#090: Apraxia and Autism:
What is Apraxia with Tamara Kasper
The first time one of Tamara’s clients had a behavior analyst on the team, was an eye-opening experience for her. In three hours, the behavior analyst taught her client with autism more than Tamara had in three months, and she knew that she needed to understand ABA therapy more. Today, Tamara trains other professionals on how to teach children with autism to speak using speech pathology and ABA techniques.
Apraxia is a neurological disorder that results in a motor planning deficit which means that kids have difficulty producing and sequencing sounds to form syllables, words, or longer utterances. Apraxia can be more difficult to diagnose in kids with autism, but Tamara argues that it doesn’t matter if apraxia is misdiagnosed. Treating children with autism for apraxia, with an eye on their unique circumstances, can only help them learn to more carefully form sounds and communicate better.
Because apraxia is about poor oral skills, we talk about some of the challenges around sippy cups, pacifiers, and bottles, which are often used by parents or teachers to keep a child quiet when they’re struggling to communicate, but which promote poor oral patterns that prevent speech.
I’ve met Tamara several times and have listened to her at conferences and I just knew I needed to talk to her about the challenges of helping children with apraxia. She is so generous with her knowledge, and I hope you can learn something new from her today.
Tamara Kasper, MS, CCC-SLP, BCBA has practiced for nearly 30 years, specializing in treatment of children with autism. Tamara has devoted her career to identifying and developing effective treatments to promote functional communication and social interaction skills. Under the mentorship of Dr. Vincent Carbone, Tamara became a Board Certified Behavior Analyst. Tamara is a frequently invited international lecturer, directs The Center for Autism Treatment, and received the Wisconsin Speech-Language Pathology and Audiology Clinical Achievement Award.
- The steps a child needs to take before you can focus on fine-tuning articulation.
- The difference between speech therapy for typically developing children and children with autism, and why it is so incredibly important to understand it.
- Why speech pathologists and behavior analysts are more effective when they work together.
- How pacifiers, bottles, and sippy cups promote poor oral patterns.
Attend a FREE Workshop!
— MaryBarbera.com/workshop (Sign up for a free workshop online for parents and professionals)
— #010: Rosemarie Griffin, SLP & BCBA: Increasing Speech
— #041: Teamwork & Collaboration Between SLPs and BCBAs: Interview with Dr. Joanne Gerenser
— #053: Dr. Mark Sundberg – Using VB-MAPP to Assess and Teach Language
— Pacifier & Bottle Weaning for Children with Autism in 6 Easy Steps
— Northern Speech Services
— National Autism Conference
— Timing of the Diagnosis of Autism in African American Children
— Center for Autism Treatment
— K & K Speech Cards
Transcript for Podcast Episode: 090
Apraxia and Autism: What is Apraxia of Speech? | Interview with Tamara Kasper
Hosted by: Dr. Mary Barbera
Mary:You're listening to the Turn Autism Around podcast episode number 90. And today I have a very special guest, Tamara Kasper, who is both a speech and language pathologist for almost 30 years, as well as a board-certified behavior analyst for a number of years as well.
Mary:I first came across to Tamara's work when I was at the Carbone Clinic in New York several years ago. And we have some funny stories during this interview. Funny stories about us both sitting up front in the conferences of Dr. Carbone. So I think you'll get a chuckle out of that. Anyway, Tamara has some great information about apraxia and autism. And we also talk about the changes to our practice since COVID. And we also get into a little bit pacifier addiction and reduction. It's just a great interview. I really enjoyed it. So let's get to this interview with Tamara Kasper.
Mary:OK, so, Tamara, thanks so much for joining us today.
Tamara:I appreciate the opportunity.
Mary:Yes, I know we've met several times in the past at ABA conferences and the Penn State conference, I think, and I think you're a wealth of information. So as I started to get a lot more questions about a proxy, you're the first name that came to my head in terms of let's have Tamara on and you go by Tamara or Tami?
Tamara:Either one is fine. Actually, my staff calls me TK.
Mary:Oh. All right. Well, there's another name for us to try. OK. So first question. Describe your fall into the autism world.
Tamara:You know, I always think it's interesting when people talk about what brought them to the autism world and, you know, I started out as a speech pathologist first and my first job at a grad school was working at a residential facility for kids with emotional disturbances.
Tamara:And it was actually a really good facility. Before you got to start working there, though, you had to do some kind of orientation. And, you know, here I am, a new grad, you know, thinking I'm gonna wear heels and skirts to my job, you know? And got in the door for the training and found out it was C.P.I training, crisis prevention intervention training. So before he could work at that facility, you had to learn how to kids to stop fighting on your arm or carefully control them when they were out of control. And so it was a good first job for me. It was really a baptism by fire into how to deal with problem behavior.
Tamara:And everyone there had a really well-developed behavior intervention plan. They looked at what was happening before the behavior, what was keeping it going. They had a plan for every child and having a plan and knowing what to do and having those plans be successful, even if you aren't in on the design of it, really helps you be comfortable working with kids with problem behavior. And so sort of from that point forward, when I went to any other job, I was considered like the person who could take on like problem behavior, which is interesting.
