Motor Impairments & Aspects of Speech

What are the motor impairments of children which impact ability to execute the motor skill of voice onset, phonation, and articulation in autism? How do we know this? What is an application of this knowledge to a direct clinical example?
Here are some introductory terms explained by Gretz (2010. Glossary. CASANA online):
Articulation-Contact between two structures (such as the lips, jaw, tongue, velum)
of the oral cavity that shapes the vocal tract.
Voiced-Speech sounds produced using the vibrating vocal folds
Phonological Awareness -Understanding of the sound structure of language, including the recognition that words are composed of syllables and phonemes that can be changed and manipulated to create new words and meaning.
Phonology-The speech sound system of a language and the rules for combining them.
Phonation - process by which vocal folds produce certain sounds through quasi-periodic vibration (those who study laryngeal anatomy and physiology and speech production in general) Other phoneticians, though, call this process quasi-periodic vibration voicing and they use the term phonation to refer to any oscillatory state of any part of the larynx that modifies the airstream, of which voicing is just one example. Wikipedia (2010. online resource).
Motor skill deficits have focused on gross and fine motor occupations especially by occupational therapists. A speech therapist may consider the motor impairments of speech acts. Poor posture may affect correct patterns of speech breathing. The lack of attention to faces and in imitation skills can hinder development of motor skills needed for speech. Davis et al. (2008) cite means, motive and opportunity as three interconnected necessities for communication. A student with ASD will have listeners in family members, teachers, aides, and classmates. There is a wide array of means for communication available especially for nonverbal students. Once motivation is present the three-fold compilation to communicate is there. In younger children with ASD obtaining a desired item is often used to begin intervention. Treating the whole system is much more complex and would take a detailed assessment using interviews, observation and standardized assessments as per Froleck (2004). Individuals with ASD can have low tone, hypersensitivities of the mouth or motor planning/coordination issues that can impair speech production. “The core impairment in planning and/or programming spatiotemporal parameters of movement sequences results in errors in speech sound production and prosody.” (American Speech-Language-Hearing Association, 2007, p. 4).
Oral- motor control also contributes to speech production. The picky diet of an individual with ASD can impede this progression if certain foods are avoided. The same muscles used in speech production are enhanced by swallowing and sucking while sucking, swallowing and chewing are not foundations for speech. The sequence of oral-motor control will be listed below for your reference (adapted from American Speech-Language-Hearing Association, 2007, p. 8-9). Also, for your reference a language development chart from the Child Development Institute can be accessed via a link on the sidebar or it can be viewed on a separate page noted at the top of the blog.
-jaw control - 15 months
-upper and lower lips
-tongue development
-individual articulators (lips, different portions of the tongue)
Although speech and feeding may use the same muscles they actually have a negative correlation “ as feeding patterns involve tight linking of lips with jaw in a highly rhythmic stereotyped pattern. To produce a variety of syllables within varied prosodic patterns requires the child to overcome the interdependent inflexible patterns associated with sucking. “ (American Speech-Language-Hearing Association, 2007, p. 8). The tongue is used for sucking and swallowing and eventually moving food around in the mouth but is also used to produce certain syllables. Motor planning and coordinating the use of the lips, tongue, jaw and breath takes time and development. Individuals with ASD may not experience the practice stage of babbling seen in typical peers that helps form and refine speech sounds. This adjustment phase continue through age 5 and 6 for articulation and even in the middle school years and beyond speech can still be less consistent than adult speech. (American Speech Language-Hearing Association, 2007).
Prizant in Gretz (1996 in 2010, CASANA, www.apraxia-kids.org) concurs that oral motor skills “can be a significant factor inhibiting the development of speech in some children with autism. For instance:
* Some children demonstrate the classic symptoms of oral motor problems such as difficulty in coordinating movement of the articulators (lips, tongue, jaw, etc.), feeding difficulties, drooling past the age when most children are able to control saliva, and low facial muscle tone.
* Symptoms that are consistent with a diagnosis of developmental apraxia of speech. These symptoms may include: use of primarily vowel-like vocalizations and limited consonant repertoire (consonants require greater motor-planning ability); intelligibility which decreases with length of utterance (single word and single syllable production may be more clear than extended utterances or multisyllabic words); differences in automatic versus volitional speech (echolalia may be more clearly articulated compared to spontaneous speech attempts).”
