Tuesday, June 28, 2011

I'm Worried My Child Has Autism: Now What?

A month or so ago, I posted about the red flags for autism in toddlers. I described them in some detail and then summarized them as follows:
  • No single words by 15 months,
  • No two-word phrases by 24 months,
  • Lack of pointing to get people to look at things,
  • Infrequent use of gestures and facial expressions to communicate,
  • Decreased use of eye contact, especially to share joy or to check out a parent's reactions to an unknown situation,
  • Decreased engagement in social games such as peek-a-boo,
  • Lack of pretend play, and
  • Decreased response to adults when adults talk to them.
You can read the whole post by clicking here; there's a lot more information about those red flags that can help you understand each one.

Since writing that post, many parents have sent me e-mails wondering what to do if their children show some of these signs.  My heart goes out to each of these parents, because I, too, am a mom, and I know how hard it is to carry worries about your child with you each day.  It's a bit difficult to give good advice about a topic as complex as autism in a blog post, especially knowing that blog post will cross distance and time and countries.  My advice, then, is broad in nature.  But I hope it is enough to get you started.

If You Are Worried Your Child May Have Autism....

Seek Out Help 

The first thing you will want to to do is talk to your child's physician.  Share your concerns.  Ask what services are available and how you might access those services. Don't be afraid to advocate for your child. Not every physician is well versed in child development. Make sure your concerns are answered; switch physicians if you need to; ask around in your community to identify those who are regarded as experts in child development; do your best to make sure your child is evaluated by the people who know what they are looking for.  Evaluation is important, because it leads to treatment, and when it comes to autism we know that intense treatment that is provided early is often a huge key to success.  You can learn more about talking to your physician about your concerns by clicking here.

Learn More 

About Screening for Autism:
In addition to reading my post on the red flags of autism in young children, you may also want to use the M-CHAT to help you determine if your child is at risk for a diagnosis on the autism spectrum.  The M-CHAT (or Modified Checklist for Autism in Toddlers) is a short questionnaire comprised of simple yes/no answers. It is designed to screen for autism in children aged 16-30 months.  Failing it does not--DOES NOT!!-- mean your child has autism. It does mean, however, that he should be seen by a professional for further evaluation. Here's how you use it. 

1. Click here to download the M-CHAT questionnaire from the website www.firstsigns.org.  To get a unbiased picture of your child, complete the questionnaire before reading the instructions on scoring it.  Answer the questions in the way your child usually acts. If he does something rarely, answer that question "no."

2. Click here to download the scoring instructions. Read them very carefully, as they can be confusing to understand at first. 

3. If your child fails the M-CHAT, talk to your physician.  Remember that failing does not mean your child has autism...just that further evaluation is needed.

About Treatment for Autism:
Treatment for children with an autism spectrum disorder can be bewildering and overwhelming at first. There are many options, and many people who claim that their option is the only way to treat this disorder effectively.  If you suspect (or know) that your child may be (or is) on the autism spectrum, you will want to start learning about the different treatments that are available. A great place to start is by downloading the 100 Day Kit from www.autismspeaks.org. It's designed to assist families in getting the information they need in the first 100 days of an autism diagnosis. In it, you will learn more about the diagnosis of autism. You will also about the different treatments that exist, such as:
  • Early Intervention
  • School Based Services
  • Speech-Language Therapy and Occupational Therapy (which are often provided through Early Intervention and School Based Services and which often utilize a variety of the approaches described next)
  • Applied Behavioral Analysis, Pivotal Response Training, and Verbal Behavior--all carefully structured treatment approaches that are based on the principles of behavioral learning. In each of these approaches, big tasks are broken down into small skills that can be easily taught and reinforced, and are then brought back into bigger tasks again. 
  •  DIR/Floortime, which is designed to help a child reach social and emotional milestones and reconnect with those he loves,
  • The Picture Exchange Communication System, in which children learn to exchange a picture for a desired object,
  • Sensory Integration, the SCERTS Model, TEACCH, RDI, and more. 

    Start On Your Own

    One of the most important things to know about autism is that children with this diagnosis learn differently. They generally don't respond to typical parenting; instead, they need to be pulled into our world to connect and engage and learn--over and over and over again.  Fortunately, there are ways to do this. Unfortunately, it's not always easy. If you can't access services to help you do this, are waiting for services, or just plain want to get started with your child, there are two books I would suggest to help.

