I was thrilled to do this Q&A with Dawn, Cali’s speech therapist. Biases aside, I believe Dawn to be one of the best speech therapist out there. Why? Because not only is she licensed as a speech therapist, but she is also trained in various autism therapies as well. Hope you enjoy her answers. Here it goes:
Question 1: There are thousands of speech therapists working and helping kids, but not many who specialize in speech therapy for autistic children. When and how did you start becoming so specialized in speech therapy for autistic children?
When I was training in college, (ok, I’m old! This was 1993-1995ish) there were not any specific classes or training related to autism. It was addressed kind of “on the side”. During my clinical work (at the college, supervised by professors), I worked briefly with 2 students with autism.
Right out of college, I went to work at Primary Children’s Medical Center. I remember that, a year or so into working there, I attended an in-service training given by one of the hospital’s doctors in psychology. I was fascinated! At that time, the diagnosis of autism was exploding and she spoke about the characteristics and how to “spot the children lurking in your practice” (after all these years, I think that is nearly an accurate quote! — It made that much of an impact on me). So I did! I considered the children I was currently working with (realized it with a few), and became better at recognizing any signs in the children I evaluated.
I was interested, and challenged – my main motivators. So I sought out training, ideas, theories, and soon my colleagues started to defer to me (somewhat like, “you like it, then you take these clients!”) So I did! I had days filled with new challenges and questions and, honestly, sometimes left work exhausted and completely rattled! But, I also sometimes saw little triumphs and found “in-roads” into reaching even the most affected kids. I was hooked!
Since then, I have still seen a variety of kids with differing speech/language challenges, but as life has taken it, I have channeled my interests toward this area of treatment. I continually seek to learn more and try new ideas to be able to help children with autism in the best way I can.
Question 2: What are some key skills that separate you from an ordinary speech therapist?
Wow! I don’t know that I am more than ordinary! But, I’d say that in particular to working with children with ASD, I have tried to become trained in many different therapy modalities and then I kind of “mesh” them with my own style. That sounds weird, but what I mean is that I have had training not only in traditional speech/language pathology methods, but also in ABA, PLAY project, Floortime, etc. And I do mean etc! I have looked into programs that parents have discovered (asking my opinion), I try to keep current on any new theories, and am always willing to try something.
Question 3: Just because a child is delayed in speech, does not mean they have autism. What other delays or tendencies should a parent be aware of when contemplating whether or not their child has autism?
In addition to speech delay, one should consider:
1. Social Behaviors such as
–lack of nonverbal behaviors such as eye-to-eye gaze, appropriate facial expression, and/or gestural communication.
–failure to develop age-appropriate peer relationships
–lack of seeking or responding to shared social enjoyment and interaction
2. Restricted or repetitive patterns of behavior, interests, or activities.
Question 4: Are there certain techniques or parental involvement I can implement from birth that have the potential to help speech emerge at a typical rate?
It has been scientifically tested and widely documented that parents (and particularly mothers) are “hard-wired” to engage in the kinds of behaviors that encourage typical speech/language abilities. You might think of it as “baby talk”, but the technical term (oh thanks scientists!) is “motherese”. This is the (usually instinctive) tendency we have to raise our pitch, vary our intonation, include gestures, and exaggerate our expressions, when interacting with an infant. (Come on! you know what I mean – you get goofy! I do it every time a see a baby near me!!)
So, doing what comes naturally is best. Talk to your baby, do the silly things that make him or her smile, play with sounds –imitating each other back and forth. I also like the idea of “baby sign”. This entails using simple gestures (doesn’t have to be formal sign language) with your young baby. Gross motor skills develop earlier than verbal skills, so a baby can “talk” to you before he or she can form the words and sounds.
Question 5: What is the difference between a speech delay and a speech disorder?
Technically, a speech delay is when a child is gaining skills in a typical developmental order, but at a slower rate. A speech disorder is defined more by irregular development (some higher skills while lacking others), or atypical patterns of communication. The terms are often used interchangeably, but you need to be careful which terminology is used if you looking for qualifying for services or insurance coverage.
Question 6: My daughter has low muscle tone as a result of her autism. Can this affect her speech? If so, what muscles are the ones affecting the speech? Do you have some suggested exercises we cam do to help strengthen these certain muscles?
Low muscle tone can affect speech production if the oral musculature is affected. Muscles involved in speech include the lips and tongue, of course, but also the jaw, cheeks, palate, larynx (voice box), and the respiratory system. Muscles involved in posture can also come into effect if weak.
The problem, however, is that current research is showing that the variety non-speech oral-motor exercises we have been using are not effective in improving speech. Yeah, I’ve used them because I was told I should, but personally never saw great results.
From Dr. Gregory Lof, a PhD level speech-language pathologist from MGH Institute of Health Professions in Boston: “If clinicians want speech to improve, they must work on speech, and not on things that LOOK like they are working on speech. Speech is special and unlike other motor movements.”
“Phonetic placement cues that have been used in traditional speech therapy are NOT the same as non-speech oral motor exercises.” You can and should still give your child verbal, visual, and tactile cues about placement of his tongue or lips to help him make a speech sound correctly. The difference here is that you’re actually working on SPEECH and not just a movement.