Toth et al. (2006, in Frietag et al. 2008, p. 1481) states that “it might be possible that difficulties in biological motion perception might underlie these impairments imitation and joint attention skills, which are skills, that are strongly linked to later social and language development.” In the How Do We Know This? Section of this blog post, agreement is made by Dr. Michael Crary as nonspeech motor functions are the first area to look at. (1993 in 2010, CASANA, www.apraxia-kids.org).
Shriberg et al. (2001, Appendix, p. 1115) describe a prosody-voice profile of males with ASD. I filled it in with commonly found areas noted throughout the article. The following findings are from a study they did using males with High Functioning Autism (HFA), Asperger’s (AS) and typical peers: It involves exclusion codes where the individual will interrupt/overtalk others or may only use one word. Prosody-voice codes include phrasing issues of sound/syllable repetition, word repetition, one word revisions and repetition and revision. The rate had slow articulation and pause time. The stress displayed issues in multisyllabic words, reduced/equal stress such as monotonous speech and excessive/equal/misplaced stress. Voice is the final area of the profile and they have determined that those with ASD tend to be loud, use high pitch/falsetto, and have laryngeal features such as register breaks and diplophonia and exhibit nasal resonance features. The HFA group took longer to speak and used stress inappropriately which may affect a listener’s patience and following the conversation, question or response. Fay and Schuler (1980, in Shriberg, et. al., 2001, p. 1100) report that some members of the HFA group may use a “sing-song” voice. Listeners may also not interact with the individual with ASD due to nasality common in their voice (Shriberg, 2001, Appendix, p. 1115). The authors also note some articulation distortions (p. 1104). In my experience it does seem as they may have low tone of the jaw and mouth/cheek muscles or praxis issues at times. In summation of this article, “Speech that is too loud and/or high pitched can create an impression of overbearing for or insistence; speech that is too slow and/or nasal may create the impression that the speaker is condescending” (Shriberg, 2001, p. 1110). An individual with ASD may have issues with voice modulation due to listed prosody factors, mood, internal or external stress or attempted sensory habituation.
How do we know this?
In the same article by Gretz on speech production “Dr. Michael Crary outlines a number of areas for clinical observation and evaluation, including: nonspeech motor functions…speech motor functions…articulation and phonological performance…language performance…other: ability to sustain and shift attention, reaction to speech, distractibility.” This would be a good reference to review prior to considering the need for a speech evaluation (1993 in 2010, CASANA, www.apraxia-kids.org).
Powell (2010) discusses two ways to assess how we know why speech delays are evident. These include quantitative and qualitative methods. Quantitiative assessments use numbers or scores while “Qualitative approaches de-emphasize the use of numbers and attempt to describe the individual's language. Standardized tests (such as the Test of Language Development - Primary:3 [TOLD-P:3] or the Clinical Evaluation of Language Fundamentals - 3 [CELF-3]) are good examples of the quantitative approach to language measurement. Analysis of a spontaneous sample of language elicited under naturalistic conditions would be an example of a qualitative approach.” (Powell, 2010, CASANA, www.apraxia-kids.org). It is best to use both as mentioned by Froleck et al. (in Miller-Kuhaneck, et al., 2004). Qualitative information can be obtained through observation in a natural environment and documenting language production. Powell (2010) tends to use standardized assessments first to rule out certain types of problems and to help gear informal observations. On a standardized assessment, it is important to note that “A low score could be related to low language ability (it could also be related to other factors such as attending, hearing, vision, compliance, etc.)” (Powell, 2010, CASANA, www.apraxia-kids.org). A final thought is to remember that speech and language are two separate entities.
What is an application of this knowledge to a direct clinical example?
