Speech Therapy
Show Notes for Embracing Autism Podcast — Ep. 109

Introduction
Lia: In this episode, we take a deeper look into what you can expect at your child’s speech therapy sessions, what target areas speech therapy can help with, and some tools that may be provided to your child.

Lia: Welcome to Embracing Autism, a podcast for parents of autistic children seeking advice and support, while spreading awareness and acceptance of Autism Spectrum Disorder.

Lia: I’m Lia!

Matt: And I’m Matt!

Lia: And each week, we’ll discuss our journey with autism and talk about how to embrace your child’s individuality while providing guidance, tips, resources and sharing our personal stories. This is-

Lia & Matt: Embracing Autism!

Discussion
Matt: So Lia and I wanted to touch on speech therapy because both of our daughters go to speech therapy. And we thought that it was one of the critical therapies that would come up after an autism diagnosis. So in this episode, we’re going to refer to speech therapy as ST. Just so there’s no confusion moving forward. So I think the first part is the main focus of speech therapy is finding communication and language skills to better aid your child moving forward. When we talk about communication, there are multiple types of different communication that they would focus on; this would be verbal, nonverbal, and also just kind of a social communication altogether. And the main focus, of course, is basically getting your child to be able to communicate in a useful and functional way in society. So I think that it’s important to note the difference between communication and speech. When we think of speech, we pretty much think of the physical ability to create sound and putting those different sounds together in what we know as language. For the concept of communication, that’s kind of a broader category in itself, where it can either be nonverbal cues, it can be a writing system, picture system, or it could also be intermittent verbal communication as well.

Lia: When you are bringing your child to speech therapy sessions due to the fact that your child has some sort of speech delay, or a speech impediment, or some sort of difficulty in that communication aspect, it may also be for social reasons. So perhaps your child has typically developing speech, but they may have difficulty in using that speech appropriately in social situations. So speech therapy will actually help in both of these categories. There’s a lot of different factors that speech therapy will dive into; different things that they will focus on. Part of what we focused on with our child was joint attention. Joint attention is the ability of your child to be able to engage with you or whoever else is with them at the time while they are completing a task. This can be something like reading a story or playing with some blocks, or if your kid’s older, maybe you guys are playing checkers together, or some sort of game that you’re participating in with them. And the joint attention aspect of that would be attempting to engage with you at some point in time. And that’s typically through eye gaze or smile, or some sort of acknowledgment. I think one of the very standard things is for a toddler, for our kid, we would be reading her books. And the expectation would be that as we’re reading the book to her and pointing out animals in the book if she got excited, she would look at us and smile, and then look back at the book and then look at us again and engage in that back and forth attention behavior. That is called joint attention. Now, neither of our children had that, however, so that became one of our speech therapy goals.

Matt: When we first started speech therapy, we didn’t have that connection with our daughter as being able to — she would come to us with interaction in mind — she would be in her own world doing her own thing. And even if we tried to engage with her, it would be we were basically doing a separate activity next to her, and she would be doing her own activity. But I think it was through books because she absolutely loves books to create a bridge into her world where she would be able to kind of connect with us with the different stories that we were reading her.

Lia: And a good speech therapist will be able to work with you to find what it is that your specific child is interested in, and try to use that as a way to get them to engage in conversation or meaningful communication. So if your child is into books like ours, then they might do reading therapy. That was one of the things that we focused on in speech therapy. Reading therapy is kind of like a subcategory within speech therapy, where we specifically used books to try to target language and communication skills. For example, we went and looked for very specific types of books. We were told to look for books that were very simplistic, only had one or two pictures on the page, so they wouldn’t be overly distracting and had really basic text on them. A lot of kids’ books nowadays have a very story-like paragraph-style text and those aren’t really particularly good for reading therapy. It’s better to have books that have basic one-line things on them. I know for our kid, one of her favorite ones was You are my sweetheart (paid link), You are my cupcake (paid link) book series by Joyce Wan and the reason that book series was particularly good in particularly helpful for us is that it has one picture per page. And it has a very short, maybe three, four-word sentence per page that describes that image. For example, one of the lines is, in fact, “you are my cupcake”, and then it’s repetitive. So each page has a “You are my…”, and then it just switches what that next word is. So the combination of short, brief sentences with simplistic pictures and repetition really helps your kid understand the concept of the book just by continuous exposure to that book.

