The Autism and Childhood Apraxia of Speech Connection
I am a UK-based Speech and Language Therapist experienced in working with children who have an autism spectrum disorder (ASD) as well as severe speech difficulties that can be best described by childhood apraxia of speech (CAS).
I have been touched and inspired by the amazing progress made during therapy and I want to, in turn, touch and inspire others by sharing my experience. I want to reassure others in the same or similar position that it is possible to help these children develop clearer speech.
CAS is generally believed to be neurological in nature. It affects motor planning and speech production in the absence of any muscle weakness or paralysis. Typically, a child will be unable to voluntarily place the jaw, lips, and tongue consistently and/or smoothly transition from one sound to another. CAS also affects a child’s ability to sequence sounds within words.
ASHA (2006) discuss CAS as “…a subtype of severe childhood speech sound disorder…likely of genetic origin…” The condition generally leads to long term speech problems.
Speech therapy needs to be delivered early, using tactile and visual cues. Vowels should be worked on as well as stimulable consonants. Therapy should be frequent, at least twice per week with carryover practice, in order to be most effective. I use a combination of Oral Placement Therapy (OPT) and the Nuffield Dyspraxia Programme (NDP).
Some sources state CAS and ASD do not co-occur, but Merkel-Walsh & Rosenfeld-Johnson (from Talk Tools) assert that “oral motor therapy including OPT for children with ASD, is an essential part of their speech therapy program…” This therapy is often used at the beginning of my work with a child who has autism, especially if I suspect CAS may also be present.
The oral motor therapy helps eliminate any underlying muscle weakness and prepare muscles for work on coordination through a step-by-step speech program such as the Nuffield Dyspraxia Programme (NDP). Murray, McCabe & Ballard’s (2015) findings show the Nuffield Dyspraxia Programme (NDP) has a significant treatment effect.
Case Study: Brendan
I first met Brendan when I was practicing in a community pediatrics role. Brendan was six years old. He was a lively boy with dark hair and a fabulous smile. He was already diagnosed with autism and had a recent diagnosis of verbal dyspraxia (UK term for CAS) from a private therapist. He was pre-verbal and used a Vantage Light communication aid to supplement his ever-expanding Picture Exchange Communication System (PECS) book.
In class, he would sit in group time passively watching as his peers joined in. With his communication aid he would distract himself and others by repeatedly pressing the icon that allowed the aid to say ‘swimming,’ enjoying how the word sounded as well as his wishful thinking that swimming might appear soon on the timetable! The only sound I heard him use in attempts to speak was ‘g-gg.’ Unsurprisingly, despite being keen to speak, it was not possible to understand his few attempts. This was a young boy who, despite his autism, was not trapped in a bubble and was not making full use of alternative communication methods.
He demonstrated to me that he had the desire to speak. So, I accepted the challenge of helping him achieve his verbal potential. We began by learning the pictures for the different sounds used in the NDP. Alongside this we explored his oral muscles to check for any underlying weakness in the jaw, the lips, or the tongue.
Brendan accepted the jaw tools without problem and quickly worked through a hierarchy to develop good jaw strength. Good jaw strength and stability is necessary to enable the lips and tongue to do their own jobs properly. It would also be crucial in establishing clarity in longer words and, ultimately, sentences.
Brendan was willingly supported by his parents and his class team, and he made a good start. He used his lips to make more vowel sounds and soon he added ‘m’ ‘p’ and ‘b’ to his repertoire. When it came to the tongue, we discovered a new barrier—Brendan was unable to gain the position for many sounds involving the tongue tip lifting up to the alveolar ridge (just behind the front teeth). The therapy manual told me we should use small round cereal with a hole in the middle as a tactile prompt for the tongue tip and for Brendan to then hold it in place.
There was a small problem—Brendan did not like this cereal! However, the creativity of the class team prevailed, and we began using small pieces of barbecue Pringle crisps instead. It worked! Brendan gradually gained the correct placement and then began to build up strength by holding the crisp in place for longer periods of time.
When he could reliably manage the correct placement we dropped the crisp but continued the exercise until he could hold his tongue in place for five lots of 50 seconds. At that point he was ready to transfer the skill into speech. He demonstrated muscle memory by repeating speech sounds in sequence, e.g. ‘n-n-n’ ‘d-d-d-,’ managing to bring his tongue back to the same place each time.
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At this point, the OPT was no longer needed, and we continued to work as a team using the NDP, helping Brendan use more sounds in more complex word structures. After 18 months of hard work, motivation, and determination, we were all rewarded with Brendan’s amazing progress.
He had gone from the young boy who could not talk to a child who could speak in sentences! He could use all his sounds, and most people could now understand him. The positive comments from people around school were so good to hear.
Brendan’s story is one of the first times I was privileged to follow a child from the very beginnings of speech right through to sentences. Since then I have used the same principles to support many other children like Brendan. You can read more about Brendan in A Journey with Brendan by Dr May Ng, a parent and consultant pediatrician.
This article was featured in Issue 94 – Daily Strategies Families Need