Tamara:So when I moved on and worked at a pediatric clinic, all the kids that came in with a little bit of problem behavior, they were like, oh, Tammy likes those kids. Let's put those kids on Tammy's caseload. And then not surprisingly, many of those infants and toddlers who had problem behavior were later diagnosed with autism because we know that autism is a disorder of communication and social interaction. And if you're not good at being able to communicate what you want and what you don't want, problem behavior works really well to get the things you want coming towards you and the things you don't want moving away from you.
Tamara:So it happened that one of the kids on my caseload there who had a diagnosis of autism was one of the first kids in my state to receive services through a Lovas replication site. And I want to tell you, Mary, that the university I went to did not look favorably upon behavior analysis. I was taught that it would make kids robotic, that it was kind of a last resort treatment for kids with severe impairment, et cetera. And so I was like, really? Like these college students are going to work with this very challenging child with autism.
Mary:You are a speech pathologist for?
Tamara:Yeah, I've been practicing for about six years at that point. So not really very seasoned, but more seasoned than, you know, I'm still paying off my student loans. The task is they're going to work with this boy. I'm like, yeah, let's see. So I actually went to the introductory workshop and by the behavior analyst in the home of that child. And in three hours, he taught that child more than I had taught him in three months. And I said to myself, self, you have got to learn more about behavior analysis. So in addition to being that child's speech language pathologist, I also became one of his behavior therapists working in his home.
Tamara:So I did a speech therapy when he came to clinic. In the evenings, I did some of his behavior analytic work, so I could learn from the ground up how they were teaching this child. And through that relationship and other relationships with children with autism who began receiving ABA services, I became a speech and language consultant to Lovaasreplication site, if you can imagine. And I was working there and had just begun doing consultations from multiple clinics because my job was really twofold. I was there. I was working with kids that were struggling to develop speech. I was working with the kids who had functional language but didn't use it socially for social communication and interaction, conversation.
Tamara:And so I was going to consult on someone in another state and the therapists there. Her name was Anne said to me, like, have you heard of this guy, Vincent Carphone? Like, he has a different kind of ABA that he's talking about. You have got to see him. And as was intended, he was giving a workshop the very next day in my set in the city I live in. And so I registered. I went. I brought him Krispy Kreme Donuts because she had told me he had talked about Krispy Kreme Donuts and his presentation.
Tamara:And I went to see him and I sat in the second row and being the shy, reluctant type that you probably already guessed I am, I like, raise my hand, ask questions. I actually volunteered some information, which I can't believe now that I see stuff. But afterwards he said to me, been said to be Tammy like you've got you've got a lot of questions, you know, why don't you come out to New Jersey next week?
Tamara:And I'm doing a parent training. You can come for free and like, just sit in and see what you can learn. Maybe you can figure out some other ways that you can help some of the families you're working with. So basically, I became his groupie and followed him around. And then he agreed to mentor me to be a behavior analyst. And I worked under his tutelage for about five years, traveling all over US and, you know, internationally, giving workshops for him and assisting him with his intro workshop and learning as much as I can and treating kids all over. So that was like such an incredible, incredible opportunity.
Tamara:And the minute that I was listened to Vince talk and a lot of people I know have had this aha moment with Vince. I was like, this is the perfect marriage between what I know is important as a speech pathologist, which is working with kids when they're motivated, making sure that they have things they're interested in so that you can teach them. And the precise teaching procedures that kids with autism require in order to learn. And in order to learn relatively quickly. So that was really kind of the big moment for me. I was enthralled by the ABA world, but I had so many questions about why we did things the way we did at that Lovaas treatment center.
Tamara:And to be honest, before I became a behavior analyst, actually studied behavior analysis, I had an impression that behavior analysis was sort of a list of treatment strategies or a bucket of strategies that you had that you like pulled out of. I didn't realize how closely and carefully you matched client variables and inventories and repertoires to the teaching procedures, how artful and precise that is and scientific in its analysis. So that was a huge turn on for me, like really learning about the precision with which applied behavior analysis is used as like a treatment, a medical treatment, not some group of strategies. So, yeah.
Mary:Wow. So I just want to tie in here. So that was all the 90s and into the early 2000s is kind of the timeline. And you've been in as a speech pathologist for 30 years over, you know, almost 30 years. And you kind of found out about Bebe, around two thousand or two thousand, two or three or whatever. And it is so funny because it's very similar to my path, actually, because Lucas was diagnosed in 1999 and he got into a Lovaas replicate. Well it wasn't a Lovaas replication site, but he had a Lovaas replication consultant because we were too far of a distance.
Mary: But she came to our house, trained three therapists and myself in the Lovaas methodology. And Lovaas is like traditional ABA. We did that. Lucas made progress. I was like after a year of this, I was like, this is absolutely frightening how little anybody knows about any of this. And I had a master's in nursing at the time and I was just like, this makes sense. You know, I manage people in my past and, you know, OK, the schedule and keeping people motivated to keep coming and, you know, teaching Lucas and taking data and graphing and all that. And then I became a behavior analyst. But my friend, who was also running a a low of US replication program out of her home, and we shared some of the same therapies. She flew down to see Vince Carbone speak in Florida in like 2000.
Mary:And she came back and she's like, Mary, we've got to change everything we're doing. And I'm like, what? You know? And so that summer, I went up to New Jersey to a free workshop in New Jersey to see Vince Carbone. And it's so funny because you were saying you were sitting in the second row. And so I got to tell this story because I think my listeners are going to crack up.
