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The impact of interrupted use of a speech generating device on the communication acts of a child with autism spectrum disorder: a case study.

Introduction

The National Research Council (2001) reported that one-third to one-half of children and adults with autism spectrum disorder (ASD) do not use speech and/or language functionally and are in need of speech-language therapy. Speech-language therapy for these individuals typically involves education, guidance, and support in the use of augmentative/alternative communication (AAC) devices and strategies. AAC devices can be customized for individuals who are verbally challenged to provide opportunities for more effective communication (Millar, Light, & Schlosser, 2006). Furthermore, Romski & Sevcik (1996) reported that children who use AAC often experience an increase in their development of language skills. Many of the more high-tech AAC devices actually use speech output technology and are called speech generating devices. Speech generating devices are frequently used in therapy for children with ASD. Several studies have reported that the use of speech generating devices with children who have ASD has a positive impact on communication behaviors such as labeling skills and natural speech output (Brady, 2000; Sigafoos, Didden, et al., 2003; Heztroni & Tannous, 2004; Ganz, Earles-Vollrath, Heath, Parker, Rispoli, & Duran, 2012).

This study examined the expressive communication behaviors of a child with ASD as his speech generating device was introduced, discontinued, and resumed over a period of approximately six years. The child was diagnosed with severe ASD at two years of age when speech, language, and social interaction skills failed to develop normally. The child was from a middle-class family and had no siblings. Prior to receiving speech-language therapy, the child was exclusively non-verbal. The Picture Exchange Communication System (PECS) and Discrete Trial Training were initiated immediately as the child began receiving speech-language therapy. In addition to private speech-language therapy, the child received privately contracted physical therapy and occupational therapy. Information regarding the frequency and duration of these services were not available to investigators.

This child obtained his first speech generating device at four years of age. He received ongoing speech-language therapy from a licensed and certified speech-language pathologist who focused a substantial amount of each therapy session on the use of the speech generating device for effective communication. When the child reached eight years of age his family relocated to a neighboring school district. As a result, his speech-language therapy was delivered by a different speech-language pathologist, who also held professional certification and state licensure. Subsequently, his speech generating device was discontinued and for the next two years his speech-language therapy focused exclusively on goals targeting the use of communication pictures and gestures for expressive communication. After two years with no use of a speech generating device, the child's family re-enrolled the child in speech-language therapy with the original speech-language pathologist. At 10 years of age, the child received the manufacturer's latest version of the original speech generating device and resumed speech-language therapy, which again concentrated on his functional use of the device.

Methods

A retrospective design was used in this case study to observe and record the child's expressive communication behaviors. The specific expressive communication behaviors studied were communication acts (CAs) per obligatory context (OC) per minute, the percent of total communication acts, the number of different words naturally verbalized, and the different types of words naturally verbalized. This design included four sampling periods. Video recordings of the child's communication behaviors were made aperiodically throughout the time span from 4 years of age to 10 years of age. All video recordings were made available to investigators for data collection and analysis. The six-year time span was segmented into four sampling periods of unequal length. Data from the first sampling period (SP1) represented expressive communication behaviors at four years of age. During SP1, and prior to speech-language therapy, the child lacked significant intentional expressive communication behaviors. The second sampling period (SP2) immediately followed SP1 and began when the child was still four years old and continued until the child was eight years old. During SP2 the child received home-based speech-language therapy that introduced the speech generating device and provided ongoing training and support of the use of this device for expressive communication. Data from the third sampling period (SP3) represented expressive communication behaviors identified as being used by the child during a two-year time span from 8 to 10 years of age. During SP3 the child had no contact with or use of the original speech generating device; however, speech-language therapy continued with expressive communication goals focusing on the use of gestures and pictures. The final sampling period (SP4) began at age ten years. During SP4 the child was granted full access to the latest model of the speech generating device, and speech-language intervention focused on the use of the device for expressive communication.

A certified speech-language pathologist, having more than 12 years of experience serving children diagnosed with ASD, provided speech-language therapy during SP2 and SP4. Two speech generating devices were used in this study: the Prentke Romich Pathfinder[TM] and the Prentke Romich Vantage[TM] Lite. Initially, the Prentke Romich Pathfinder[TM] was provided to the child. The Pathfinder used a Unity[R] Language System. The child had full access and training in the use of the Pathfinder for approximately four years. The second speech generating device, the Prentke Romich Vantage[TM] Lite, was used after the child reached the age of ten. This device was the newest version of the Pathfinder having many new features and capabilities although the overall design was not radically different from the original Pathfinder. As with the Pathfinder, the Vantage[TM] Lite also used a Unity[R] Language System. The device was capable of storing more than one hour of recorded speech in memory. The digital speech options included DECtalk, Acapela, and RealSpeak. A minor cosmetic difference existed between the two speech generating devices. The Pathfinder[TM] incorporated a keyboard for icons and the Vantage[TM] Lite incorporated a digital touch screen for icons. Both devices functioned quite similarly.