Matt: And I also think that helps on the other element of developing the language to be able to repeat the common phrase. In the book that we used, You Are My Cupcake, she would start to learn ‘You are my’ and then just change out each word on the different pages. So she is able to slowly start to basically repeat the phrase moving forward.

Lia: So she basically started to learn the book and memorize the book. And initially, when she picked up those phrases, it was just a matter of completing the phrases in the book. But after time, she started to be able to apply those phrases to real-life situations where it was actually appropriate. So reading therapy helped us get her to a place where she was able to gain language that initially didn’t seem to do much for her because it was, like you said too, scripting or parroting. For those of you who don’t know, scripting is repeating phrases verbatim and parroting is repeating stuff that you’ve heard. The scripting can be from a book; for example, if they memorize the line, they might repeat the line verbatim back to you. That was part of what she started doing. However, it was actually helpful because it expanded her vocabulary. So she went from nonverbal to scripting. Some parents get worried about that, but it’s actually a good sign because it’s showing that your child is progressing, they are picking up language. And even though that language might not be what we might consider natural language, yet, it’s completely better than nonverbal, because they’re at least getting through that transition period of nonverbal to verbal through the scripting.

Matt: It also allowed for the development of her language as well in the You Are My Cupcake, since everything is so repetitive, if we read the phrase, “you are my…” she would be able to fill in the blank saying “cupcake”, and then it was kind of almost in a way that we were asking her a question she was filling in giving us a response as well.

Lia: And what also helped with that is if you get a simplistic book and the simplistic book is really all dependent upon your child’s specific situation, and age appropriate level; So the You Are My Cupcake book — that may be appropriate for your 11-year-old child, as well as a two-year-old child depending upon the level that your child is at with that language development skill. So just look for books that you believe are age-appropriate for where your child specifically is at language and communication-wise, and consider doing that sort of reading therapy structure that we’ve done with our speech-language pathologist who ran the speech therapy sessions. We started with books because it was a special interest of hers, but also because it really is an easy way to practice things like joint attention, as well as distal and proximal pointing. Distal and proximal pointing was another thing that our children both kind of failed at during the autism screening. Distal and proximal pointing is your child’s ability to point at something that’s far away or follow a point of something that’s far away, and to also be able to point at something that’s close up; basically the skills that are needed to communicate non verbally. So that’s like if you wanted to communicate with somebody and explain to them like, “Oh, look, yeah, the movie theaters over there”, and you’re showing them a point, it’s an important life skill for that child to be able to understand. And when the person’s pointing, they need to follow that point and understand what it means. So that’s another nonverbal thing that depending upon the age of your child might be tackled differently. But books were a great way to start out the proximal pointing, which is the pointing really up close because you can point to images in the book.

Matt: So I think there’s a difference between the two different points because in our case, our daughter was able to grasp one of the points faster than the other. I’m thinking of late at night, when we were taking our daughter home, if there was a big harvest- Full Moon, it was a clear night, I’d be walking in with her and I’d be able to point at the moon and say “moon”. And she was able to relate that to one of her books that we were reading, Where’s the moon-

Lia: -Or I See The Moon, I think.

Matt: But she was able to make the connection of ‘Oh, I see the moon and my dad is pointing to the moon’. So she was able to draw the connection there. It was interesting because when we were inside and I was pointing at something much closer than the moon, she wasn’t able to follow what I was pointing out. So it’s just interesting to see that she was able to see something very far away, but not necessarily something much more subtle. That was much closer.

Lia: And that actually was another thing that was brought up during speech therapy was how to be able to transition those skills between proximal and distal pointing. So if your child does struggle with point they will help a lot with that or if they’re not particularly good at either they come up with nice tricks, depending on your kid’s specific special interest that might get them more into attempting that point.

