When Speech Gets Stuck

[vc_row][vc_column][vc_column_text]BY MARGE BLANC, M.A., CCC-SLP

THE STORY THAT FOLLOWS HAPPENED EXACTLY
THIS WAY… IT’S ALL TRUE, EXCEPT FOR THE NAMES.
I walked through Eddie’s backyard, where I had
gone for a first home visit. I had just met Eddie
and his sister, his mom and his dad. Eddie imitated my name quietly, almost in a whisper,
saying “Mah” as we ran along. Without any signs of obvious enthusiasm, he went over to his swing set, whispering a short syllable. It was such a quiet voice that I almost missed it. But his quiet “sih” (for “swing”) was unmistakable
to ears that have become acutely tuned to such fleeting, subtle pronouncements.

“I hope you can teach Eddie to talk,” said Eddie’s mother; and his father echoed an equally fervent plea. How was I going to tell them that Eddie already did talk? I had been in this situation many times before, and knew that an instant retort would be ill-timed, and seem lacking in credibility. I knew I’d have to
wait until I knew Eddie, and his parents, better.

Parents are clearly not to blame for not “hearing” Eddie and others like him. In fact, we are all “programmed” to think that talking comes in a certain form, with a certain loudness, with a certain rapidity, and, of course, with accompanying eye contact and referencing (pointing, gesturing, etc.).

We think this is always true because it almost
always is! Our phone systems expect that we will
pause no longer than two seconds. If we do, they
cut us off. Our voice mail systems expect us to
never talk at a high frequency, or too loudly, or too
softly. If we do, they cut us off. It is just “not done.”
And, we are programmed as parents and teachers to expect that
kids will make eye contact and gesture long before they begin
talking…a handy order-of-events for us, so we’ll know that they
are talking, that they’re talking to us, what they’re talking
about, and that they want us to listen and to respond.

But, those of us who know and love at least one child on the
spectrum know we don’t have the benefit of this “expected”
order of events. Rather, out-of-the-blue one day, we may hear
a sound, a word, even a phrase or sound contour…and never
again. We think our ears have deceived us…and we are sure
that we should not take it seriously. We think we can’t afford to
delude ourselves into thinking our child actually talked, or has
the ability to use the language it would have required. We are,
somehow, “bound” by our child’s diagnosis to think that our
child’s language must be “disordered,” and that since his
speech doesn’t sound like real words to us, that it is “babbling”.

Back to Eddie… Unlike his parents, I didn’t have to worry
about being deluded. I had heard dozens of children like Eddie
say things that were later validated by repeated, clear productions, and/or other signs of communicative intent, like independent typing. Waiting for that next time a child said a particular word or phrase, though, sometimes seemed to take forever. Usually it did not, however. I learned that if the people surrounding a child believed his words to be real, they would reappear sooner.

That was the key! What if Eddie really didn’t say my
name, though…or didn’t tell me what he wanted to do? Would it do him any harm
if I thought he had and responded accordingly? Does it do infants any
harm when moms hear “mamamama,”and presume [read: “hope”] it means,
“Mama?” No, of course not. It is this delighted parental reaction to sound that
teaches kids that speech has meaning. It is how children learn to talk!

Shouldn’t our “non-verbal” ASD kids
have the same opportunity? Of course
they should! And it should be delivered
with even greater regularity and “benefit
of the doubt.” I’ve witnessed, first hand,
the positive results that can be achieved
with our kids when we presume their
communicative intent and respond
accordingly. (Blanc, 2004.)

We have all read that, historically, nearly
half the individuals with Autism Spectrum diagnoses have failed to
develop useful oral language. They have been known as “non-verbal.” And
we have all known that motor coordination problems are
prevalent across the spectrum, with Occupational Therapy
leading the way towards understanding the complexity of
“praxis” or motor planning. But it was not until 1997 that
Speech-Language Pathologist Gail Richard reported in her
book, The Source for Autism, that the 40% or so on the spectrum
who are significantly challenged with Apraxia of Speech (Verbal
Dyspraxia) are the same 40% who have not developed useful
speech.