Oral motor exercises have their purpose. While they seem to be mostly ineffective for improving speech production, they are effective for treating many issues related to feeding. And that is an important distinction. If your child is drooling, or unable to move food around with his tongue and chew, Oral Motor Therapy can be very effective if provided by a competent therapist.
Bottom line — to strengthen speech, work on speech.
Question 7: Most autistic children have a difficult time with eye contact. Does this play a part in speech delays? If so, can you give some quick tips on how to improve eye contact?
Reduced eye contact definitely affects speech and language development. Typically developing children soak in information by watching others. This includes information about forming sounds and learning new words.
My main tip is going to sound far too simple, but hear me out. It’s this:
We are so anxious to help our child, to get them to speak, that we often fill the space with too much verbal input and direction. If you know what your child wants (and you are there to provide it), wait expectantly for your child to look at you. If he or she is verbal, and repeating the same request over and over again, but without establishing at least brief contact, be quiet and wait. Likely, he or she will eventually turn to you to see why his/her requests are not being met. At that point, immediately provide the request item or action. Use animated, big social reinforcement (truck! Here’s the truck!!), but it is not always necessary to reinforce “good looking”, or to direct “look at me”. Sounds simple, but is harder than it sounds. But, I feel like any skills a child learns “on his own” (i.e., figures out what to do to get his wants and needs met) is much more powerful than telling or instructing him what to do 100 times over. I have a couple blogs about this (Wait, and Stop trying to get your child to talk on Autism Journeys blog).
Question 8: At what point to you consult a speech therapist about your child’s delayed speech?
In my opinion, as soon as you have concerns! Sometimes there are things you can do to “kick-start” speech/language development at home. If this is the case, earlier is better. Then, if early strategies are not producing results, further assessment and intervention may be necessary, but you will be ahead of the game, knowing what has and has not worked.
Parents are the best judges of their child’s abilities. Rarely, have I encountered parents who are worried without reason. If you feel something is not right, seek help.
If you really want age recommendations, even under 12 months is not too early if you have other behavioral concerns as well. If your child is not beginning to use single words by 1 year or so, consulting someone would be appropriate, especially if there is a lack of gestural communication, or babbling sounds.
Question 9: I tend to stick to reading books and using flash cards to help improve my child’s speech? What other techniques and avenues can I take to help establish typical speech?
Books are such a great way to develop language. You can expand on reading them by asking questions such as “What do you think will happen?” or “Why is he sad?”. Also add comments that link information to your child’s own life (e.g., “That’s like when we …,” or “You like things like that..”). You can also expand on book themes by doing related activities. If you are reading a story with frogs, you can also sing 5 Green and Speckled Frogs, look up different kinds of frogs on the internet, do a “frog” craft like a drawing or a puppet, talk about what parts a frog has, what a frog does, where a frog lives, etc.
Other basics can be:
Not anticipating your child’s need. Let him/her have to communicate wants and needs.
Providing a model by slightly expanding on your child’s utterance (e.g., child says, “truck”, you add, “red truck” or “go truck”.
Question 10: What are the speech related milestones I should be looking for after my twin girls turn 3 and 4? Do you know of a good resource for me to reference when searching speech related developmental milestones?
Y ou can found reliable information on the American Speech-Language-Hearing Association website at
Question 11: When my child reaches a vocabulary of about 50 words, how do I help him put words together, besides modeling? For example he knows yellow and bus. How do I get him to say both together?
You can try making it necessary to use 2-words to request by having choices or alternatives. If there is only 1 bus and it’s yellow, it is not really required to use both words to get it. However, if there is a yellow bus, a green bus, a yellow block and a green block, you need 2 words to specify the right one. You can do this with favorite snacks, maybe offering non-preferred alternatives if needed (for example, red and blue m&ms, with red and blue paper scraps – saying “red” doesn’t clarify, but if you know your child wants the candy, give him “red paper”. Then you may need to model, “oh, you want red candy… red candy.” You can do similar tasks with big/little ___ (what kid wouldn’t rather have a big cookie than a little cookie?), more/alldone ___, open ___, etc.
Question 12: After hearing tests are administered and the results come back positive, should a parent then be concerned about the quality of their child’s words? For example, if bus sounds like “busch”? How can we make their words clearer?
Positive as in no hearing loss? Or positive for hearing loss? I’m gonna assume no hearing loss, then..
Whether to be concerned about speech quality or the production of specific speech sounds, depends on the child’s age and skills relative to other communication skills.
There are things you can try to improve speech sound production
Model speech sounds in play. Blow up a balloon and as the air goes out, say “ssssss”.
Point out the sound in different words, “sssun”.
Point out “minimal pairs” – as in the difference between a “bus” and a “bush”.
(If results were positive for hearing loss, you should seek advice from an SLP with experience in working with children with hearing loss.)
Question 13: My daughter has been in speech since she was three (she just turned 7). She’s made excellent progress but still struggles with her “r” sound, especially if i’s in the middle of a word (like in the word worm). Will she always struggle with that sound?