Matt: And I think like anything else, the more you work at it, and they get the idea of when you are pointing it is for a purpose. So in some cases, if my daughter wasn’t able to understand what I was pointing at, I would do my finger extended, like I was pointing, and basically walk up to the item that I was pointing at, and basically touch it. So she could see that from a distance, I had my finger pointed out pointing at something. And then as I get closer and closer and closer, she could see exactly what I was talking about. And I think doing this over time, she was able to kind of grasp that concept.

Lia: Another thing that speech therapists will really focus on is nonverbal communication. So the pointing is part of that. But this can also include not just gestural communication — which is the pointing or facial gestures and expressions — but it can also include things like training with the PECS system, which is the Picture Exchange Communication System, or electronic talking devices and other nonverbal communication tools. This will depend heavily on the needs of your child. With our first child, we didn’t really have to dive too deep into this because she picked up language pretty well with the speech therapy. But with our second child, it has been a little bit more of a struggle to get her to verbally communicate. So we have had to attempt to use a Picture Exchange Communication System. This is a system where you are essentially using pictures that have a representation of what it is you’re trying to say on them along with the word. So for example, if you’re trying to say that you’re hungry, and might have a picture of food, and then it says “eat” on it or something like that. So then you would essentially teach your child that when they’re hungry, they will give you the picture that says “eat” on it. And in exchange, you will give them something to eat. So that’s why it’s called the picture exchange communication system because you’re trading the picture for the item that’s on the picture.

Lia: Now the other items on here, the electronic talking devices, that can be something like an iPad with a software program that’s installed on it, that is very similar to the PECS System, and that it will have images and words as well. But the child or teenager, this is usually for the older kids will be able to just push buttons on that iPad app, or it might be a device itself that has the pictures on it. And every time they push that button, the device will sound out loud, whatever that says. So for example, they might learn to push a button that represents “I”, a button that represents “want” and a button that represents “snack”. And then when they push those buttons, the device might then say out loud, “I want snack” and some sort of like robotic voice. And that would give them another way of doing it. Some do a combination of that. So our child right now is in a speech therapy school program. And one of the things that they’re doing there is the PECS system on a board, where they’re teaching her to point to pictures to communicate what specific snack she wants. And it’s also about expanding language. So we had with our child is that she started off just saying one word phrases. And so if she wanted chips, for example, she would just say, “chips”. And you would assume that chips means I want chips, but she just said chips. So as she’s been going through this program, they’re teaching her to use the full phrase, I want chips. And this is something that I’ve seen her actually do really well with, with just — what, two months of school so far?

Matt: Right. And there are other areas that she’s expanded into short phrases as well. I think one of the ones that she used to say was if she needed help, she would say “help you”, which most people wouldn’t necessarily know if this little toddler came up to you and, missing, saying ‘help you’ you’d be like, ‘No, I don’t need help. I’m perfectly fine’. But when she was saying help you she meant that she actually needed help. And actually just recently she’s been able to switch it and say “I need help”. I think that was actually today. Today this afternoon, which is a huge transition because pretty much everyone will be able to know ‘Oh, you need help instead’ of help you because help you doesn’t necessarily mean anything. So just these small little phrases are making a huge difference. And I also think for the PECS system, it’s also something that you definitely have to work at because I know it wasn’t terribly intuitive for our youngest daughter. It definitely took some give and take trying to get her to see what the picture actually was and trying to relate it to what she was actually feeling. So if she wanted a snack, it was very repetitive, repetitive of us working with the picture to try and show her- ‘Oh, in this picture is a snack and you are feeling hungry, so you want a snack’ and being able to draw that connection to her.