Looking at Eddie, one can understand why. Eddie’s voice was
extremely quiet…not just because his confidence in being
understood was so limited. His muscle tone was low, making
all his movements slower and weaker, and the timing of his
verbalizations seemed “random,” so no one knew when to listen.
Essentially, no one could hear him. Without some encouragement and feedback, Eddie was not going to become a competentspeaker on his own. But kids like Eddie are not alone any more. Our kids with
apraxia now stand an excellent chance of defying the odds of
the past and becoming verbal!

How? The rest of this article will address that. First of all,
know that there are now excellent resources and many trained
SLP’s, OT’s, and PT’s to help. If your child’s therapist is trained
in Sensory Integration, your child will have a good start. Why?
Because we now know that the sensory/motor “pieces” that
challenge your child in his overall sensory
and motor learning affect “praxis” as well.
And what is praxis, you ask, and how does
this translate into speech?

Praxis, as defined by OT’s (after the pioneering work of Jean Ayres), and now used
by the rest of us, refers to motor plans…that
is, formulating an idea, or an “intention” to
do something unique with one’s body, initiating it, following through with it, and ending it. It is important to note that dyspraxia is a disorder of motor planning, not automatic motor execution. If a motor pattern
has been practiced long enough to become
automatic, it is no longer a “plan.” Our kids
are readily able to return to familiar motor
patterns. We see this is so easy, in fact, that
they become “repetitive behaviors,” and
may risk being labeled “stereotypical
movements” or “stims.”

Let’s look at an example at a whole-body or
gross motor level. A motor plan might be
formulated when a child sees a favorite
food (a cookie) on a counter top in the
kitchen and decides to climb up to get it.

Initiating the plan might mean climbing up
on the chair that’s conveniently, but uncharacteristically, right
in front of the cookie. Following through with the plan would
include getting over to the chair, climbing up, reaching for the
cookie and successfully getting it. Ending the plan would mean
NOT continuing to climb up higher, NOT crawling over the top
of the counter, but stopping long enough to eat.

Do you see your child in this scenario? I see some children who
go over to the chair but never get to the point of standing on the
seat. I see others who get up onto the chair successfully, but
who don’t stop climbing. I see many others who start towards
the chair, but get “sidetracked” along the way, making their
original intentions a challenge for us to read. I remember vividly the first time a child, with severe motor planning challenges,told me, “I’m stuck,” as he literally could NOT move from his
sitting position at the top of a slide.

It is important to observe kids closely, since we will see kids
getting ‘stuck’ far more often than we will have the opportuniO U R K I D S
with apraxia now stand an excellent chance of defying the
odds of the past and becoming verbal!

8 September – October 2004 AUTISM n ASPERGER’S DIGEST
ty to hear them tell us about it. This is because such kids are
usually rendered speechless too. Yes, praxis can affect the
coordination of any muscles of the body, including those that
produce speech. An amazing array of muscles needs to coordinate before a child can talk fluently…muscles of breathing (specifically exhalation), muscles of voicing/phonation (vocal
folds), and the muscles of articulation (oral speech), including those of the jaw, tongue, and lips. So, it is a rare child who can tell you that the rest of his body is “stuck.” His muscles of speech
are probably “stuck” too, even more so. or “jargon.”

When the “stuckedness” occurs at the level of breathing, there
is insufficient air with which to produce voice. Kids might
move their lips, but nothing comes out. The stuckedness can
occur at the level of phonation, too, so sometimes a child can
whisper, but not say something out loud or loudly enough to be
heard. SLP’s are quite used to another kind of stuckedness, that
of the speech articulators. Kids might be able to produce a nice
voice but without a coordinated flow of sounds or syllables.
“Classic” apraxia of speech is like this…unintelligible, disjointed sequences of sounds, with a quality that is flat and forced.
But, even kids who are typically unintelligible, or even silent,
occasionally have “islands of fluency,” when it all comes
together perfectly…once in a blue moon. They enjoy their
moment in the sun, never able to recreate it again.
All of these scenarios, and dozens more, are within the rubric
of apraxia, or, more accurately, dyspraxia, referring to problems with praxis, but not lack of it altogether. It all seems very
confusing, I know. But, getting our kids ‘unstuck’ is possible,
using a hierarchy of supports that we have developed in our
clinic and use with our ASD kids with dyspraxia every day.
We’ve witnessed that severely dyspraxic kids do make
progress…tremendous progress…as long as the supporting levels for physical development and coordination are honored and provided. It cannot be stressed enough that “speech is
movement,” and, as such, “speech therapy” is movement
therapy…fun movement therapy!

