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(#45)  Six Strategies to Use When Imitation Doesn't Work

Greetings, SLP!

Squeezing in time to find, read, interpret, and figure out how to apply the results of research articles is difficult at best. Honestly, when I was a school therapist, although I wanted to read them, writing eligibility reports and IEPs, planning therapy, etc., being with my family, and living life took precedence.
 
If you have the same conundrum, I hope this once-a-month Research Review helps fill your needs.
 
I’ll do my best to choose articles that are beneficial and pertinent to therapy. (My personal bias is that ALL research should be therapeutically beneficial, but alas, it isn’t.)
Today is the first Research Review.
 
Following is a summary of the article, interspersed with my thoughts. My personal comments are in italics.
 
I think you’ll appreciate the practicality of this research compilation. In fact, when an article begins with a dialogue between a low-verbal 2-year old and a Speech-Language Pathologist (SLP) during therapy, you know it’s going to be practical. This article is extremely relevant and beneficial to any SLP that works with young children who struggle to talk.
 
Article
When “Simon Says” Doesn’t Work: Alternatives to Imitation for Facilitating Early Speech Development (2009)
 
Authors
Laura S. DeTorne, University of Illinois at Urbana-Champaign
Cynthia J. Johnson, University of Illinois at Urbana-Champaign
Louise Walder, Private Practice, Mahomet, IL
Jaime Mahurin-Smith, University of Illinois at Urbana-Champaign
 
Journal
American Journal of Speech-Language Pathology, Vol. 18, pages 133-145, May 2009
 
Link to the online article at ASHA's website; Click Here.
 
Purpose
To provide clinicians with evidence-based strategies to facilitate early speech development in young children who are not readily imitating sounds. Relevant populations include, but are not limited to, children with autism spectrum disorders, childhood apraxia of speech, and late-talking toddlers.
 
Method
Through multifaceted search procedures, the authors found experimental support for six (6) treatment strategies that have been used to facilitate speech development in young children with developmental disabilities. A summary is provided of the underlying rationale, empirical support, and specific intervention examples for each of the six strategies.
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Research in our field typically focuses on how to select and treat target speech sounds in therapy and emphases the importance of speech sound imitation. But what’s a therapist to do if the child doesn’t readily imitate and he doesn’t produce speech sounds?
 
The authors emphasize a void in our literature regarding this therapeutic dilemma and they attempt to fill the void with six, well researched, well thought-out practical strategies.
 
As you may know, I believe that SLPs can never have too many therapy options at their disposal. We work with little ones and while there are commonalities, there are variables such as age and where they are on their developmental path, as well as cognitive and learning differences, personality and compliance differences, capability differences, and many more. My advice to you and myself is: Be prepared--learn as many methods as we can. This article offers several.
 

Evidence-Based Strategies for Eliciting Speech-Like Vocalizations

1. Provide Access to Augmentative and Alternative Communication (AAC)
 
They highlight the use of AAC—manual signs, communication boards, electronic devices, etc.--because of the strong empirical support and its underappreciated role in facilitating natural speech development. See Millar, 2006; six studies were sited where 89% of the cases increased their speech production.
 
They shared several studies and examples as well as suggested websites. I’d like to include a plug for two of my favorite SLPs: Pat Mervine and MariBeth Plankers. Each of these ladies shared amazing information and ideas about AAC on The Speech Link podcast (you can also listen for free on iTunes, etc.). Also, I highly recommend Pat’s website for practical resources, www.speakingofspeech.com. She and her site are a wealth of information.
 
2. Minimize Pressure to Speak
 
High-pressure situations can have a negative impact on motor performance in both adults and children across a variety of tasks, including speaking. They cite several good studies to support this. One, (Baskett, 1996), resulted in children verbalizing more when interacting with the examiner via a video screen rather than face-to-face in person. They also suggest that using a puppet as a conversational partner decreases communicative pressure.
 
Strategies can take on a variety of forms, depending on the child (what he/she finds stressful) and the environment. Based on a variety of studies, they suggest avoiding direct requests for imitation, minimizing time pressure, and avoiding “test questions.” They do suggest following the child’s lead, utilizing familiar interactions and settings, as well as doing simultaneous vocalizations (“vocal contagion, Marshalla, 2003). This is where everyone vocalizes simultaneously, it creates less focus on the child’s voice.
 
3. Imitate the Child
 
Imitating the child is a low-pressure strategy, may help to engage the child, and may teach the child how to imitate. Imitation is an important piece in several therapy programs: The Hanen Program for Parents, and Greenspan’s Floortime approach. Hanen stresses the importance of imitation: “One of the best ways to connect with very young children who are just beginning to communicate is to imitate their sounds, actions, facial expressions and words” (Manolson, 1992). Another study (Field, Field, Sanders, Nadel, 2001; 20 non-verbal children with autism, ages 4 to 6), resulted in increased vocalizations when the adults imitated the children’s behaviors and vocalizations, compared to no increase in vocalizations when the adults only played with the children. They site several other positive studies.
 
A therapist’s imitation of the child might include verbal or nonverbal actions. Imitation of oral-motor movements could provide a useful springboard for facilitating verbal interaction.They suggest, what I call, “expansion.”If the child yawns, you yawn and add sound, for example.
 
Another suggestion by Marshalla, 2003, is to expand into song. The child says “baba”, you say “baba” then use that production to start the song “Baa Baa Black Sheep. It enables the therapist to assign meaning to vocalizations that are in the child’s repertoire.
 
