contributing to why they're not developing functional and fluent speech?
Speaker 7: I love the fact that you used the plural on differences, because there are several of them.
From the literature, what we know is that there are a couple of different sources, about five or so, depending on how you classify them, different areas of challenge that might inhibit, spoken language development in a particular child. There's social cognition, by which we usually mean joint attention. If you're unable to figure out what another person is focusing on, then it's gonna be hard for you to attribute what they're saying to that object. So, that could make it slower for you to learn words and learn more about the world around [00:02:00] you from that person. There is receptive language ability, which kind of has two components:
there's just the basic capacity for understanding language. But there's also potentially a speech perception challenge that some kids may have, in that if it's hard for you to tell the difference between really similar sounding words like 'ball' and 'doll'. It's gonna be hard for you to understand that those things, those sounds refer to completely different objects in the world.
And so that would interfere with word learning and language learning. There could be sensory differences in terms of something like hearing impairment, which we know makes it very difficult, to learn spoken language. There can also be motor differences, and here again, there's a variety. Fine motor and gross motor challenges can cause what we think of as developmental cascades. Basically, it sort of creates a delay that might propagate over time just because you're [00:03:00] not able to explore your world enough And also speech motor challenges might do a similar thing. If you're just not able to get literally the words out, it's gonna be hard for you to interact through spoken language with someone, and so then you just don't get much practice in language.
There's also the possibility that whatever's causing those individual motor challenges has some cause, so some common cause, and that means your brain in those areas is different. It might also make changes to the language areas of the brain. So there's a lot that could be going on with any child.
It could be more or less of one of or more of these factors for any particular individual.
Speaker 6: Wow. So you're looking at the iceberg effect. When we see a child with autism, we see a child who is minimally speaking or not speaking. And we will too often fill in the blank. Yeah. He's not speaking because he lacks joint attention or he's not [00:04:00] speaking because of motor delays. And, really oftentimes, it could be 'all of the above'.
Speaker 7: And over time, one or more of those factors might be the limiting factor at that time. If you work with kids for a really long time, you might choose to work on speech for a while. Then, as their speech gets better, you might then choose to work on language for a while, and then generalize to other social contexts, et cetera, et cetera. Kids are dynamic, and there's always a lot going on with them.
Speaker 6: You're mentioning something we don't talk about a lot in our field.
Mm-hmm. In our field, traditionally in speech language pathology, we talk about a lack of joint attention, and a lack of language development. And if we work on joint attention and language development, the child should talk, and there's nothing- Maybe. That is what- Yeah
we've learned in our graduate- Yeah ... school classes. This is our mama's therapy that we largely practice today. That's right. And it's almost taboo, or many are hesitant when you say the word speech [00:05:00] motor disorder. And, Childhood Apraxia of Speech, I get it that it's its own diagnostic criteria.
Yeah.
Speaker 7: Mm-hmm.
Speaker 6: But many times they don't fit in that criteria.
Speaker 7: Mm-hmm.
Speaker 6: And it's kind of a motor speech disorder not specified, or unspecified motor speech disorder. When do you feel comfortable saying, "This is a motor speech disorder unspecified"? What are situations where you've come across children that present with that profile?
What does that look like?
Speaker 7: I'll answer that by talking about how I diagnose childhood apraxia of speech for my research studies. So, um, as you know, there are different lists at, of criteria for diagnosing CAS. What we do is we use a list from Dr. Jenya Iuzzini-Siegel
from 2015, 'cause she gives really nice operational definitions of all the signs. We look at least one speech task per child. The kids we work with [00:06:00] are minimally speaking and minimally verbal, so we're not gonna get a conversation. Multiple syllable word repetition isn't really gonna be feasible for them.
But we can get them to do, single word, at least try to repeat single syllable words. And so we can then look at that task and see what signs of CAS we might see. And so if we find five or more, then we classify the child as meeting criteria for CAS, but we call it suspected CAS because we're not doing a full diagnostic workup in our research studies like we would if we were in the clinic.
We might also find that a child does not show five or more, signs, and so that could mean that they have subclinical CAS that's not strong enough to really meet criteria for a diagnosis, or it could mean that they have something else, like a phonological or an articulation disorder.
And then there's always gonna be a group of kids who just don't produce enough [00:07:00] speech to be able to tell, and that's the catch-22, because theoretically, you could have apraxia that's so severe that you can't even phonate on request. But how would I, as a clinician, ever diagnose that if you literally can't even produce any speech?