Mary:So I go up and I I was like, I have a bad sense of navigation ability. So I'm like, I don't wanna get lost, you know? So I, I get there like an hour early, like to the venue and it's a free workshop. So I show up. I walk in. I sit literally in the first or second row. And Dr. Carbone is setting up his equipment. Now, this is back in like 2001. Right? So the equipment is like DVD players and big speakers. And I literally I asked him if he was the AV guy. I had no idea what he looked like, but I was there and I was just like, oh, my God.
Mary:But I think my friend had told me and we had actually, my Lovaas consultant ended up moving south right at the time she got back from the conference. So we had actually started move started to move into the Abels, into Beeby and that sort of thing. But once I heard Dr. Carbone speak and saw his videos, I was like, oh, my God. Like, we have to totally switch gears. And back then it was like the Wild West. Like nobody, including myself, knew how how to do verbal behavior programing. And so really over the past two decades and the way I found your name was I was part of the Pennsylvania Verbal Behavior Project, which is now the Patent Autism Initiative for seven years. And we in 2003, we went up to Carbone's Clinic, and that must have been the time when you were there and and you were, you know, helping him break down like language.
Mary:So instead of cookie, then it be E would be the easiest and ooo-eee would be the next. And it just made sense. And from my nursing background and taking Lucas to speech therapist and working in Lovaas, you know, Lucas always had speech. His articulation wasn't great. He's still not conversational at 24. But anyway, I started hear your name, but I had to tell a story. When you said you were sitting in the second row, I was like, I got to tell my are you the AV guy story? That is just classic. Classic.
Mary: Anyway, OK. So I think that's an excellent segue into when I said cookie and E and Oookie and why I wanted you on so, so much as a guest to talk about apraxia and autism. So can you tell me and the listeners what is apraxia First of all, just not related to autism. What is actually apraxia?
Tamara:Absolutely. So apraxia of speech in the field of speech language pathology, we really apply a medical motto. So we look at etiology of the disorder as a guide to the best intervention. So, you know, if we like a nurse, right, we would look at what's the medical diagnosis and then what are the treatments that are used for that particular diagnosis. So apraxia of speech is believed to be some kind of a neurological disorder that results in a motor planning deficit. That is that kids have difficulty producing and sequencing sounds to form syllables, words and longer utterances in its most severe form. Like kids can't really can't even open their mouth with something without some kind of manual guidance. They'll be having like oral apraxia.
Tamara:And then verbal apraxia would be just with the production of sounds and sequencing of sounds. So, I mean, that's like the, you know, a simple explanation. If you look like on the ASHA website, they have like a definition that is several pages long. And the problem is or the unique challenge, I guess, when we're talking about questions like, well, how many kids with autism actually have apraxia of speech or what's the comorbidity of those two diagnoses? Is that even though we have this lengthy definition. There's not a lot of agreement about what assessment tool really sifts out, kids who have apraxia speech versus kids who have some other severe articulation or phonological disorders. So and for people who aren't speech pathologist, you know, we look at differences in the types of areas, the topography of the areas that kids produce.
Tamara:And that's one of the ways that helps us categorize kids according to these different diagnoses and then leads to the, you know, should lead to selection of an appropriate treatment. So basically a syllable, a sound production and sequencing issue. And the question, you know, that often follows is like how many kids with autism have apraxia? We look at the percentage of kids with autism that are nonverbal. Do all of those kids have apraxia? The problem is that the differential diagnosis is difficult. There's not a lot of agreement about a particular diagnostic instrument. But there was one study that they did actually at Hershey in Hershey, at the medical complex there, where they looked at a group of kids that were diagnosed with autism and they found that 64 percent of those kids also had a diagnosis of apraxia. So it is thought that it probably is a fairly high percentage. But the data I mean, that's one small study where they looked at that.
Tamara:So the data is not really strong on that. But what I guess as a behavior analyst, when I think about a diagnosis of apraxia, sort of I say, who cares? Because of what I look at is, again, let's do a very careful inventory of what this child can do in terms of his approximations or sound production and what he can't do. And then let's take that. And whether or not someone has a formal diagnosis of apraxia, the procedures that are designed for kids with apraxia of speech, there's almost no danger of misapplication. If someone had a severe articulation disorder or phonological disorder and did not have apraxia of speech. And then I know one other point that you brought up when we were doing our talk right before the podcast was like one of the barriers to us being able to diagnose kids with autism with apraxia of a speech is your repertoires are so limited early on.
Tamara:Their motivation to try to talk, their motivation to be with people. Both of those things are impaired. That's how they got the diagnosis of autism. Right. So if you're motivation to speak and to interact with others is low and you don't have a formal communication system or a very limited one, then it's hard for us to tell whether your lack of speech or your difficulty with speech production is due to some kind of neurological deficit or if it's due to lack of practice in under the appropriate motivational conditions. So it's you know, parents will often say to me, do you think my child has a apraxia? And I'm I'm usually say, I don't know. But regardless, I know we know how to help someone. We know how to help someone like this, you know, to learn to speak.