Praxis is about figuring out how muscles move together, and, for our kids (all 40% of them)
who are “stuck,” we need to provide frequent and appropriate
movement opportunities that give them all the feedback their
growing bodies need. When provided with enough of the right
supports (including the help they need to access them), kids
will move (although it may not be steadily) through the hierarchy, eventually achieving fluent speech that honors their drive to communicate and matches their internal intentions.

This process will likely take years, which seems discouraging, I
know. But, I can tell you from considerable experience that in
the context of the interaction, communication, and play where
most of this ‘training’ occurs, kids love it! And it’s clearly better
than the alternative – remaining minimally verbal.

Before addressing the hierarchy in depth, it’s important to
review some of the foundation “pieces”. These come to us from
the extensive work of OT’s like Jean Ayres, and are now being
incorporated into the work of many SLP’s. It helps to look at it
this way: in the example above, if the child trying to get to the
cookie can’t see where the chair is in relationship to the cookie, doesn’t yet know how to climb, and doesn’t have the
strength to hold out his arm or grasp with his fingers, the “plan”
could never materialize. In other words, praxis depends on a
“body schema” (Where are my knee joints? Where are my fingers?) and a sense of where one’s body is in relationship to the
room, the chair, and the cookie. All the senses must be working well enough to know these things. Successful praxis particularly involves the tactile (skin) sense, proprioceptive
(joints and muscles) sense, and vestibular (balance) sense.
What SLP’s are realizing is that the same is true for the mouth
– a pretty mysterious space if you can’t feel and move it’s parts
– and the internal connections among breathing, voice, and
articulation. Most of us were never faced with “planning” how
to move our jaws and tongues in order to learn to talk. But for
our kids, it is a truly awesome task, when you think about it.
Nothing, even deep breathing, is automatic, and exercising
until it becomes automatic seems to take forever. Our kids have
to actually “plan” to exhale (witness the kids trying to talk on
inhalation rather than exhalation). When it comes to coordination with voice (to make a sound of any kind), the “work” is
intensified. That our kids want to talk so badly that they voluntarily practice each step over and over and over is a tribute
to their deep intentions and will! Fortunately, we can make
their practice fun and rewarding, and they can learn the power
of speech early on.
Amazingly, our kids tackle even more than these praxis challenges on their way to becoming fluent speakers. If the oral
senses are not fully developed, or are overly sensitive, “oral
motor” therapy can do for the mouth what PT/OT does for the
rest of the body. Oral motor therapy can be “hands on”
(Beckman) or “hands off” (Marshalla, 1999), but typically cannot be overlooked completely. Even if every sensation the
mouth feels is noxious to a child (sensory defensiveness), this
can be successfully addressed with the Wilbarger Protocol
(Wilbarger, 1991). And, you can rest assured that oral motor
therapy and praxis therapy work together and concurrently.
Back to our main topic. The supports for dyspraxia begin at the
level of the whole body; sensory/motor work at a gross motor
level will get your child started. The hierarchy works with
the knowledge that gross motor comes before fine motor
development, and that speech articulation is the “finest of
the fine,” when it comes to the numbers of small muscles that
must work together for intelligible speech to occur. As will
become apparent in reading the hierarchy, speech is a multilayered phenomenon, only a part of which is movement of the
muscles of the lips, tongue, and jaw. If we only view articulation as the complete definition of “speech,” we risk teaching
splinter skills, verbalizations that the child will not be able to September – October 2004 AUTISM n ASPERGER’S DIGEST 9

access in any way other than the one in which they were learned
(think of kids who can say “m” only when prompted, “say ‘m'”).
Such skills – usually taught before a child was developmentally
ready – are limited and more importantly, limiting, because they
are not a part of hierarchical, supported development.