The short answer is we can't, so we just have to guess. And at some point, maybe it doesn't matter what the diagnostic label is. If speech is gonna be so hard for one individual that it's just not a realistic mode of communication for them, then, that, that kind of turns into a dead end, at least for the time being, and we work on other ways of providing that individual with ways of communicating.
Speaker 6: You're saying with this kind of child, you're gonna look for the most efficient mode for them to communicate. And if this is the hardest, least efficient mode. Are we going to put our limited eggs in that basket? Yeah. And we have to say, where are we gonna put our eggs?
Are we gonna give them [00:08:00] a robust AAC system so they can really communicate their ideas- Mm-hmm ... or are we gonna spend the year on them vocalizing 'uh' on purpose? So what would you say if you see a child who can fluently and use a robust system- Mm-hmm ... that's communicated, could attempt strong language skills- Mm-hmm
and is groping to communicate? You see the pursing of the lips, you see the attempts to communicate. You see the inconsistency, where sometimes it comes out and sometimes it doesn't, and they don't have control over that. Would you say this is a child that you would likely say is suspected of having a motor speech disorder?
Speaker 7: That's what it would look like, just on the face of it. If I thought it was important enough to, really evaluate clinically, then I would give them some sort of speech tests: either a single syllable repetition or a word repetition, or try to see what happens when they do try to talk.
But overall, I would first wanna know why I was putting the person through that [00:09:00] set of evaluations, because if they and their family are happy with the way that they're communicating- I'm fine with that. I'm a firm believer that we all deserve all the ways of communicating.
I communicate obviously by speech, I communicate by text with friends, and I'm clearly gesticulating and it's good for everyone to have access to all of those ways of communicating, 'cause the one really nice thing about speech or vocalizations is it doesn't need batteries. But if it's so hard for you that it's not worth spending hours and hours and hours of time on when you could be learning more advanced syntax or pragmatics, then that's not necessarily the most productive way to go therapeutically. That all, I think, has to be a conversation with the individual and the family. I mean, if it's a small child, they get some say, as much as a small child has. But, it's really more of a family- clinician [00:10:00] decision there.
Speaker 6: So when it comes to an evaluation, you have a speech pathologist, who's working with a preschooler who's minimally speaking, what should she evaluate in terms of the speech development? What should she look at in terms of speech development with the children who, child who's minimally speaking? And I know that the definition of minimally speaking, it used to be minimally verbal, but minimally-
verbal is encompassing language, so we wanna use minimally speaking. Right. Right. And let's just say this is a child that has a vocabulary of less than five words that they use consistently. Mm-hmm. What would this preschool-level speech pathologist, what should she be evaluating when it comes to speech?
Speaker 7: I love that you brought up the terms minimally speaking and minimally verbal. I think that would be my first question. So the way I think about it is that minimally speaking means someone who doesn't use speech as their main mode of communication, regardless of what their language level is.
Minimally verbal means someone with severe language [00:11:00] impairment, regardless of what mode of communication they use. Mm-hmm. For a preschooler, we can't really say that they're minimally verbal yet, because we typically wait until about age five to make that classification as 'minimally verbal' or not.
Before that, we would say they're pre-verbal- Mm-hmm ... 'cause there are some kids who are really late talkers. So I would want to know how easy is it, essentially, for that child to produce speech, and that would, clinically be my question: Is there a motor component to their lack of speech?
I also wanna know what their language comprehension level is, as well as their language expression level, and I also wanna know what their non-verbal IQ is so I can get a much better picture of that child's palette of strengths and challenges.
Speaker 6: And, do you think a physical therapist should be involved in this evaluation in looking at the child's motor skills?
Speaker 7: I would welcome that kind of collaboration. I also think that if [00:12:00] people don't have the access to those other professionals, there are ways that we as speech pathologists can get information about gross and fine motor performance. And one option is the Vineland Scales of Adaptive Behavior.
It's basically a structured interview with a caregiver, and there are pluses and minuses to every single test instrument. The nice thing about the Vineland is that it has a specific section on fine motor ability, a specific section on gross motor ability, as well as a variety of other sections on expressive and receptive language and adaptive behaviors and activities of daily living.
So it can really provide a lot of information for you.
Speaker 6: Wow. We'll make sure to put this in the show notes. This, I've never heard this before. I know the Vineland is used a lot in research.