Lia: So PECS is definitely one of the biggest tools that is used right now. It’s kind of like a go-to if your child’s nonverbal to help them get that boost. And speech therapy in general will go through a bunch of other things, too. It’s not just PECS systems or communication devices. They work on a bunch of different types of language, as we mentioned before. So for kids who are I would say, a little bit older, so they understand what body language is, those children who are able to understand that might then go to speech therapy to work on body language. So some of the things they might address for again, the older child is how can you tell if the person you’re having a conversation with is joking or serious, it might be something like teaching them how to judge when is the appropriate time to join into a conversation? Or when is that conversation a private conversation that you should not be trying to get into? The speech therapists will help them learn how to recognize those physical signals and body language so that they learn how to communicate appropriately that way as well. They also work on some skills like asking and answering questions which we touched on a little bit. Children who are autistic, typically, when they develop, they don’t really understand that the ability to ask and answer questions is something that is innate. But autistic children tend to have a little bit of a delay in that. So the therapist can help teach your child how to recognize a question, and how to provide an appropriate answer. So sometimes, if you’re asking them a question, they don’t necessarily understand it’s a question, they might read it as a statement instead. So they don’t understand that you are expecting a response. So that’s something a speech therapist can help with as well. And again, that tends to be I would say, with a little bit older kids, not so much the toddlers, because that’s more of a complex scenario. Now there’s a bunch of other things they help with as well. There’s something called speech pragmatics, and speech. pragmatics is basically just the day-to-day conversation styles of people. So for example, it’s useful to be able to say to somebody, “Hey, good morning”. But it’s also important to know when it’s appropriate to say “good morning”, and who it’s appropriate to say good morning to, it might be really weird, if you just went up to somebody you don’t know on the street, tap them on the shoulder and said, Good morning. So that’s another thing that they help with is speech pragmatics training, which is helping your child understand the appropriateness of those situations, and also the use of idioms, which is again, understanding how those phrases are used. And when they’re taken literally versus maybe — not sarcastically but when — yes, another thing that they work on is something called prosody. Prosody is the melodic sound that your voice makes when it goes up, and it goes down. And there are inflections and at the end of a question, I might say, have my notes go up, or I might just make my notes go down. And that up and down of your voice is something that autistic people tend to not necessarily catch on to in terms of what it might mean in the person’s sentence. So typically developing children and adults, this is a skill that you gain to understand what is meant by certain inflections of your voice. This is a lot more challenging for autistic children and adults. So this is something a speech therapist would help a child be able to identify and to be able to develop in their own vocal skills as well. You might also not think about this, but grammar is something that speech therapists can help with too. Grammar is something that can be confusing as well, because some autistic children — I know our child would refer themselves in third person. So our child did this a lot. Anytime we referred to her by her name, she learned essentially, ‘oh, if other people are referring to me by my name, that must mean that I must call myself by my name as well’. She had difficulty understanding that when you talk about yourself, you say I or me, and this is something that is pretty standard with a lot of autistic children, as well as something that they work on, is teaching the child when to use your name versus when you should be referring to yourself as I or me and first-person rather than third person.

Matt: And I think this was actually probably harder for us than for her. Because since she was repeating what we were saying we had to basically speak as if we were her. So we’re using I language, which for her, and it was just kind of getting it was kind of a jumbled mess of is she going to be able to get the connection, or is it going to make things even worse, but thankfully, I was absolutely amazed. She was actually able to figure out that she was able to use ‘I’ and be able to transition without any serious delay there as I would have assumed otherwise.

Lia: Yeah, and the switch on that was really when our speech therapist told us that we needed to change our language. So it will feel really awkward and uncomfortable at first, because in order for you to help your child learn — I and mean language — you have to start talking to your child in that language, even though you know you’re not referring to yourself. So for example, if you have a child, Johnny, Johnny wants apples, and Johnny is always saying Johnny wants apples when they’re hungry, you would then turn to Johnny and say, I want apples. So you’re telling him I want apples so that he learns to repeat I want apples. So it definitely feels a little weird when you’re doing it. It’s really awkward at first, but it works.

Matt: Right, it took us a little while to get the hang of it. But then after a while, we saw that it was making a difference for her. And then honestly, we didn’t have to keep I mean, once she had it picked up, we didn’t have to keep repeating the same phrase to her, she kind of took the ball and ran with it.