The reason the hierarchy works is because each level has been
adequately practiced and developed, in the context of fun and play,
before it is used to support the next higher level. While there is
clearly cross-over among the levels, each successive level is targeted until it is reliable enough to support the next.

Conversely,when something becomes challenging at any particular level,
there is a next-lower level to fall back on to find
comfortable production. We always find it helpful to talk about
these forward and backward movements with kids, so they know
that it is OK, even expected. It is not “regression.” It is just part
of the process.

Part 2 of this article will start with broadening the typical concept of “speaking,” so that you will be able to rejoice along with your child as you embark on the first of the eight levels that make
up the hierarchy of supports for dyspraxia. You will learn that we
all use our breathing and our voices to communicate, even when
we never open our mouths! We’ll then share some successful
tricks of the trade to help dyspraxic kids move from being ‘stuck’
to becoming fluent speakers!

In Part 1 of this article (September-October
2004), we explored the idea of developing fluent, flexible speech from “the bottom up.” This
means deep breathing, helping your child coordinate breathing (exhalation) with voice production (vocalization or “phonation”), and
finally, coordinating all this with more and
more refined movements of the jaw, lips,
cheeks, and tongue (the speech “articulators”).
In Part 2, we will see how oral communication is
achieved at even the most foundational level if
we are well-attuned to our kids. We will revise any misconception
you might have had that “speech” is just what happens with the
mouth, and instead, help you to know that whenever your child is
making ANY sound with exhalation, that he is speaking! And he
communicates when you listen!
We will then move up the eight-level hierarchy of support for
dyspraxia, assured that while communication occurs at each
level, its expression becomes more and more understandable
(intelligible), as we move up the continuum. While the process
takes many years, they are fun years, and infinitely more rewarding than remaining minimally verbal!
Our goal at each level is spontaneous, fun, and fluent output,
regardless of how “basic” that output seems. It all matters, and is
foundational to what is to follow! By “fluent,” we mean freeflowing, unhindered and unforced production (no, “Say …” is
wanted here!) Imitation is difficult with dyspraxia on the continuum, and no matter what you read about dyspraxia off the continuum, don’t ask your child to imitate until the time is right
(somewhere between levels five and seven)!
We want your child’s production at each level to
become so easy that it will support the next higher level. Believe me that it can be done! And your
child will have fun getting there! All you need to
get started is a sturdy bed to bounce on (most of
us eventually get trampolines though!) and as
many pillows as your family can put in one room.
While you will want to pursue an OT and/or PT
evaluation sometime soon, if your child is unable
to bounce, or if it feels aversive to him, you
should pursue that evaluation right away.
Let’s start now to become familiar with the support hierarchy for
speech. The first, or foundational, level is breathing, specifically deep (“diaphragmatic”) breathing and exhalation. It occurs
at a whole body level, and is what happens when a child is jumping on the bed, running hard, swimming, climbing through a pillow pit, or leaning over an inner tube and swinging. This level is
all about fun exertion, which promotes lots of long breaths in and
long breaths out. Your child may make some noise here, and that
is a plus…but it’s not necessary for success at this level. At this
stage, we are primarily thinking about the middle of your child’s
body (the “core”), where deep breathing takes place. Amazingly,
this area also supports the trunk, shoulders, neck, and arms. The
eventual support for gesture, and even the jaw, lives here, and the
more the upper body can become coordinated with the lower
body, and deep breathing, the better. OTs and/or PTs will be crucial at this stage of the support “game.”
Knowing about this level will serve you well at all the successive
levels, because as you move up the continuum, and all else fails
(as it will sometimes), returning to level one is “grounding,” and
10 November – December 2004 Autism n Asperger’s Digest
SSSS kkk
A HIERARCHY
OF PRACTICAL
SUPPORTS FOR
DYSPRAXIA IN
CHILDREN
WITH ASD
PART 2
BY MARGE BLANC, M.A., CCC-SLP
When
SpeechGets
Stuckwww.autismdigest.com n November – December 2004 11
restores a sense of support to the voice and speech systems. Your
OT, PT, or SLP will help you find equipment that can be added to
your child’s play area, and advise you about what activities can be
taken on at home or at the playground. The best rule here is to
“find the smile” in your child, and watch for good deep breathing
from the belly area, as the muscle of deep breathing, the
diaphragm, lowers to support it.
The second level of the support hierarchy is voicing, or vocal
production. This is what happens at the
level of the larynx when adequate air