    1. The first is Overcoming Autism by Lynn Kern Koegl and Claire Lazebnik.  Chapter Two is entitled, "Ending The Long Silence: Teaching Your Child To Communicate," and is a wonderful introduction to using the principles of behavioral learning to help your child with autism begin to communicate. The rest of the book is full of practical, hands-on advice for helping your child across a wide variety of subjects. 

    2. The second is The Child With Special Needs by Stanley Greenspan. The first half of this book describes Dr. Greenspan's view on biological challenges, as well as the six developmental milestones through which Dr. Greenspan believed children need to progress. It's important information, for sure. But if you are looking to get started, flip further into the book, to the chapter titled, "Floor Time 1: Attention, Engagement, and Intimacy: Helping a Child Become Interested in The World and Connect With People."  This chapter, and the ones that follow, are full of easy to understand suggestions for helping your child reconnect emotionally with the world.

    (A note: Some professionals and parents who are well-versed in the world of autism may find it odd that I am recommending two books that explain two approaches to treatment that can sometimes be seen as highly contradictory and at odds with each other. Indeed, Overcoming Autism is based on the principles of behavioral learning, while The Child with Special Needs utilizes the developmental methods promoted by DIR/Floortime. Some professionals believe that you have to choose one or the other.  It is my own opinion, however, that the best treatment approaches draw from both sides of the coin; our children need both skill and emotional connection. Therefore, I am recommending both).

    Have Hope
    I have never been in the shoes of a parent with a child with autism, so I can not claim to fully understand how you feel.  But I have been through enough in my own life that I do understand how hard it is to be at the beginning of what may seem to be a daunting journey, headed steeply uphill. And I have walked next to dozens and dozens of parents as they have worked their way through the pain and come out the other side, stronger and full of love for the child that they have been given to parent. Have hope. It will get better.

    Do you have a helpful hint for families just starting out on this journey? Please leave it in a comment, below. 

    Greenspan, S., Wiedner, S., & Simons, R. (1998). The Child With Special Needs
    Koegel, L., LaZebnik, C. (2005). Overcoming Autism 


    Tuesday, June 21, 2011

    How To Help Your Child Produce Speech Sounds

    When most people think of speech-language therapists, they think first of the speech part of our jobs--the part that involves the actual sounds that make up the words we say.  Although our real job is much broader than this, and covers both speech and language, helping people learn to produce speech sounds correctly is certainly a large part of the job.  I've already written about the ages at which most children usually produce certain speech sounds correctly--you can find my post on typical speech sound development by clicking here.  But how do we actually help children produce speech sounds? That, my friends, is what this post is about.

    What's the difference between articulation and phonology?

    Before getting into the actual mechanics behind speech sounds, a quick word about the difference between articulation and phonology is important.   

    Articulation is the production of individual speech sounds in syllables, words, and sentences.  It's the thing you probably think about when you think about a speech therapist-- articulation therapy involves working with children to more accurately produce a specific speech sound such as "s", "l", or "r".

    Phonology, however, refers to the patterns of errors children typically make when developing speech sounds.  You can read more about these patterns by reading this post.  Often, when children are young, we work less on specific speech sounds and more on the patterns behind the errors they are making. For example, many young children will leave the final consonant off of all their words-- no matter what the consonant is.  So we work on helping them learn to produce a variety of consonants on the end of words, rather than focusing on one specific speech sound in particular. When we are using a phonology approach to treating speech sound disorders, we focus less on the mechanics and more on the patterns. The distinction between phonology disorders and articulation disorders is important, because they are treated differently.

    How do you help children produce speech sounds? 
    Having said all that, there is certainly a place for knowing how speech sounds are made, especially if your child is having difficulty producing once specific speech sound. It goes without saying that the best way to help your child is to seek out a great speech-language therapist to help you and your child figure out what sounds should be worked on and how to work on them. There is much more to speech-language therapy than could ever be contained in one blog, much less one blog post.  However, accessing speech-language therapy isn't always possible, and some parents simply want to try working on speech sounds on their own first. With that in mind, here are some tips and tricks for helping children produce speech sounds.