Mary:And especially when kids are really little, you know, two or three and they're not speaking. And when somebody says, do you think they have apraxia. I'm like, probably. There probably is something going on if they're not speaking at all. But the same early learning materials, the same procedures, keeping the demand, pairing up the situation, pairing up the people and the materials, you know, speaking in an animated tone, holding things up to your face and being fun and playful and getting kids to want to be with you, to want to run to the table to one, to run to the activities. There's so many things going on, especially with the early toddlers, where you don't really know if it is just a speech delay, apraxia, or if it's going to turn out to be ADHD, if it's going to turn out to be autism.
Mary:There's a lot of people that are waiting in line and they're worried about so many things and so many things are kind of going awry. I listened to your talk through the National Autism Conference, and we're going to talk about that in a minute. But I also listened to two talks by Ami Klin, Dr. Ami Klin from Emory University and his whole thing. He just published a fantastic paper on we can link that in the show notes that its 2020 publication and really shows that autism is really just the breakdown of the parent child dyad of communication of imitation. That gets off track. And then parents, it starts to deviate.
Mary:Then they become obsessive with the iPad, or then they refuse to take a bath or they have problem behaviors. They have hitting instead of talking. And the more it gets off track, the more problems there are. And then parents are forced to wait in line for diagnosis, for treatment, for help. And so that's really been my mission over the past five years, specifically is through online courses to show parents it doesn't matter what it is or if it's autism plus apraxia or if it turns out to be a learning disability plus apraxia or a severe language disorder.
Mary:You've got to get on it. You've got to try to repair that back and forth and that pairing of everything to make the child want to be with you. Want to talk and want to be, you know, motivated, which is easier said than done. But I think it sounds like with your experience with apraxia and autism, especially in the very young kids, without a lot of, you know, instructional control, without a lot of motivation, it's hard to assess, really.
Tamara:Absolutely. Establishing a pool of reinforcer and then being able to run a lot of acourt trials, having lots of opportunities for those kids to attempt to speak under reinforcing conditions then gives you the ability now to assess. Is this someone who now really is having a significant issue with producing sound sequencing sounds? And as you know, like during that time frame when we're doing our pairing and manding and trying to contrive all those opportunities. The other thing that I do as a speech pathologist is really take a very careful look at their babbling repertoire through that process. And look at, am I getting an increase in the number of different sounds that someone's producing? In the number of syllable shapes or different combinations of consonants and balance that they're producing?
Tamara:Even if they're not intentionally producing words yet? Do I have more variety there? Because those kids who remain sort of dead quiet, who are producing very few sounds and syllables. That's another strong indicator for me that I'm probably going to have to teach augmentative alternative communication form initially. And also that this is someone who might need some very specific training in order to develop their speech production in terms of their echoic training later during their structured teaching and in how we're trying to prompt vocalizations during national environment training.
Mary:Yeah. So you did create with Nancy Kaufman, who is also a world renowned speech pathologist. You created the K and K card. So what are the K and K cards?
Tamara:So I know that people who are listening won't be able to see them, but I'm just going to get them out for you. And I should mention also, obviously, according to our code of ethics, as behavior analysts and as speech pathologist, that this is something that I financially benefit from. And I have a relationship with Northern Speech Services. I do some webinars for them also. So I just need to mention that as a disclaimer. But what happened was I had gone to see Nancy Kaufman, who, as you mentioned, is an expert in the treatment of a practice of speech. And I went to see her not once, not twice, but three times. I was pretty sure she was talking to me the entire time.
Tamara:And by the third the third time that I went to see her, like we had become friendly. And she would say when people ask her questions about kids with autism, she would say, I don't know, but I bet Tammy does. And then she would ask me to answer the question. So I started answering the questions and that's how I got sort of hooked up with her and Northern Speech services. But what I had done was use Nancy Kaufman's procedures that she outlines in her whole product line and her video presentations and all that stuff, her system for teaching kids to talk. And I had been modifying them for kids with autism.
Tamara:And I sent her some videos because she always said, you don't need my cards. You can teach any child if you are a good speech pathologist and can figure out how to break down a word, you can teach it. So I sent her like a compilation of a bunch of my kids who with their before and afters like she does in her presentation. Just showing them the progress they made and thanking her. And then she was like, hey, how did you write those breakdowns for, like those other words, like those other words they're using for their requesting or manding or whatever you're talking about? And so that's when we got together.
Tamara:And what we tried to do was create a product that could be used by behavior analysts, parents, teachers, speech pathologist to help them help kids learn to produce more complicated words. Because as you know, even though a child with autism doesn't care if the word that he is the thing that he loves the most is the most complicated thing to say.
Tamara:He's not going to choose the easiest syllable shape to start with. So we started out with our sign to talk nouns. And those were you know, she asked me, is there a pool of reinforcers that most kids with autism enjoy? And I'm like, no, absolutely not. All kids with autism are individuals. And she's like, well, is there one hundred and fifty or two hundred words that would be more common? And I said, yes. So I know you used the example cookie. And so what, on the back of these cards, what we did was two things. We wanted to be able couple of things. We wanted to be able to have it as a sign language resource, not you don't show the child the picture of the person signing on the back of the card, but it's for teachers to use as a resource about what the sign is, because some things that kids with autism often do like Cheetos, don't have a sign in a sign language book.