Speaker 7: Yeah.
Speaker 6: Is it okay for a speech language pathologist to give this test and to include this information in the report?[00:13:00]
Speaker 7: It is. Like many other tests, it requires a little bit of training. And in order to give the structured interview version of it, you would wanna get reliability with someone who already has reliability, giving that structured interview.
But there are a lot of us out there in the research world who can help you.
Speaker 6: Thank you. That really opens the door to treating the whole child, and seeing what lies below the iceberg, and really getting an idea of what's contributing to- the speech delay. That is a great, great suggestion.
So another question I have, when you're looking at the child's speech, in your research on melodic intervention.
The children that took off could imitate phonemes. Yeah
Speaker 7: A- M- M- A- T stands for Auditory Motor Mapping Training, and it's really the brainchild of my first post-doctoral mentor, Gottfried Schlaug. And, you've used the word melodic. It was really developed as sort of an analogy to melodic intonation therapy for aphasic patients.
So the idea [00:14:00] was that if autistic kids are having trouble speaking, a lot of them really like music and are more sort of interested in the prosody of speech rather than the phonetics, let's say. And so maybe a melodic version of speech would be more salient to them And so what we did was to create a series of two-syllable words and sing the syllables at different, pitches that corresponded to the stress of the syllables.
So a word like bubbles with stress on the first syllable would be bubbles. So this has the effect of elongating the syllables a little bit, giving the child time to process those sounds and watch your face as you're producing those words And then we used a scaffolding hierarchy that's really similar to the ones that have been used in acquired [00:15:00] apraxia of speech and that have been adapted for, treatments like dynamic tactile and temporal cueing for childhood apraxia of speech.
And so all of these kinds of ingredients have been combined, and some kids were much more interested in the melodic speech than the regular 'I'm-talking-to-you' speech.
Speaker 6: This is fascinating, 'cause what you're talking about is the autism and the speech development is multifaceted.
Yes. Reasons under the iceberg why they're not developing speech naturally are different, and they pop up at a different times. Then, you're also talking about jumping into the intervention. The intervention needs to be multimodal, and, you're speaking about looking at what happens when someone has a stroke, and they're- Yeah ... not speaking naturally. Right. And what has been effective with these populations in developing speech? What if we try it here where children are not naturally developing speech? Right. The Dynamic Tactile Temporal Cueing, as you mentioned before, was also from Rosenbek. That's right
and we [00:16:00] took it to childhood apraxia of speech, and it's the most effective method in childhood apraxia of speech. In Melodic Intonation Therapy, you took it to children with autism. You kind of did what Edythe Strand did.
Speaker 7: Yeah.
Speaker 6: You did it. You did it with Melodic Intonation Therapy.
Yeah. What you're showing is, when speech doesn't develop when you say it by imitation. I say, you say. That's not working. Mm-hmm. Why don't we do something different and do multiple modalities, multiple sensory, nature? And the effects, now you studied, I believe, seven children, and then 14 children were studied.
Speaker 7: Mm-hmm.
Speaker 6: And it was very promising.
Speaker 7: Yeah, yeah. And, and it's complicated because when you start out developing a therapy, often what happens is you pick kids for a case study who really seem to respond, and you're like, "See? It can potentially work. There's a really big signal there.
Let's try it with some other kids." And then so you bring in kids who are like that other kid, and, but maybe have some differences, and then you [00:17:00] might see- A good effect, but an attenuated effect because now you have more variability in those participants. And then you might compare two different therapies among groups who are selected randomly so that any differences are not gonna be associated with the outcome.
They're just gonna be completely random. And maybe you'll see a smaller effect because you're now comparing two different therapies. And so if therapy is the thing that works, then both groups will on average find some improvement, and then it becomes a question of what are the characteristics of the kids in each group that help them benefit from this therapy rather than that therapy?
It gets very complicated very quickly, but still really interesting to pursue.
Speaker 6: And all things the same, I think you would say it's safe to say that doing more than imitation will get you better results.
Speaker 7: I would say yes, but I'll also caution you because I think that [00:18:00] imitation is literally the foundation of how people learn to talk, everyone.
Vocalizations for most people just happen as a result of their brain development. Even in kids who are deaf from birth, they still vocalize a little bit, and then it kinda trails off 'cause they just don't need that for communication. So there's some kind of internal drive to vocalize in the vast majority of people, that then gets refined by imitation.