“Frequent practice of sounds and words helps to improve speech (Velleman, 2005) and reduce some of the pressures associated with expressive language.” (in Solomon, M. and Pereira, L. 2010). Repetitive books are suggested as one intervention. They are because of their “predictability, presence of carrier phrases, frequent practice of target sounds, familiar inflection, and an introduction to phonemic awareness.” (Solomon, M. and Pereira, L. 2010). Books may be especially good with those who have ASD due to having pictural accompaniments which may help predict what comes next as well as the rhyming. It lessens their cognitive demands and may increase willingness to communicate. Having a cozy comfortable reading environment may also be conducive. As you read the same story after the child is familiar with it, you can leave blanks for them to fill. This is also good with common songs while winging as another example. This promotes more active involvement in the occupation. This activity also lessens the response which may be easier at first to entice the child. Later, depending on the story expectations can be made for phrases or sentences. Some children’s book also can be purchased with puppets for when the story know and can say the majority of the story. You wouldn’t want to use all character puppets demanding a fine motor task along with the motor task at first. To increase motivation, the therapist may have a puppet of the main character. If the child is very resistant to this method they may want to read along with a cassette version of the story to prepare them. You always want the just right challenge to encourage self concept and decrease frustration. It also may help those with ASD produce inflection, stress and pauses or other prosody components at appropriate places as they will tend to memorizes the lines. It can also help with emotional expression depending on the story. Since those with ASD may already use a sing-song voice, this may be a good starting activity to be generalized as progress is made. See the List of Repetitive Books & Helpful Hints by Solomon and Pereira by clicking on the page at the top of the blog.
In Summary, motor impairments need to be considered when assessing the individual with ASD’s ability to use speech. There are some characteristics specific to the diagnosis that impact speech performance. This occupation must be distinguished from language and quantitative and qualitative measures together are most beneficial in assessment. There are numerous interventions. A basic one that may appeal to children with ASD has been provided. Please see further links related to this post added as pages to this blog.
References
Davis B, Velleman S .Semin Speech Lang. 2008 Nov; 29(4):312-9. (2008) Establishing a basic speech repertoire without using NSOME: means, motive, and opportunity.
American Speech-Language-Hearing Association. (2007). Childhood Apraxia of
Speech [Technical Report]. Available from www.asha.org/policy.
Frietag, C.M., Konrad, C., Haberlen, M., Kleser, C., von Gontard, A., Reith, W., Troje, Nl., Krick, C. (2008) Perception of biological motion in autism spectrum disorders. Nauropsycholgia, 46: 1480-1494.
Froleck, Clark, G., Miller-Kuhaneck, H. and Waitling, R. in Miller-Kuhaneck, et al (2004) Chapters 6: Evaluation of the Child With an Autism Spectrum Disorder. Bethesda, MD: the American Occupational Therapy Association, Inc.
Gretz, S. (2010. online resource).Glossary of Speech and Language Terms. The Childhood Apraxia of Speech Association of North America (CASANA). www.apraxia-kids.org http://bboard.misericordia.edu/webct/cobaltMainFrame.dowebct?appforward=/webct/startFrameSet.dowebct%3Fforward=manageCourse.dowebct%26lcid=463865245001
Gretz, S. (2010 online resource). Speech Production and Children with Autism. The Childhood Apraxia of Speech Association of North America (CASANA). www.apraxia-kids.org http://bboard.misericordia.edu/webct/cobaltMainFrame.dowebct?appforward=/webct/startFrameSet.dowebct%3Fforward=manageCourse.dowebct%26lcid=463865245001
Powell, T. (2010). A Brief Overview Of Language and Approaches To It's Assessment: One Professional's Perspective. The Childhood Apraxia of Speech Association of North America (CASANA). www.apraxia-kids.org http://bboard.misericordia.edu/webct/cobaltMainFrame.dowebct?appforward=/webct/startFrameSet.dowebct%3Fforward=manageCourse.dowebct%26lcid=463865245001
Shriberg, L. D., et. al. (2001) Speech and prosody characteristics of adolescents and adults with high-functioning autism and Asperger syndrome. Journal of Speech, Language, and Hearing Research, 44(5): 1097-1115.
Solomon, M. and Pereira, L. (2010). Repetitive Books: An Effective Therapeutic Strategy for Children Diagnosed with Apraxia of Speech. The Childhood Apraxia of Speech Association of North America (CASANA). www.apraxia-kids.org http://bboard.misericordia.edu/webct/cobaltMainFrame.dowebct?appforward=/webct/startFrameSet.dowebct%3Fforward=manageCourse.dowebct%26lcid=463865245001
Spitzer, S. in Miller-Kuhaneck, et al (2004) Chapters 5: Common an Uncommon Daily Activities in Individuals with Autism: Challenges and Opportunities for Supporting Occupation. Bethesda, MD: the American Occupational Therapy Association, Inc.
Wikepedia. (2010 online resource). Phonation. http://en.wikipedia.org/wiki/Phonation