flows through the throat. When the muscles of the larynx (vocal folds) vibrate,
voice is produced and the child is “vocalizing.” Sometimes, a child’s first pleasant
experience with voice happens during
laughter (crying and screaming in pain
rarely work as productive vocal experiences, since there is so little awareness of
voice under such strain). Laughter elicited through joyful physical experiences
such as spinning or tickling (whatever a
child truly delights in) is a wonderful first
voice experience. I will never forget the
wise child who silently lifted up his shirt
for a tickle so that he could “find” his
“lost” voice when he laughed. When a
child has been essentially silent all his life,
this stage of supported development is
magic. The child feels power and the
world knows he is there! Loudness is
enhanced with more air flow…more
bouncing, etc., and with adequate playful
experience making sound, kids have a
second, solid place to return to when “all
else fails” at the levels higher up.
Another important part of support at the second level is shared
joy in movement, fun, and vocalizing. This is where adults get to
be kids again, to let go and have fun…yelling, singing, laughing,
and humming on a kazoo the entire time. This not only takes the
pressure off the silent child, but “models” the kind of vocal output we are supporting at this stage. Remember that dyspraxia is a
disorder of “planning,” so the key here is to never have expectations for your child! The moment a child senses your expectation, he has to try, and when he has to try (or “plan”), he is rendered silent, or his sound becomes forced!
The third level of the hierarchy is that of intonational support.
Parents and therapists should not even think about this level
until kids achieve pretty reliable, automatic “vocal access” at level
two. This does not mean vocalizing whenever a child “wants” to
(since “trying” makes it harder, of course). It means that kids
know that they can run and get on the trampoline whenever they
want to get their voices going again, and they enjoy joining you
in yelling, screaming, laughing, and generally playing with the
immense variety of ways voices go up and down (intonation).
In our clinic, we spend lots and lots of time supporting kids at
level three, because, truth be known, most of the meaning of oral
communication is carried with intonation, and not with words at
all! Listen to conversations at an airport, in the other room, on
the bus, and hear how intonation sounds when you can’t hear the
particular words.
Once kids develop some intonation, we
begin to understand what they know. If
you are so fortunate as to have a child
who is already at this stage of development, listen carefully in the next week,
and see how many “intonational utterances” you can hear. Hypothesize what
your child might be saying with his
voice…and, over time, you will probably
find out that you were right! When the
clarity of “No way!” or “I know!” or
“Come on!” emerges at later stages in this
progression, you will be amazed at how
long your child has been “talking.”
The transition from level three to level
four is a huge one, and one you want to
make sure your child is ready for. You
know that your child can enact some gross
motor “plans,” and you can see that his
sense of his body in space is improving. He
doesn’t get “stuck” at the tops of slides or
in his car seat nearly so often. He probably
has plenty of automatic motor sequences
that he can’t get out of, however, and this is
classic level three behavior. You’ll see what
I mean in the next paragraph…where we start to address stopping
and starting (or “initiating”).
The fourth level of support is the first where “control” starts to
emerge.We do not want to rush into this stage, and you will want
to have an experienced SLP listen to your child before deciding he
is ready. This level is one of starting, stopping, and maintaining
sound. Your child will know how to keep his voice going already,
and stopping is often just a matter of running out of air. First
attempts at “starting” voice, however, are another story. They
often come in brief “fits and restarts,” like saying “ha ha ha,”
where the pause between syllables is short. This is because true
“initiating” is the hardest part of the challenge of dyspraxia, and
usually, kids just have to sneak up on it.
Supporting your child at this stage means knowing that momentary successes cannot, yet, be duplicated. That is fine. Let it go for
the day. Return to it tomorrow. And, in between, drop back to the
third level and have fun talking! A great trick here is to get your
…true
“INITIATING”
is the hardest
part of the
challenge of
dyspraxia,
and usually,
kids just have
to sneak
up on it.child giggling in whatever way you know will work. Then
“model” (everything we say is an unintended “model”) something fun like, “Gotcha!” or “Wow!” or “Hey!” When your child
“initiates” vocalization in the midst of your vocal play, it won’t be
“from scratch,” but, hey…giggling is vocalizing! It is a “backdoor”
technique that will feel like initiating, and will, over time, become
more commonplace.
The fifth level of support has often been going on for one or
more levels already, but it is not until now that we give it our