Tamara:But I worked with a sign language instructor in the deaf community here in the Midwest. And then we came up with signs for those things too for like Cheeto or Doritos or, you know, Oreo or something, anything that was really specific to that child. So the signs are on the back so that if you're doing sign language instruction with your child with autism, that you have that as a resource. But then the systematic shaping of the vocalizations is also on the back of the card so that the shaping using successive approximations to the target, where people who aren't speech pathologist just means that you can take any word that might be difficult to say. And when you think of a word like cookie, it doesn't seem like it would be that hard to say. But the K sound's actually kind of tricky. And it's not one of the first sounds that kids develop. It's usually in that second set of sounds that they are able to produce volitionally.
Tamara:So what you do is you take the most difficult parts of the word and you omit it or change it to what a typical child that's learning how to speak would say. And I bet most parents out there, if you had a typically developing child and I asked you, like, what would your child say early on for Banana, you would say Nana. Or if I said, what would your child say early on for Cookie? You would have said, Oh, I think he said something like 280 and our cookie. And that would be true because kids would do that. So that's what we do on the back of the cards, is guide them through like systematic approximations to the target, easier syllables followed by more difficult syllables until they can produce it. So like you said, for Cookie, it's like, ooo-eeee.
Tamara:And then tooo-tooo. Too-eee. And then Coo-ee. Kee-kee and cookie. And all of that is actually based on typical development phonological processes, they're called. But it's the motor simplification kind of rules, if you will, that kids use when they're learning how to speak. And that's why you see that a lot of kids say "bado" for bottle or that they say dada for daddy because it's a common motor simplification. So the cards have multiple applications to be used for Sign Language Dictionary to be able to teach the child the successive approximations to that target. And then we used real pictures of.
Tamara:Hopefully, hopefully, fun looking pictures of the items on the front of the card so that you can use them for other verbal operance. For tacting, for receptive I.D., for teaching feature function in class so that they can have multiple applications.
Mary:Yeah. That's excellent. And the K and K stands for Kaufman and Kasper, right? Those are your two names. And Kaufman developed initial cards that were not fun, did not include signs and that sort of thing. So you took it and collaborated with her to make these cards specifically more for kids with autism. But I'm sure they're very helpful for young kids with other issues as well within their speech.
Tamara:I do get e-mails from families where they're saying like that their kids call them, one kid called them like the cool cards. They're bigger. They're different. There are really a lot of kids really do. Actually seeing the picture functions as a reinforcer for them. So how we teach it, part of our teaching procedure is that until they're able to like a myth, what we're going to accept as their best approximation, they don't get to see the picture on the front, the card.
Tamara:So that's something that's different from how Nancy uses her cards also is that we sort of use seeing the picture as a reinforcer for a more accurate production. And then what happens over time is because we paired delivering reinforcement with seeing the picture, over time just seeing the picture begins functioning as a reinforcer. And that allows you to do, you know, multiple trials successively without creating ratio stream. So kids are more cooperative. If you teach if you teach the cards correctly, use them correctly. Good. Using good sound principles of behavior analysis in controlling your motivational variables.
Tamara:So that was a big part of my life for a lot of years, was traveling around and teaching other speech pathologist a some of the things that Vince has taught me and that, you know, that you bring to the public teaching those skills about contriving motivation, pairing, manding, teaching sign language to other speech pathologists so that they can get kids in that just right position to be able to benefit from a very sequential approach like this, or like Nancy Kauffman's cards, which are amazing and are based again on systematically increasing the difficulty. Right. Hers are not ordered by motivation, but rather by what's easiest to say. What will give you the most success early on? And now what's more difficult to say? Can we bridge you to that more difficult type of word?
Mary:Yeah, I think that's great. And I do want to bring up a point, and I am not sure if you're going to agree or disagree or whatever, but I've also seen Barbesh speak a fair amount. And Barbesh is the creator of the ISA, the echoic assessment part of the VB-MAAP. And she's PhD level BCBA-D and excellent. And one of her things and I know we talked about a little bit is the need to practice and the need to say kookie 100 times before. And it might sound like "tootie" or EE or whatever.
Mary:Before we get worried about necessarily, I mean we have to get echoic control, we have to get instructional control. There's just a whole lot of things to worry about before we get into fine tuning articulation. And I see people like they might be like, oh, let me get these K and K cards and I'll start. And like, the child doesn't have the ability to sit and attend and they don't have the ability to you know, they haven't said "oo-ee" a hundred times. So, you know, just if it's highly motivating, like my philosophy is like bombard kids with language that rich materials and get them practicing babbling sounds and word approximations and words and get them all wanting to be at the table with you, wanting to engage with you and, you know, having pictures, putting them in a shoe box that serves as a reinforcer, as you're saying, like these cards, seeing the cards can serve as a reinforcer. So I think sometimes people try to jump to fine tuning articulation when they really need to back up and start just pairing, manding and all that stuff. And allowing the child to practice babbling and word approximations before they worry about like that doesn't sound right.
Tamara:I couldn't agree more. That's actually why I developed the workshop for the speech therapists is because they were trying again, working with children with autism is very different than working with kids who have more typical motivational variables. So they would try to apply these kinds of intervention to kids who weren't ready yet. And so that's why the first half day of my workshop was always about pairing, manding, establishing instructional control. And you're absolutely right. We owe it to kids to give them hundreds of opportunities to learn how to vocalize under reinforcing conditions before we try to do more structured echoic work in almost all cases. And I know, I was listening to one of your other podcasts and you were talking about, you know, the amount of time that kids should spend in natural environment activities.