And so that is always gonna be a piece of the therapy. The question is, if that alone isn't enough, what other techniques and scaffolds can we bring in to help a child who's not progressing the way we might hope?
Speaker 6: Yeah. This is fascinating work that you're talking about. And I do agree with you, because the children that were researched in the initial study could sit at a table, could attend, and could imitate [00:19:00] phonemes. Yeah. So these are children that are ready to talk. Right? Yeah. They have joint attention.
They have postural control motor skills to sit at the table. You're opening doors on what more we can do to improve the outcomes, which have been flat-lined for the last 25 years.
What can be done differently?
Speaker 7: You put your finger on a couple of really important points just now. The question of who benefits from something like AMMT was a really big question for me. And so we did a research study on it, and two of the things that we found were that, first of all, the kids with a larger phonemic repertoire at the beginning experienced more improvement, which makes sense, because they already have some skills, and you're building on those skills.
If you don't yet have those skills, it's gonna be really hard for you to leapfrog over, over a couple of developmental stages. But the other thing that we discovered, which was a bit of a surprise to me, was that, in fact, it was the older children in our sample who improved more, and I think it's
related to [00:20:00] what you just said, that they had more practice at kind of tabletop work. So they were a little bit more ready to learn, and maybe what that speaks to- Is that whatever previous therapy that they had had before gave them those underlying requisite skills like joint attention, like self-regulation, that kind of gave them a foundation from which to try this really, really hard thing, which is talking.
Speaker 6: Wow. You're opening all of these doors because it's, you're, what you're telling me is they're not in the fight, flight, freeze amygdala brain. They're in the prefrontal cortex. They're in the higher level language thinking brain ready to learn.
Speaker 7: Hopefully.
Speaker 6: Hopefully. But what you're saying to me counters the research that as children get older with autism
And they're not talking, the less likely they will talk. So at age three if they start talking, that's good. At age four, it's less good. At age five, it's less good. Every year the [00:21:00] prognosis is worse.
Speaker 7: Yeah.
Speaker 6: But you're saying in this study, some of the older children took off were ready to learn, had the self-regulation, had the joint attention.
Speaker 7: Yeah, so I think we need to do a lot more studying and thinking on what makes a child ready for speech therapy to understand, again that you're making a child do something which is literally the hardest thing in the world for them, and is it going to pay off for them?
In other words, is it going to improve their communication skills, or can we give them more skills by focusing on alternative communication, some other mode of communication? And maybe that, again, that might change over time. Again, that's not a bad thing because everybody deserves all those ways of communicating.
Keeping the child in that self-regulated, ready to learn state is so important. And that's [00:22:00] another area in which, being a careful observer of behavior is where I think speech pathologists really excel.
Speaker 6: You're bringing in so many different concepts.
Now you're bringing in the demands and capacity model. Yeah. And if the child doesn't have the capacity and you're demanding things the child can't do, you're gonna flip the scale. Yeah.
So you can't blindly come in with a plan and say, "This is what you do with a toddler to teach them to talk," when
the toddler is in flight, fight, freeze brain mode. This isn't good practice. I love what you're saying about all of the above. Consider all of the above when you're doing intervention, and do something different as the child evolves.
Speaker 7: It makes it seem like our job is really hard, doesn't it?
And I would say yes. It's very complex and sophisticated, and I feel sometimes like the world doesn't necessarily, see our job as being that, that sophisticated. But it really is. These are kids who all deserve a way to [00:23:00] communicate that does not involve hurting themselves or others, and we are the ones, as speech pathologists, who are the best educated about how to develop those communication modes for them.
Speaker 6: You have just really opened so many doors to us not doing the fill-in-the-blank, 'do this'. If you want them to talk, do this. Yeah. That's never the answer. No. And how, I like how you want us to be dynamic and do something different with every child with autism you work with.
There is no plan that you walk in with. There, I think there can be a couple of basic plans that you then adapt to the particular child that you're working with. We know that there are very successful therapies like JASPER, for example, for, pre-verbal or minimally verbal autistic kids that provide them with a lot of those prerequisite skills to then be able to learn language and spoken language, or language through an AAC device.
Speaker 7: I have [00:24:00] never heard of JASPER.
JASPER stands for Joint Attention, SP is Symbolic Play, and ER is Emotional Regulation. And this is a naturalistic developmentally informed behavioral therapy for autism that was pioneered by Connie Kasari at UCLA.