attention. This is the level of vowel sounds. Vowels are a result
of changes in the size and shape of the oral cavity (mouth) when
air flows through it and voice is produced. It’s nothing more than
that, but the effect is powerful!
As with all the levels, support comes from the bottom up, with
play partners using the open sounds “ah” or “uh” in their play,
and all the others too, such as “oh,” “uh oh,” wow, and hey. Ask
your SLP to note how flexible your child’s mouth is, and include
any exercises recommended to “stretch” it. Food variety and
mouthing toys are helpful in your child becoming more aware of
his mouth and how to move it. By this time, you have learned a
trick or two from your OT and PT also, and know that how your
child supports his head (especially his jaw) is critical to his success with vowels. Trunk control is as important as it ever was, so
go back to some of the OT/PT “basics” as well.
The sixth level of support is that of consonant sound development, even though the child may have already developed a
few consonants along the way (the “m” sound is nothing more
than voicing with the mouth closed). But at this stage in the
hierarchy, kids are really ready to take off in their consonant
sound production, usually following a developmental progression from lip sounds (m, b, p) to back-of-the-tongue sounds (g,
k, ng), to front-of-the-tongue sounds (n, d, t), and then the
more controlled sounds (l, r, s, sh, f, etc.). This level is the one
most people think of as “speech,” and it is helpful to realize how
much must happen before it can be really successful. We know
that a “splinter skill” like, “Say ‘b’,” for
example, fails to generalize into conversation and play. If this level is targeted when the child is ready, however, generalization happens readily,
because all the lower levels support it.
The sixth level involves the production
of all the consonants of the language,
in all their variations, as they precede
or follow other sounds. These movement patterns involve accurate timing,
pressure, and grading of all the muscles
of articulation, while maintaining
vowel production, intonation, and
voice. Support at this level involves play
with rhythm and timing, singing and
chanting, coordination with motor
movements such as gesturing, signing,
clapping, and finger tapping, specialized oral motor “tricks” like resistance
(horns, straws, etc.), and facial touchcuing like PROMPT (Hayden, 1984).
Work closely with your SLP to learn
how to use supports your child likes
and finds helpful, and remember that
this is still play, not imitation
work…yet.
The seventh level is putting it all
together in running speech, sequencing sounds in all the possible orders of
the language, coordinating the transitions from sound to sound, and using
10 Tricks of the Trade to help.
dyspraxic kids get unstuck.
and moving towards fluency:
1Give your child fun, easy access to equipment and space for bouncing,
climbing, jumping, and pushing/ pulling his arms…at all times! Make sure it is
considered ok and even “cool” to use it all day long, not just for “sensory
breaks”. 2 Join your child in every activity…never hold back from jumping,
laughing, yelling, making sound effects, or just being silly! You are making
reciprocity possible, offering your child the give and take that was never
possible in infancy. 3Gently “motor” your child into getting started whenever
s/he gets “stuck”. 4Rely on the level of support just below the one you are
targeting in your play or work. 5Remember that “speech” is not just
“articulation” of sounds sequences. Rather, it is all the beautifullycommunicative intonational contours kids learn at level three, and involves all
the levels, down to level one. Your child is a speaker…he is learning to “talk
better”. He is not “non-verbal”. 6Know that the hierarchy works! It may take
years before the layers underlying articulation are supported enough that you
can effectively “work on speech”, but when the time is right, articulation will
have the opportunity to “take off”! 7 Learn to listen closely! You will become
an expert at “reading” your child’s voice and intonation. 8 Don’t panic! I
cannot stress enough, don’t panic! Your relaxed attitude will comfort your
child…and take the pressure off him. Rest assured that a child who has not
been essentially silent all his life will be thrilled just to be heard and taken
seriously! 9Stay in constant contact with your SLP, and share your child’s
latest successes frequently, if not daily. This person will be your ally for years,
so get into the practice of letting each other know what you’ve heard, and what
to listen for in your child’s blossoming speech. 10 Stay hopeful! There is
good reason to!www.autismdigest.com n November – December 2004 13
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The Hierarchy of
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a rate that eventually approaches “normal.” The practice work
your SLP will provide at this level involves saying target utterances, while varying the emphasis and intonation, thus changing meaning. The level of practice material changes at this point,
because spontaneous imitation will be pretty easy now. That’s
what “fluency” is all about…imitation only when it is not “trying”
any more!