There’s no reason she should always struggle with it, given effective treatment strategies. The “r” sound is one of the most difficult to produce and the middle of the word as you are describing, is the trickiest. There are actually different kinds of “r” productions phonetically. The one you are referring to is the “stressed vowelized “r”, and I usually work on it last.
Question 14: My son is VERY inattentive. Do I need to work on the attention first before the speech? Will the speech ever come if he doesn’t know how to attend to instruction, teaching, or activities?
That’s hard to say for your child individually without seeing or trying some things. However, speech therapy does not have to be “sit at a table and look at me”. I certainly have a couple kiddos that make me sweat! We play and jump and run and go upside down, and fall silly to the floor. At the same time, we work up to developing attention in a more structured way. So, to answer the 2nd part of your question, speech can develop, but working on the attending is also important and once established leads to a great potential for progress in speech and other areas.
Only in a few circumstances have I recommended delaying speech therapy when a child is unable to attend, and that is only because I work with a team of wonderful therapists to whom I can defer for more “developmental” work in the interest of making the best use of the child’s time and the parents’ resources.
Question 15: My son’s speech therapist gives us flashcards to work on at home. He hates practicing though. Do u have any techniques that might encourage hime to cooperate better without having to bribe him (he’s 4)? Ha….I’m laughing at this one!! This one might have you stumped;) Although maybe you could explain that you do use reinforcers, which some would call bribes, but explain why reinforces are a good thing.
Ah, flashcards. Wow, they can be boring! Don’t get me wrong – I own a lot of them and use them. They are often the easiest way to represent a concept or word. However, using them exclusively, over and over again, is not effective for some kids. I have certainly had them thrown in my face a time or two! But I don’t stump that easily One time that this happened, I thought “ok let’s do it!” and we threw the cards. Once the game was established (and most kids think it’s at least kind of funny), I could delay throwing until we practiced. This is now a favorite of mine and has many variations. You can tell the card “bye ___”, or “go ___”. Sometimes even having something manipulative to do with them is fun. We have slid them under the door, put them in a slotted box, taped them to the wall and looked for them with a flashlight, or taken turns hiding them for each other. In short, if there is something to do with them, kids might be more tolerant of the practice.
Reinforcers – in a nutshell, are necessary and effective when used correctly. None of us do much without being reinforced for it (we go to work to get a paycheck, do special things for our family (because we love them) but also because we enjoy their appreciation). The misunderstanding is that reinforcement is bribery. This is only true if used incorrectly. Also, reinforcers don’t have to be treats. Sometimes an exaggerated “woo hoo”, high five, tickle or hug is all it takes. Lately, Cali works for time to watch My Little Pony on my IPAD. I’ve even made it more specific so that she earns tokens for “working”, each equal to a minute of watching (only took once of only getting 1 minute vs. 5 before she got the concept). This way, tokens can also be removed for not working or for problematic behavior. The most effective reinforcement system depends on each child’s abilities and interests. I’ll work on a more detailed explanation of reinforcement options and post it soon on our Autism Journeys blog (I think Where did the Bird Go? links to it).
Question 16: At what age should I be concerned that my child stutters or has a lisp?
Well, actual “stuttering” should be diagnosed by an SLP with experience in that area. During development, kids can produce dysfluencies in their speech which are normal. True stuttering is different from that in its nature and severity of how it affects the child. At any age, if the dysfluencies in your child’s speech make a listener take note and feel uncomfortable, or your child is frustrated or struggling, seek an assessment.
A lisp – honestly I don’t know. I have tried to find an answer to this, as well. My first 2 children did it. There are some that say it is developmental and will “go away”. Others who say it is never normal in development. So here’s what I’d say, if it bothers you, or especially your child, see some further advice. In my mind any age guidelines are super seceded if the child is becoming negatively aware of any speech difference, being teased, or avoiding communication because of it.
Question 17: Are there any games (board games or card games) that help kids with speech delays?
Tons! A favorite company of mine, and now, Chelsea’s, is Super Duper School Company. They have lots of specialized materials for a wide variety of speech and language targets. I have to say though, that often these products can be overpriced and sometimes too specific. If you don’t see yourself being able to use it many times, or in many ways, consider fashioning your own version. I like many “regular” games that I can use in many situations, modifying the rules or play to target the specific child’s needs (e.g., Candyland, Lucky Ducks, Chutes and Ladders, Go Fish, and on and on).
Question 18: My son will say, “I not know” or “her not want that”. Is this considered a speech problem or is that part of normal development?
Depends on his age and other skills. By itself, not necessary unusual for a 3-, 4-year-old or younger.
Question 19: My son qualified for speech therapy through our school system, once a week for 30 minutes. I feel like he needs more. Do I have a say in this? Or do I just have to accept what they give me?
That sounds so familiar. That is often about what they offer, given limited resources, but NO! you don’t have to accept it and you absolutely have a say. You do not have to a sign an IEP you don’t agree with. Speak up and ask for more
Thanks Dawn for all the answers given. If even of you have more questions regarding these topics or totally new questions. Leave a comment below and we can shoot it over to Dawn.