    Some speech sounds are highly visible and relatively easy to teach. For example:
    • The sounds /m/, /p/ and /b/ are all made by putting your lips together. You can generally show children these sounds and ask children to imitate you, and they will.
    • The sounds /n/, /t/, and /d/ are made by placing your tongue tip just behind your upper front teeth. Sometimes children need a bit of help getting their tongue in that precise spot, but once you show them this, they can imitate the sound.
    • The sounds /f/ and /v/ are made by placing your upper teeth on your bottom lip and either blowing (for /f/) or vibrating/humming (for /v/).
    Because these sounds are so visible, they are often easy to teach by just showing children what to do. Other sounds are more hidden and, thus, more difficult to teach. And some speech therapists (um, that would be me) need all the help they can get helping kids to produce certain speech sounds (oh, you dreaded /r/ sound...you haunt me so).  And that is where my new favorite blog, 2 Gals Talk About Speech Therapy comes in.  The two gals have done a fantastic job laying out some tips and tricks on how to help children produce certain speech sounds.  All you have to do is click below to find out...

    Want to learn more about speech sounds and kids?

    Friday, June 17, 2011

    Childhood Apraxia of Speech: What It Is and What To Do

    If you are a parent of a child who has speech and language difficulties, you may have heard of childhood apraxia of speech (CAS). Or, you might not have. Why? For two reasons.  First, childhood apraxia of speech is only one of the many reasons that children might have difficulty with speech or language.  When reading about apraxia, it's very important to remember that not every child who has difficulty with speaking has apraxia; in fact, most professionals think that apraxia is actually pretty rare. Second, the topic of apraxia of speech is much debated within our field--there is disagreement about how many kids have apraxia, how to diagnose it, how to treat it, what to call it (it's also called developmental verbal dyspraxia and developmental apraxia of speech or DAS), and even if it actually exists at all. Which means that I must openly state that what follows is my personal opinion about childhood apraxia of speech-- an opinion that is based on a mix of formal education, research review, and experience working with children who I believe do, indeed, fit into this category.

    What is Childhood Apraxia of Speech?
    So. First things first. What is childhood apraxia of speech? It's thought to be a motor speech disorder which makes it very hard for children to accurately produce speech sounds.  Children with childhood apraxia of speech can use their mouth muscles for things such as eating with no difficulty at all. They struggle, however, when they purposefully try to use their mouth to speak.

    Initial signs of childhood apraxia of speech are as follows:
    • Limited history of babbling
    • Late in starting to talk
    • Use of only a few vowels
    • Use of only a few consonant sounds
    • Very hard to understand
    • Might say words out of the blue and then never say them again
    • Often (but not always), understands language very well and attempts to express her wants/needs/ideas through gestures, facial expressions, and intonation.
    However, children can have these signs and not be diagnosed with apraxia of speech. This is because it's really only possible to accurately diagnose apraxia of speech when a child does start talking, or at least when she's only enough to really understand what is being asked of her and can try to imitate sounds and phrases upon request. This is when we start to see the following types of errors in speech that suggest that a more probable diagnosis of childhood apraxia of speech:
    • Vowel errors
    • Unpedictable and inconsistent speech sound errors-- a child might say a word one way one time and another way another time. This helps us differentiate between apraxia of speech, typical speech development, and a phonological disorder.  In both typical development and phonological disorders,  kids make speech sound errors, but the errors are usually consistent (for example, a child might always say "tat" for "cat"). You can read more about what consistent errors children typically make here.
    • Increased errors as sentence length increases (for example, saying "mama" well when saying it as one word only, but not being able to say it when saying it in a two-word phrase)
    • Being able to produce a word in a learned and often repeated context (for example, while reading a repetitive book) but not another new context
    • Difficulty producing new words and phrases as compared to words and phrases that have been practiced many times
    • Groping or otherwise physically struggling when trying to produce a speech sound or word
    • Difficulty imitating oral motor movements (for example, difficulty imitating you sticking out your tongue). This is called oral apraxia.
    What should I do?