The idea is that you teach in a play-based milieu all those skills that JASPER stands for and it has had remarkable success
Speaker 6: if you were to say, "These are specific strategies that would work with a preschooler to help in speech development,"
What are those go-to strategies that universally are going to help children with autism develop speech?
Speaker 7: Ooh, that's a great question i'll just give a framework what I would want to do I would wanna find out through a play session with them where they are in terms of their speech abilities, their language abilities, their social abilities, and their play skills.
And I could do [00:25:00] that in 10 or 15 minutes with a selection of toys, and just video record the whole thing, and then go back later with a developmental checklist say, "Okay, I see you, you did this with the toy so you, so I'm gonna assume you're right there. You produced these phonemes, so that's a start.
It's not maybe all you can do, but it's what you can do comfortably." And so on in the other areas. And then I'm gonna say, "All right, what's the next logical step for you? Is it improving your phonemic repertoire so that you can produce more sounds so that I can then work on more words with you? Is it improving your play skills?
What's the priority, and what's your next logical step?" And then I'm gonna see if I can create three little therapeutic tasks that we can work on in whatever your priority area is. One where I know you've mastered that skill, one where I think you're on the cusp of developing the skill, and one that I think it's gonna take us probably a few months to get to.
And then when we meet on [00:26:00] Monday, I'm gonna try you with that thing I think you're just on the cusp of, and I'm gonna see how you react. So that might be producing certain sounds in the context of animal names, and I might do that in an activity where we're playing with animals. And even if your play routine is just stack, stack, stack, stack, crash, I can work with that because we can put the animals down, say their names, and if you don't wanna participate, you're gonna sweep them off the table, and I can be like, "You did it.
You crashed them. Let's do it again." Any way of engaging that child. And I'm gonna see how they react when I try to get them to say the names of those animals, the words I've specifically chosen to be right in their zone of proximal development. If it's too hard and the child isn't able to regulate, I move back down, and we just concentrate on something that I know that they can do.
We do that for a few minutes, a half an hour, or maybe the whole session. If that's too easy, then I already have this other thing in my head planned that maybe we [00:27:00] can combine two of the words, two of the names, and that automatically makes it a harder speech, task.
But it kinda keeps the child moving dynamically, within centering on their zone of proximal development, but also hopefully advancing, and then having that fallback to, "Yeah, I can do this."
Speaker 6: Oh, I like that. So do you want them to be kind of at a 80%, four out of five challenge point?
Speaker 7: Yeah.
Speaker 6: Where they're participating 80% of the time, and if they're not, then you're going to move back to get to that 80%, or then you're gonna move up if it's too easy, they're 100% on this, you're gonna move up to, okay, now we're saying the animal names. I think that's wonderful. Just always coming into a session, with an easy challenge point, harder.
Speaker 7: Yeah.
Speaker 6: Being able to move up and down the scale like that.
Speaker 7: Right, exactly. And then, over time, you begin to see what the child really likes, what they kind of might get stuck on, and you can have a variety of activities for them [00:28:00] that each have that little sort of, those brackets around them. We can do this activity, and here's an easy, a moderately hard, and a challenge version of that task. We can mix and match, so that I'm always kind of titrating that dose.
I'm not giving them, like, three new things to do all at once, but I'm saying, "I'm giving you things you're really comfortable with and just changing this about it to make it a little harder in this way. And then maybe if that's too hard, 'cause I'm gonna watch you and see how you're reacting, and if it's too much, you will tell me, hopefully not by hitting, but you will tell me, and then I will back off and either provide more support or go to something else that you can succeed at and have more progress with."
Speaker 6: I love this. What you're talking about does remind me of dynamic tactile temporal cueing in that you're constantly in a dance with the child moving forward and back, because the child in the beginning of the session might be very motivated- Mm-hmm ... and the end of the session is like, "I'm tired, I'm done with this."
And you don't set them up for [00:29:00] failure, you pull back. It's not one-way therapy- in which this is what we're doing today, or that's what I got planned. Yeah. I think that's wonderful.
Speaker 7: And again, you've put your finger on a really important point that not only is the therapy dynamic, and I will say that JASPER shares that dynamic aspect with DTTC, which is the reason I love both of them, but also that the therapy is a collaborative effort, and I think that is so important for every child, but especially for autistic kids, because that is the essence of social communication.