A word to the wise is in order here. Your child’s expressive language will start to explode now, as his consonant sounds start coming. Sounds won’t be reliable for some time to come, however, and you may not be able to understand him as well as you did!

As ironic as this seems, this is classic “apraxia of speech,” where
sounds get mixed up, and the sound your child intends for the
end of the word, for instance, occurs at the beginning. Resist asking him to repeat himself just yet…even if he can, it requires more “planning” than it is worth at this point, and it will probably
come out differently anyway! Better to teach yourself to replay his speech in your own brain…and with your own lips…and to listen closely! Remember that intonation is still your best clue, and that your child’s timing will become better! As it does, you will see the “referents” (e.g. the cookie) more often, and have more tangible clues for understanding! The eighth level involves accessing all the levels of support,
under more and more purposeful conditions, within the real
challenges of daily life.

Remember that apraxia is a disorder of “trying.” So when trying becomes harder, so does the possibility that an individual must rely on a more foundational level of support to approach a particular situation. Specific strategies at this level will include role-play and practicing under simulated conditions (you’ll find that all those apraxia “programs” will begin to fit here), and then under a variety of supported real-life conditions.
Now to summarize: one of the nice things about a hierarchy is
that it has, as part of its structure, a level for everyone, whether
they’re having a good day or a bad day, that provides positive
support. There’s always a level to drop down to when one level
is challenging.

One area that will likely remain a stumbling block for months, if
not years, is level four, initiating voice. Kids like the boy mentioned earlier who asked for tickles in order to start his voice, had learned that “initiating” the motor plan of speaking is often the
hardest part of talking. How many kids do you know who can talk “till the cows come home” once they get started, but, if they become too sedentary, their silence can stretch long into the day?
Kids will advance beyond level four, but still need to return to it
(and even level two) when they have momentarily “lost” their voice.

Kids realize this, and so they often want to keep talking, just
so they won’t lose their voice and have to initiate getting it started again. Don’t be surprised at this, and don’t let your child become discouraged. It is a natural part of what the OTs call14 November – December 2004 Autism n Asperger’s Digest “alertness” or “arousal,” and when kids become too sedentary,
and have lost deep breathing, support for voice is also lost. Get
them up and moving, get their “engines” going, and they will
learn that this is their “fail safe,” and rely on it for years to come.
(DeGangi, 2000; Williams and Shellenberger, 1996)
Now you know the fundamentals and how you can help your
child, in a developmentally-appropriate way, alongside the treatment he is receiving from your SLP (and OT and/or PT).

With this understanding available to us, we are prepared to revisit the common portrait of our children, the 40% of our ASD kids who would have remained “non-verbal” in the past, the ones we
called “low functioning.” Arms at their sides, standing on the
periphery of life, they appeared disinterested and perhaps intellectually limited. But now that we understand the hierarchy of supports for dyspraxia, we can ask one crucial, informed question, “Can this child initiate action…of any kind?” If he cannot motor plan with his legs…or his arms…or his voice, he is “stuck.”
But, what if we started him running, or climbing, or sliding, or
jumping…what could he do then? And then where could he go
next? Try it yourself…again and again and again…remembering
the hierarchy…and you will find out![/vc_column_text][/vc_column][/vc_row]

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