    What if you suspect (or know) that your child might (or does) have Childhood Apraxia of Speech? It's impossible to capture all the possible suggestions in one little blog post, but here are some tips to get you started.
    • Learn more. A really great website for learning more about apraxia of speech is www.apraxia-kids.org.
    • Seek out a great speech-language pathologist. Apraxia of speech can be frustrating for everyone involved and can take a while to resolve-- a good SLP can be a great guide down the road that you'll be following for a while. You can read more about speech therapy for children with apraxia of speech here and learn how to find a good SLP with knowledge of apraxia of speech here.
    • Use repetitive books, repetitive songs, and carrier phrases such as "Ready, Set, Go!" Children with apraxia of speech will often find it easier to begin to speak when they are able to "drop" a word into a phrase they have heard many, many, many times.
    • Start small and build up. Children with apraxia of speech have difficulty moving from one place to another in their mouth, so we don't make them do this at first. We start with very simple consonant-vowel words with easy sounds, such as "me" and "boo" and "hi" and then help them move to simple two syllable words such as mama and dada from there. Then we keep building. You can read more about which sounds and syllable shapes are easy and hard here.
    • Help your little one learn to communicate with signs or pictures for a while. This will not prevent her from learning to talk, but it will help relieve some of the frustration that may result from her having difficulty expressing herself verbally.
    • Have patience....this is the hardest, but the most important of all the steps. With hard work, determination, and time, things will get better.

      More posts on Apraxia of Speech:

    Strategies for Apraxia of Speech:

    Forrest. K. (2003)  Diagnostic criteria of development apraxia of speech used by clinical speech-language pathologists.  American Journal of Speech-Language Pathology, 12(3), pp. 376 - 380

    Friday, June 10, 2011

    Two Word Phrases: What To Expect and How To Get There

    Around 18-24 months, kids reach a very important language milestone: they start putting words together into two-word phrases. This usually happens right about the time they reach a vocabulary of 50 words, and it's important because it often marks the beginning of a language explosion, during which children begin to acquire language rapidly.

    The fun thing about two word phrases is that your understanding of a two word phrases is dependent on your knowledge of the situation at hand. As children get older, they can be much more precise about what they are saying because they use longer sentences and grammatical markers such as possessive -s (e.g., daddy's shoe) to clarify their meaning. But when children are dwelling in the land of two-word phrases, one phrase might mean many different things. When my daughter says, "Daddy shoe" for example, it could mean, "Daddy look at my shoe!" or "That's daddy's shoe!" or "daddy take my shoe off," or "daddy my shoe fell off!"  The only way to know which one she means is to look at what she is doing and do our best interpretation (and run the risk of a toddler tantrum if we get it wrong!).

    Despite their lack of clarity, there is some predictability to these phrases.  During this phase of language development, most young children will use the following types of two word phrases:
    • Description word + Object (Big bubble)
    • Possessor + Object (My bubble)
    • More + Object (More bubble)
    • All done/gone + Object (All done bubble)
    • Negative + Object (No bubble)
    • Object + Location (Bubble up)
    • Person doing action + Action (Mama Blow)
    • Action + Object (Blow Bubble)
    • Person doing action + Object (Mama Bubble)
    As speech-language therapists, we like to look not only at the number of two word phrases that a child is using, but also at the variety.  It's important that children learn to use a wide variety of these types of phrases. Usually this happens all on its own, but some children will get stuck in one type of two-word phrases;for these children, it's our job to help them understand how to use a wide variety of phrases to express their needs and ideas.

    There are lots of ways to help children with two word phrases. Here are just a few.
    • You can use expansion on a regular basis. When your child uses one word, put it into one of the above listed two word phrases for him, making sure that the two word phrase you choose is related to the meaning of what he said. This is something all parents can do on a regular basis to give their child's language a boost.
    • You can integrate two-word phrases into the choices you give him. (More bubbles or all done bubbles? Bubbles up or bubbles down? Mama blow or Ben blow?).
    • You can set up motivating situations in which you model and require two word phrases, as I described here, in a post on Joy's Autism blog.  In the post, I suggest using pictures to help children understand that each word has meaning, but pictures are optional. They work best for children with a diagnosis of autism, children who are highly visual learners, or children who haven't responded to other methods of increasing their use of two-word phrases. 
    Looking for more information on two-word phrases?