Tamara:And I think it was one to one that you did with Mark Sundberg. And he was talking about the importance of natural environment training and about all of those avenues. And so I think that the point you're making can't be made enough that you're really looking at the whole child and not just like what is his sound inventory and what's the next step? And can I get I'm not going to get a perfect swing from someone who's only been vocalizing for three months. That's really not a good motor expectation of that child.
Tamara:So that, I think, is why there is a need for collaboration with speech pathologists and behavior analysts as well, because behavior analysts are so amazing at being able to identify appropriate and conceptually systematic sequences of teaching and teaching procedures that are precise and use excellent differential reinforcement. And speech pathologists know a lot about development, how sounds are produced, what's developmentally appropriate, and that that information can also influence what approximation you would accept from a child, at what age or what age of talking. I like to say, yeah, he's seven, but he's only been talking for six months. That's very different from a seven-year-old. So I agree with you wholeheartedly.
Mary: Yeah. And one final thing about articulation. You know, I've worked with people with 50-yearolds or even my son, 24 years old. He's not conversational. He has language, but his articulation is not perfect. And sometimes I think, like for older kids, like hyper focusing on articulation isn't that helpful either. Like, I mean, we could, you know, get the K&K cards. But it's like if his speech is understandable to most of the people around him, you know, he just had a new hab worker start. And her name is a little bit harder to pronounce, you know. But he hasn't practiced it 100 times. It's understandable.
Mary:But like some people jump in and they like do all this work on articulation. Meanwhile, you know, the older child can't shower themselves or they're having problem behaviors or there's just a whole lot more to the picture. And I think sometimes I think people over focus on articulation when, you know when is good enough. I don't you know, I'm sure that that varies for each child. But, you know, does it change as kids get older with how much she would focus on articulation?
Tamara: So what? What I can tell you is that in my in my Penn State presentation, which was about, you know, originally was about, you know, extending the vocal repertoire in children with autism. And then I added, like in a COVID world, because what happened to me with COVID was that I essentially eliminated middle management and did like telehealth with like one staff in a home or with a family. And it like removed any barriers between me and like direct interactions, on a weekly basis with parents. And I really had learned so much about what's really the most important.
Tamara:And I think what you're saying, Mary, and I agree with you, is like for every child, like every six months, every year, we have to really think, like, what are the most important things for this child? And one of the things that I identified for some of my kids was what's the most important thing, having independent work that the child can do, an independent play activity so that their parent can take a shower or do their conference call. And I had not put as much emphasis on that as I because I was always working on shaping articulation and making sure they could use, you know, speech production across the verbal opperance, etc. And that was really telling to me. And the other thing is exactly what you're saying. At a certain point we're looking at, I'm always trying to have a five-year plan and a 10-year plan with all of my families.
Tamara:And if we're looking realistically at someone who's 13 and saying their five-year plan is they're probably going to be living in a group home with the same group of individuals on a regular basis, they really only have 50 or 75 reinforcers that we've been able to maintain. Then as long as they can ask for those fifty or seventy-five things than we've done our job in terms of teaching them, you know, good enough articulation to be able to meet their needs in that context. So it's all about treating the child as part of their family unit or their future unit that they'll be working within and really honoring and listening to my parents and to what their values are and trying to appreciate how I can use some professional humility in goal selection so that I'm not trying to push the agenda on what I feel is most important for a family, but that I'm helping them to have their child reach the most important goals for them as a family unit.
Mary:I think that's excellent. And I did watch, it's called the National Autism Conference. It's held at Penn State every year. But this year, because of COVID, it was virtual. It is, the whole conference is free. And it provided very low-cost behavior analyst and ASHA credits and all kinds of good stuff.
Mary:But your talk was really good and you provided case studies of kids that you worked with during COVID specifically and how you altered your approach and how you really train the families and train. You know, and it was really good. And one thing you talked about and we can link that that presentation in the show notes, I think it's excellent. And I think it's great in some ways that the conference was virtual because it was filled with a lot of great talks.
Mary:But one of the things you said and I have been harping on this for so many years, is that one of the big problems I see with the talk, especially with the toddlers and preschoolers that come into my online courses, is pacifier addiction or overuse of bar bottles or even sippy cups? I know Joanne Gerenser. I did a podcast with her and she's another speech pathologist.
Mary: She came to talk in my local area one time and I brought her to my house for like a little drive by, look at Lucas. And he was four at the time. And she's like, you got to get rid of that sippy cup. And it was a spill proof sippy cup. And she's like, it's just as bad as a bottle. And like, I've never heard about that. And I think so few people in the autism behavior analysis world at least talk about pacifiers, bottles, sippy cups and the oral and not eating off of a spoon, which is, you know, your oral motor system gets off track. And the more it gets off track, then you got problem behaviors revolving around picky eating and all kinds of problems. But you did talk in your lecture on pacifier use and pacifier weening. I do have six steps to wean that. I can put in the show notes as well. But can you talk a little bit about like. Is that you talk about that a lot. Like I do yours. Was that something unique with this, with this talk?