I feel like teaching social communication by saying, "We're gonna do what I wanna do," is unrealistic. It just doesn't seem functional to me. But on the other hand, there are ways of saying, "Yes, I am the adult, I need to have control over this situation and I get to say what goes and what doesn't, but you have choice too, and we react to each other, [00:30:00] and we're in that relationship with each other, and this is how we get along, and this is how we accommodate each other and learn new things about each other."
Speaker 6: Wow. And what you're saying, I think, is so huge because the children with autism are so powerless. Yes. And when you have the ability to communicate- Yeah ... communication is power. Mm-hmm. And in giving them some agency and giving them choices within the activity as an equal partnership.
You've really opened new doors for me, because I always think of partner-provided cueing and prompting when it comes to what we're gonna do differently on a moment-to-moment basis. You're talking about changing the task on a moment-to-moment basis as well, based on- Mm-hmm
the child's interests and that adds so much richness, Thinking in those two dimensions, at least.
Speaker 7: Just because we're interacting that way and I'm giving the child some agency doesn't mean everything goes. There are still expected standards of behavior, and we have to figure out some way of working that out.
For me, when I'm not the one saying, "You have to do it this [00:31:00] way," I am a lot more regulated, and I am a lot more comfortable, and I am able to observe the child's behavior much better, and the whole session goes so much better.
Speaker 6: You are receiving from the child and responding instead of pushing. Yeah .
Speaker 7: Sometimes you push, sure, like any good coach. But, it's not all me. The child obviously has their own behaviors that they can communicate with, and all behavior is communication.
And by taking that into context and respecting that without, again, letting someone else be the whole determiner of the situation, I think that really makes for a very rich interaction.
Speaker 6: So when it comes to speech goals, if you were to write speech goals, which speech goals do you think are most pivotal for a preschool-aged child who's minimally speaking, who has five words they're using on an inconsistent basis?
Mm-hmm. What are a few pivotal [00:32:00] speech goals that you would create for that child?
Speaker 7: I think it would depend on what their five words were. I think that, there are a couple of dimensions that I might think of expanding. One might be expanding the Number of phonemes that they're using, so introducing new words that are, that refer to objects or actions that are very important to them.
Another piece could be just learning more words and maybe they have some of the same phonemes, and we're not trying to stress the speech motor system, but we're building out the semantic aspect of speech. We're still working on producing the words that you do have really consistently to get you a good motor pattern there.
Mixed in with that, I would also want to choose some words that are verbs. Mm-hmm. And I know that's not a speech goal, but it can be adapted to a speech [00:33:00] goal if the verb you're using has phonetic characteristics that are consistent with whatever the speech goals we're working on are.
The reason I want to choose verbs, even if we're working on a speech goal, is because verbs are words that have lots of little slots in them for other words to go with them. Mm-hmm. And so that can really, at the same time, make a kid ready to kind of build out their syntactic skills. I like what you're saying: the research supports diversity.
Speaker 6: We can go there with interests, but we're gonna have a lot more diversity in terms of the nouns we use, verbs we use, types of words we use and the phonetics that are coming out as a result to improve outcomes.
Mm-hmm.
Speaker 7: It's really hard to combine a string of nouns into a sentence. Mm-hmm. Whereas if you have a verb, that naturally leads to a two-word combination being its own sentence. Mm-hmm. Especially if you have a transitive verb where there's a subject, the verb, and then the object.
Now you've got a three-word [00:34:00] sentence, and you've encapsulated that kind of meaning, as well as working on your speech and your syntactical. Verbs provide that extra fuel for the, for developing more syntactic forms. Mm-hmm. A few sentences ago, again, you brought out this really, really nice point about, increasing the diversity of the forms that the child uses, and I think that is really the goal of a lot of the aspects of therapy that we provide.
We wanna give kids more phonemes so that they can produce more words, so that they can make more word combinations, so they can produce more ideas, and then recombine those into lots of different combinations to tell us about things that happened to them yesterday, or that haven't happened yet or to have their imaginations really blossom.
Just to give them more of those little frames that they can combine and recombine and, build on.
Speaker 6: I hear you.
How [00:35:00] important do you think consistency is? Should that be a goal that the child can produce speech on a more frequent basis, or a more consistent basis, the five words they do know?
Speaker 7: Mm-hmm. The more practice a kid gets, the better, as long as you're not pushing them in the zone of frustration. And I also think that, producing the words that they do produce consistently is important because that's the best way for other people to understand them.