Lia: And then the two final areas that speech therapists will work on. The first one is concept skills. This is a person’s ability to be able to stay abstract concepts and understand that that doesn’t necessarily mean a literal thing. So autistic adults and children alike tend to struggle sometimes with abstract concepts, specifically abstract verbal communication or written communication. So something like ‘I’m so hungry I could eat a horse’, they may take literally, and they might think like, ‘wait, what you want to eat a horse? Why would you want to eat a horse?’ So sometimes that break in consistency is something that a speech language pathologist might help with, and might try to teach them that. Now when somebody says they’re so hungry, they can eat a horse, it’s an expression that means they’re really, really hungry. So that’s something else that they will work on. And the final bigger thing that they will work on, particularly with the older kids is the social skill development aspect. So when you’re starting off with the younger kids, you’re really focusing on those basic fundamental building blocks of language and communication skills, you’re far more concerned on just trying to make sure that you can communicate with them, before you move on to more complex things like social skills. This is something that would work on things like recreational therapy, drama therapy, art therapy, things like this, that helped build social communication skills, and include things like the ability to ask and answer questions have like a back and forth conversation with someone that keeps flowing, to be able to judge the appropriate distance that you should be standing next to someone when you’re talking to them. So teaching them when is it an invasion of space, private space versus when is it too far, and just giving them that level of awareness in a conversation, as well as being able to judge the mood of the room. So this might be very important for somebody, for example, who may have a sense of humor, and doesn’t realize that maybe you shouldn’t crack a joke at a funeral. So that’s, that’s things that surprisingly, enough speech therapists actually do help with as well.

Matt: You actually jogged my memory when you mentioned the physical distance that two people might stand when they’re having a conversation. And this kind of brings me back to language, it might not be something neurological, that is the struggle, it might be a physical disability that is preventing language to happen in the first place. I know there is the idea of —what do they call… I think Tongue-Tied ?

Lia: tongue ties, yes.

Matt: Right. So as far as your actual tongue and not being able to lift up in your mouth to actually make the sound to produce whatever the word is that requires that sound. And I mean, there would be other struggles if there are disabilities that would prevent language from actually taking place in the first place.

Lia: And one of the things that we mentioned in our previous episode about occupational therapy is how occupational therapists look at motor planning delays. That’s something that a lot of autistic kids struggle with. What I learned, surprisingly, through our speech therapists was that you can also have motor delays in language. This was something that they were keeping an eye on for our second child who has had a particularly difficult time with language development, she is even more behind than our first child was. And so they were keeping an eye on that because it is possible to have that same motor processing delay that our child had with being able to understand, okay, I need to first think about moving my foot in order to move my foot. That kind of disconnect can also happen in the mouth and with your vocal cords and with your tongue and all of that. So it’s possible that your child may be like my child and have a motor planning issue specifically with speech, in which case that aspect is more of a neurological condition. And they would be able to target areas there to try to help with that as well.

Matt: Right, because we see the difference between our oldest and our youngest for oldest, she had a delay, but then her language eventually kind of started to get caught up in the process, as where I think our youngest still falls in the category of nonverbal.

Lia: Yeah, she’s, she’s almost two, and she still pretty much doesn’t have a whole lot of words or communication.

Matt: I was gonna say we rely relatively heavily on other communication to kind of bridge the gap into figuring out what she needs, she’ll rely a little bit more on sign language than speaking, for example, to get her message across to us.

Lia: Overall speech language pathologists will help you during speech therapy sessions to really focus on your child’s ability to communicate verbally or non verbally, as well as socially, it’s really important to note that your expectations and speech therapy should be focused on being able to get your child to communicate, it doesn’t matter how your child communicates, it may be that your child will go from nonverbal to verbal, and I know that a lot of parents really hope for that. I know for us, you know, it was fantastic to finally hear our daughter, say, Mama for the first time. But realistically speaking, not all autistic children get to the verbal communication aspects. So I just like to put that out there so that everyone knows that it’s really case by case, your child may or may not verbally communicate, no matter how much speech therapy you put them in. But that’s not really the goal. The goal is to be able to get them to communicate at all. And that is something that they can do through the PECS system with pictures, they can use an electronic assisting device, they can use sign language, there’s so many ways that they can communicate. And that’s really what I would focus on. Because once you unlock communication, there’s been so many breakthroughs for us with our children. I know our second child who’s pretty much nonverbal still at this point, we have been able to recently get her to try about two sign language gestures.