Tamara:No, this is something that is really consistent with most of the kids that I work with is trying to make sure that they are engaging in feeding patterns that are going to promote the best type posture for them to be able to produce sounds. So when we talk about, you know, when I was talking about motor the motor ability in apraxia speech to produce sounds, I was talking about motor simplification of a specific word to make it easier to say. The other thing that happens as a child grows and matures is that sort of their airway changes, their articulatory structures change. And one of those changes is when you start getting off of your bottle, like if this is if those of you can see if your tongue is normally more forward in your mouth and it moves back and forth when you're extracting liquid from a bottle or is a spouted cup or when you're sucking on a pacifier.
Tamara:And then as you get a more mature swallow, right. Your tongue comes back. And what that does is you get the back of your tongue is more stable and now you can move the tip of your tongue up and down and out of your mouth and groove the sides of it. And those are all the things you need to produce a T a D a TH an S an SH. Right. You need to be able to channel air. And use your tongue in different ways. If you're constantly having your tongue more forward in your mouth, either because you're using a pacifier, a bottle, a negative pressure spouted cup, which those I would like to when I seem at the grocery store, I would like to throw in the garbage just like Joanne, like those promote that kind of oral motor pattern, which is what we don't want.
Tamara:And so the case study that I did for NACK was, you know, someone for whom they came in and their daycare had actually been putting the pacifier mouth all the time because he was biting other children because he had no communication system. And so they were actually promoting like pacifier use 24/7 while he was at daycare. And so when he came in, I think it was the fourth thing that he came in. I just threw the pacifier back in the car and I just took it, took him up. And there are many, like, great systems for winning kids off of pacifiers. And I know that people use pacifiers appropriately for kids who are having trouble developing like nutritive socks in there.
Tamara:You know, this is a huge topic, but I'm talking about specifically kids with autism who are using pacifiers, who don't have oral motor deficits where it would be there would be a necessity of anything like that. And that there are ways we can teach them. And I know another resource for that is Sara Rosenfeld Johnson. I mean, and she actually has for some of her kids, she'll just like cut the tip off of the pacifiers. So they're no longer satisfying. But at the same time, then we're talking about someone who is engaging. Right. Pacifier use is maintained by automatic reinforcement.
Tamara:No doubt about it. Right. It feels good to do it. It's you know, it is not socially mediated usually. So we're looking at a situation then where we want to then teach them other more appropriate self-stimulatory behaviors. So that's called toy play. Right. So when we're trying to get someone to engage in that. We can talk about other things that are sensory match for that. So this conversation could get very complex. And I do do other things to help kids to be able to get rid of their pacifiers much more simply or systematic reduction. But for some kids, it can be as simple as just leaving it in the car. We don't have to overthink it. We can do a straight extinction. We can teach them to compartmentalize. There I mean, there are so many procedures in the field of ABA that can be applied to an issue like this. And they're the same ones that we look at with other self-stimulatory behavior for many children.
Mary:Yeah, I agree that I think it starts out as automatic reinforcement. But the cases I've seen with kids that are two and older, it tends to be you know, they cry because it's an access to tangible issue. You know, they're screaming. And even one kid, I forget where I talk about this or maybe I wrote about it, I had this one child, that doorbell would ring therapist. He'd scream, you know, and they brought me in after a year of this nonsense with the speech, and OT going and everybody rang the doorbell and he'd be so avoidant of work.
Mary: And so I'm like in there. I think they gave me, like, every other week for an hour or two to figure this out. I'm like, OK, I don't even know what's happening. And so I, you know, I'm trying to pair up the table and I mean, you know, and he's not having it. And he goes bolting out of the room. And I said, what? What's he looking for, you know? What's he seeking? And she goes, he's probably looking for a pacifier under the sofa or something, you know? And sure enough, we go out and he's sucking on a pacifier. And so it turns out that fifteen minutes before any therapist would arrive, mom would take the pacifier and she'd turn the TV off to get him ready for therapy. So then the therapist would come in and he was just wanted them to leave to get back to his pacifier.
Mary:And so we worked with the mom. We created what I called a binkie box, which is just a little shoe box that he could have it at naps and then put the pacifier, you know, get rid of 10 pacifiers, get rid of 10 bottles, you know, if you're gonna try to we like get one of them that you can control or two, you put it in the binky box. When he wakes up from his nap, it can go high up on the shelf. And that was I mean, this kid did so well. So I think it does take on other functions, especially as the kid gets older and it just drives me nuts because a kid screams and then they get plugged up with a pacifier. And it's just so reinforcing for the parents to just plug them up if they're screaming. But yet plugging them up for screaming is going to worsen problem behaviors and it's going to worsen language. And so I was really excited when you start doing about pacifier reduction and everything, because it's like I do think that that's sometimes a big part of the puzzle.
Tamara:No, I agree. And obviously, what we add to a picture as behavior analysts and speech pathologists. Right. As a behavior analyst, we add that systematic assessment of the function. And here you're actually talking about the function of the crying, not the function of the pacifier. So the crying was maintained by access to the pacifier. And so I understand what you're saying. Like, we're not talking about purely automatic reinforcement here, that there are other contingencies. But now the crying is followed by pacifier, which results in escape from demands. So that's a complex scenario.