You know, there's sort of the level of a kid may be able to produce their words or phrases consistently, but not intelligibly to the people outside the family. That's fine for a start because at least someone will be able to know what they're saying. But if a child is completely inconsistent with their speech, they could say something to me, and even if I know them well, I wouldn't necessarily get what they were trying to express to me.
So I think that consistency is really important to begin with. And then the other piece you were talking about is [00:36:00] volubility, like how much speech they're able to produce. To a certain extent, the more the better because you just get that much more practice. But, that has to be nuanced because you don't want to put the child in a position of practicing errors necessarily.
You wanna be able to keep them, again, in that zone where they're about 70- 80% accurate.
Speaker 6: I find that many children with autism develop speech because they have an obsession with letters and numbers. 30% of- Yeah ... children with autism have interest in letters and numbers.
Speaker 7: Mm-hmm.
Speaker 6: That is something that they're first able to say on a consistent basis-
Speaker 7: Yeah ...
Speaker 6: or label on a consistent basis, and then after that, it creates a pathway.
Speaker 7: And
Speaker 6: other words flow out because the road's been paved by letters and numbers.
Mm-hmm. Do you find that if you have a child interested in letters and numbers, go there?
Speaker 7: Absolutely. As long as I can make it, again, building them out to get a larger diversity of communicative forms. If it turns [00:37:00] into, " I just wanna do this repetitively, and I don't want you to interfere," that's a different question.
I need to figure out what is so stressful about what I'm trying to vary that makes you just need to focus on your own thing. I want to help you be able to be flexible, so I don't wanna just let you go off in your own world about, your interests. You can do that at home. I have no problem with that, but when we're working together, part of my job is hopefully to draw you out.
Speaker 6: Mm-hmm. Yeah.
This has been a wonderful interview in which you've shared so much with us about what do we need to look at when it comes to the evaluation, the goals, some great intervention strategies.
What have we not talked about today that we need to talk about when it comes to children with autism and developing speech and what we can do? What have we missed?
Speaker 7: I feel like we've talked about a lot of the different issues, and maybe the remaining [00:38:00] piece is, I'm gonna say a call to clinicians and researchers to, to help develop better ways of assessing non-verbal IQ and receptive language in children who may have really severe motor praxis disorders.
I think there's pretty good agreement that a lot of the assessments we have don't necessarily do a really great job, because if you have difficulty scanning a page with four pictures on it and focusing on one, and then aiming your hand to point to that one, the PPVT is gonna be really hard.
Or sometimes, kids will get stuck scanning. I'm choosing the one that I want, but now it's really hard and my hand automatically just goes to the upper right all the time. I didn't mean that, but that's what it's doing. Ugh. So I think we need to [00:39:00] develop better methods for assessing those cognitive and language skills in individuals with motor challenges.
Speaker 6: And are you thinking eye gaze, through digital means? Mm-hmm?
Speaker 7: Possibly, yeah. I, I suspect that for every method we come up with, it'll work for some people and not for others, and that's fine, again, as long as we have that variety of methods. But I think eye gaze is one.
I think maybe touch screens that are maybe adapted to the way that a specific person moves so that they're not too sensitive or too insensitive. I think we just need to think really creatively about this.
Speaker 6: Well, thank you so much. It has been such a pleasure having you here today. You have done such amazing research.
I've had the pleasure to see you at ASHA and give oral presentations there, which just knocked my socks off. I'm so happy that you are here on the Preschool SLP podcast to share this amazing information that we just didn't learn about in continuing [00:40:00] ed courses. We didn't learn about this in graduate school.
Looking at all of the above, looking at all of the contributors to why this child is having difficulty developing speech and what we can do about it, this has been just an amazing experience for our audience, and it's gonna change so many lives. How can we get in touch with you so we can learn more from you?
Speaker 7: You can always Google me, and I respond pretty quickly to emails. Mm-hmm. I'm happy to be pen pals with anyone.
Speaker 6: Mm-hmm. We are so fortunate for you. You are definitely a pioneer in this field, and you are expanding new frontiers where no one's gone before.
Thank you so much.
Speaker 7: Thank you so much for having me, Kelly.
Speaker: Thank you, Dr. Chenausky, for sharing your immense knowledge with us. Now you do what you do best, which is to roll up your sleeves and make the world a better place one child at a time. You will always be first.
Speaker 5: One child at a time. You are always going to be first.