Matt: Yeah, she would never really tell us when she was hungry. And we really struggled with the PECS system, try and have her bring us card for a snack to let us know, oh, I’m hungry. It didn’t catch on terribly great, I would say. But then she was able to figure out the sign language for eat. So she’s been doing a really great job of signing when she’s hungry and wants to eat. And we know when she actually gives us a sign she’s not kidding around, we put her in her chair. And pretty much whatever we give her she scarfs down so that is kind of her telling us like ‘Hey, Mom and Dad, I’m starving, like give me something to eat’. But that’s been really helpful for us because it gives us an idea of what she’s feeling. It’s the same thing with a diaper change, she’ll kind of let us know when she needs to be changed. If if we’re walking around, she has her pants on and we can’t see the blue line on the diaper she’ll let us know that she needs to be changed as well. But I really think that the sign language has been very helpful for kind of us moving forward with her.

Lia: Yeah, so I just I’m gonna wrap things up here. But I just want to let you guys know and reiterate, communication is all you’re really looking for here, it doesn’t really matter which form of communication, just find the way that works best for your child and work with them as best as you can to get that communication because it really opens a lot of doors. And I will tell you from personal experience with our kids, sometimes they start off nonverbal, but then that communication system that you put in for them to start unlocking doors to verbal communication as well. Our first child, we started her off with sign language, it was very difficult because of some sensory issues she had with her hands. But that triggered something in her mind to start connecting language, the use of signs to assign meaning to a physical object like food, it’s somehow triggered something in her mind that she then was able to start associating the words to that item. And she basically didn’t need to use sign language anymore. So we ended up just skipping it for her because it was enough of a transition to help her get that extra push that she needed for language.

Matt: Yeah, I think there definitely is kind of — at least we kind of see like a breakthrough moment or a silver lining where there’s just a window into when there’s that connection that’s being made where there’s no communication whatsoever. And then they get some type of communication where they understand that, ‘Oh, I’m able to send a message to someone letting them know something that I’m feeling’. And it is very helpful. I mean, even if it is through sign language and not actual verbal communication.

Lia: And I think the most important thing I’ll leave you guys with this is, a lot of times people assume that because a child is nonverbal, that they don’t understand what’s going on. We have learned through this journey that that’s not the case, most of the time, it seems like most of the time, they are actually quite aware of what’s going on. And they are learning and they are absorbing things like little sponges, and they just aren’t able to express it. So because they’re not able to express it through communication, we just assume that they don’t know. I will challenge you guys to take into consideration and just try to assume that your child actually does know what you’re saying when you’re talking to them, rather than assuming they don’t understand. Because you may find out later down the road if you go through speech therapy, and you’re able to unlock communication for them, whether through verbal or nonverbal, they might come back at you and say, ‘Hey, by the way, Mom, I understood you the whole time’. So be careful what you say. And definitely, definitely don’t take for granted that communication piece because you never really know.

Matt: that’s true. I think that’s a great helpful hint.

Outro
Lia: So that’s all we got for today, guys. Thanks for listening. To review. In this episode, we talked about what your child may work on in speech therapy, how your child does not necessarily need speech to have communication and tools that may be used, such as the picture exchange communication system, sign language and electronic communication devices.

Lia: Thanks for listening to embracing autism. Join us next time when we take a look at applied behavioral analysis or ABA and answer questions such as Why are autistic children often referred to ABA? What can ABA help my child with and why is ABA so controversial? This has been Embracing Autism.

Resources
What is the Picture Exchange Communication System or PECS?