Mary:And access to tangibles. Yeah. It's multiple functions.
Tamara:The crying is maintained, I think the part where you self though, you know, when we think about that. Knowing the function or how others have like taught up pacifier use is really important when you're thinking about its elimination. I mean, one of my other NACK individuals with someone who is using urination. Like to escape demands and, you know, a 13-year-old who's using it repeatedly. And so when you talk about like, let's be very careful about our analysis of how pacifier is being used, what the true function of the pacifier is in that home environment. I think that's critical. And those things. You're right. There's not like, oh, you can use Sarah Rosenfeld Johnsen's or your program either.
Tamara:You have to, as a behavior analyst, look carefully at what's happening, what's the antecedent. They were using it as a blocking mechanism. Guess what? It also blocks speech production. If you have a pacifier in your mouth, you're not vocalizing, you're not vocalizing with the right types of movements in your mouth. So we have to also look at what else happens with that? Does it block someone from crying? Does it block someone from biting? Absolutely. But are those worth the payoff of not being able to hear someone's voice? So I really like that you're always bringing it back to the core principles of behavior analysis and having a good understanding of the function of any behavior that a child exhibits.
Mary:Yeah. And it can, like I said, it can get complicated. I'm glad you pointed that out, that it's the crying and the function. But for parents and that's really what I strive to do, is get the parent to become the captain of the ship and look at the whole picture. It's complicated, right?
Tamara:You know, the problem there wouldn't be teaching the child to ask for the pacifier. The problem is changing the teaching procedures. And changing the situation so that the person's not signaling that now pacifier is no longer available. Video is no longer available. Your life gets worse when you see your teachers come in. That's the problem. They're not specifically the pacifier. So, you know, it gets really complicated in these. Yeah. Working to arrange this.
Mary:But I would I was glad to see all the discussion about pacifiers. And I think it's something that more parents and professionals need to think about. OK. So I want to wrap up because I think we're getting close to the end of our time. But first, before we end, I want to ask you two things. So we talked about the K and K cards. And you said you have a webinar. So how can people find you, find your work and get into your world?
Tamara:I mean, you can learn more about me at my Web site, which is www.CenterAutismTreatment.org. And I'm located near Milwaukee, Wisconsin, actually. My clinic is quite small, but you can contact me there and the K and K materials and that webinar that's about it's really about teaching kids all the way from pairing and mandating to multi word utterances. It's called progressive and systematic teaching of language to children with autism. And that you can get it with the K and K cards at Northern Speech Services. So that's you know, we can put the link in, but it is Northern Speech Services. I do want to say thought that as part of that as part of the webinar, anytime I talk, you really don't need the cards in order to use the procedures. Any good speech pathologists can write successive approximations to the target. So the cards are there as a resource. But I just want to be clear that any good speech pathologist can do this type of work. It's just makes it more convenient.
Mary:Is the webinar for speech pathologists or is it for parents or both? Both. OK. So anyone, behavior analysts, any pathologist, anybody can watch.
Tamara:Interested in learning about the use of those procedures and or anyone who's interested in learning things about basic sign language instruction, how to use echoic trials within the mand. And then it gets into more precise teaching for kids who are really struggling. Both what you would do during your structured teaching, during your ITT table work or and what you would do during your natural environment training for someone who's really struggling to learn how to speak.
Mary:OK, so we're just about ready to wrap up. Part of my podcast goals are for parents and professionals to be less stressed and lead happier lives. So I'm wondering if you have any stress reduction tips or self-care practices that you would recommend to parents and professionals.
Tamara:You know, I think this is such a great question and so important, like during Colvard, where we have to have so much more self-compassion than ever because we're all struggling right now. We're struggling with, like, the limitations in what we're able to do and what our kids are able to do and the uncertainty and the changes that occur every day as a result of it.
Tamara:And so I guess I hate to say something like lower your standards. It's not lower your standards, but select your goals carefully. And don't hold the bar quite as high to select those goals that are the most important. And those are the conversations that I've had with my parents. They were like, tell me the top three things that are important for you to get through the next week. What would help you with your child the most? The three most important things to you right now. And when they told me those, I found there was often a mismatch between what I thought and what they thought. And so then we worked on those things or a component skill for those things. And I made the component skills small and manageable so that they could do that.
Tamara:And then, you know, when you're saying taking care of yourself, I mean, I hope that I do embody for my staff like that, even though we're very busy trying to keep everything afloat here and trying to meet the needs of all our families without, like, exposing them to too many staff that I still managed to get some exercise in every day. I still manage to try to spend some quality time with my family like we assume I have a weekly meeting with my seven brothers and sisters and those things staying connected to people socially and giving yourself some time to do something that's important to you, like exercise or going for a walk like that.
Tamara:You need to build those things into your day so that you can be refreshed and able to help your clients or your children in the best possible way you can. And I know those are incredibly basic, but like, just choose your goals. Choose them carefully so that you can attain them and feel good about doing that piece each day and give yourself that little bit of time to just refresh so that you're able to cope with the whatever the changes that COVID is going to bring that day.
Mary:Yeah, well, that sounds like great advice. So thank you so much for your time. I really enjoyed getting to know you better. And I'm sure our listeners will love this on this podcast as much as I did. So thank you so much. Thank you, Mary.
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