Personally, imitating the child’s expressions (words, sounds, phonations, facial expressions, body movements) is one of the most effective techniques I use. If you’ve never used this technique, the first time you do it be sure to watch the child’s response; most are stunned. (They’re used to adults trying to get them to imitate.) Some children repeat the sound or action to see my response. It’s a great way to engage and hopefully keep the interaction going. I believe “reflecting back” encourages the child to focus on what he/she is saying and doing. Through the years, I’ve observed several children who were not consciously mindful that the sounds they heard were actually coming out of their own mouth. I love to see the look of surprise, and awareness, vocal play, and experimentation that eventually emerges.
 
4. Utilize Exaggerated Intonation and Slowed Tempo
 
Exaggerated intonation is commonly employed. They suggest that the primary rationale is that neural mechanisms involved in singing can be used to “bootstrap” speech production due to partially distinct but also overlapping neural networks(between music/song and speech production).
 
They sited a case study (Wade, 1996; a master’s thesis), that compared the effects of the use of Melodic Intonation Therapy (MIT) verses oral motor treatment with a 3-year-old girl with apraxia. Results indicated that the MIT was more effective for increasing phoneme production.(I am unable to locate the actual study therefore I do not know what type or techniques of oral motor therapy was used.)
 
Converging evidence supports the use of melody and exaggerated prosody to facilitate children’s attempts and accuracy at speech production. Exaggerated prosody can be overlaid onto any meaningful word or phrase.
 
5. Augment Auditory, Visual, Tactile, and Proprioceptive Feedback
 
Though established speech production is usually highly automatic and accomplished without attention to sensory feedback(I could be wrong, but when I return from the dentist with a new filling, sensory feedback seems awfully important….)the latter likely plays an important role in establishing new speech behaviors. Consequently, when imitation of a new speech movement is challenging under natural circumstances, they recommend enhancing sensory feedback to guide the new movement.
 
The small amount of literature on the benefits of enhancing sensory input or feedback focuses largely on manipulation of four domains: auditory, visual, tactile, and proprioceptive.
 
Examples: Face the child and accentuate the auditory and visual characteristics of speech. Amplify the sound of the child’s speech through headphones, an echo mic, or other chambers that creates an echo to attract the child’s interest and provide feedback. Enhanced visual feedback can be promoted by face-to-face interaction, mirror work, and gestures. A puppet can be used. In the tactile and proprioceptive domains touch-pressure cues and a variety of oral tools have been used to draw attention to key articulator locations.
 
Oral sensation is a primary factor in speech production. We don’t hear much about it, probably because it’s not visible. We only get an impression as to the capability of another’s sensory perception by initiating a stimulus and watching their response (similar to hearing testing; another sensation). Direct tactile input does immediately call attention to the touched location.
 
6. Avoid Emphasis on Nonspeech-Like Articulator Movement: Focus on Function
 
They quoted Lof (2006): Some of the most commonly used oral motor activities include blowing, tongue wagging, and smiling, in which a body part such as the lips or tongue is the focus, yet the direct relation to speech sound production is unclear.
 
The authors of this article conclude this section with the following: Although to date most studies of oral motor activities have focused on older children who are already attempting speech sound imitation, we recommend utilizing nonspeech activities judiciously and only when a child is not yet imitating speech sounds. In addition, the nonspeech activity should mimic the position, movement, and function of the target speech sound(s) as closely as possible. One final note: It is important to distinguish between the use of nonspeech oral motor activities, such as blowing bubbles or licking a lollipop, for therapeutic verses motivational purposes. Such activities may serve as motivating materials through which to implement the strategies we discussed, but may not in and of themselves facilitate speech sound production.
 
There have been times when working with low-verbal children that I would have given anything to hear something from the child that was even close to a speech sound. If it approximated a speech sound, I quietly celebrated.
 
Many children I’ve worked with had no awareness they even had a mouth. After all, unlike hands, you can’t see your own mouth, unless you look in a mirror and that’s second hand. Direct oral awareness is relegated to touch and proprioception (and auditory feedback to a degree, but that occurs after the mouth has done its deeds).
 
When doing therapy, the smart and successful therapist takes it case-by-case and designs and modifies his/her therapy according to what the child needs and is capable of doing. With most kids, I believe if they could say the speech sounds we’re asking, they would.
 
When we, as a profession, espouse that in therapy with all children we must stimulate speech sound production it is prudent we keep in mind what we’re asking our kids to do.
 
In my experience, repeatedly asking a child to say a speech sound that he can’t say is counterproductive and frustrating to both. It makes total sense to do therapy according to the child’s capabilities. Keep therapy child-centered. Begin with what he can do—even if it’s non-oral imitation--then shape, nurture, and expand into speech sound approximations/productions as the child develops the abilities to do so.
 
Conclusion
 
In addition, they suggested future research topics, and provided the following concluding remarks.
 
“In sum, many children who do not readily attempt sound imitation pose a significant clinical challenge in regard to targeting speech development. When experimental support is not readily available, clinicians need to give conscious consideration to the rationale for their techniques, and the research community needs to take seriously the charge to fill current gaps in the clinical knowledge base. Due to the paucity of explicit and comprehensive resources of facilitating speech sound development in children who do not readily imitate, we considered the theoretical frameworks and empirical research finders to emphasize six strategies to guide intervention.”
 
Yes, they did, and I agree.
 
The above is but a summary; this 9-page article is worth reading and digesting. For references, please go to the article. They have four pages chock full of references.Here is the link to the article to access their information.
We SLPs are on the front lines and have the honored responsibility of guiding our therapy-kids. I’m grateful to the authors of this article for giving us the rationale, evidence, and strategy examples that we therapists can use.
 
Thanks so much for all you do. Have a wonderful week!
Char

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