Data for this case study were collected from multiple video recordings of the child both with and without the speech generating devices over a period of more than six years. Observations for SP1 were taken from a video recording of the child at four years of age and prior to the introduction of the speech generating device. This recording was approximately 14 minutes in duration and served as the first sampling period of this study. SP2 featured a similar video approximately 31 minutes in duration, recorded after six months of speech generating device training and use followed by an 18-minute video recording after one year of speech generating device training and use. Both of these videos were recorded during routine speech-language therapy sessions with the child using the speech generating device. The child continued to use the speech generating device without interruption for the next four years. At eight years of age the child's use of the device was discontinued for a period of two years for reasons not associated with this study. During the two-year hiatus (SP3), from eight to ten years of age, the child did not utilize any type of speech generating device but communicated primarily by gesturing and the use of the Picture Exchange Communication System (PECS) (Bondy & Frost, 1994).

At the age of ten, the child received the Prentke Romich Vantage[TM] Lite. Immediately prior to the child's reception of the new device, a 29-minute video sample was recorded of the child's expressive communication skills in a natural environment. Data from this 29-minute video sample were analyzed in SP3 of this study. Once the child received the Vantage[TM] Lite, eight video recordings were collected during the following six months that documented the client's functional use of the speech generating device during speech-language therapy and the child's expressive communicative progress. These videos preserved approximately 80 minutes of routine interaction with the speech-language pathologist during regularly scheduled therapy sessions. These eight video recordings served as the data source for language observation, categorization, and analysis during SP4 of this study.

Communication behaviors from all video recordings were independently tallied and categorized by two trained observers who systematically identified the child's expressive communication acts. For purposes of this study, a communication act (CA) was defined as an interactive behavior consisting of 1) gestures, 2) natural verbalizations, 3) verbalizations produced synthetically by the speech generating device, or 4) any combination of the three behaviors that were directed toward another person. Each natural verbalization used by the child to produce a communication act was tallied and categorized as follows: 1) a functional word (i.e., a word articulated with sufficient accuracy to be intelligible to the listener) or 2) a representational word which was operationally defined as an abbreviated natural verbalization with sufficient phonological structure to be interpreted as representing a word by a familiar listener (example: "/m/" for more). Gestures performed by the child, as well as synthetic verbalizations performed by the speech generating device at the direction of the child, were also considered to be communication acts.

The number of obligatory contexts (OCs) was totaled for all video recordings during each sampling period of the case study and an OC per minute of video was determined. The CAs per minute were divided by the OCs per minute to obtain the number of CAs per OC per minute. The CAs per OC per minute was believed to be a reasonable unit of measurement for comparison of the child's communication behaviors, regardless of the expressive modality used, across each sampling period of this study. These data were tabulated and graphed for comparison.

To further explore the nature of the CAs, data were examined to determine the percent of total CAs that were either gestures produced by the child, words or phrases synthetically produced by the speech generating device at the direction of the child, or natural verbalizations uttered by the child. The data, reported as percentages for each sampling period, were also tabulated and graphed for comparison. The graphs illustrated the impact of the speech generating device on the child's ability to expressively communicate, as well as the child's various communication behaviors over the four sampling periods.

In order to better understand the speech generating device's potential influence on the child's expressive communication behaviors, the number of different words naturally verbalized and the different types of words naturally verbalized (i.e., representational words or functional words) in each sampling period of the investigation were tabulated. Raw data, for the number of different words as well as the different types of words verbalized per sampling period were graphed.

Results

Data for this study were in the form of CAs per OC per minute, percent of total CAs, number of different words verbalized, and types of words verbalized. Data for each of these components are shown for each of the four sampling periods in Figures 1, 2, 3, 4 and 5. Figure 1 shows the child's CAs per OC per minute. The following outcomes were analyzed: SP1, the first sampling period with no use of a speech generating device, 0.38; SP2 during the use of the original speech generating device, 0.55; SP3, the sampling period during the discontinuance of the speech generating device, 0.6; and SP4 with use of a new model of the speech generating device, 1.08. Results from SP4 revealed a number greater than one (1.08) which was the result of spontaneous CAs. It is clear from Figure 1 that the child's CAs per OC per minute increased in both SP2 and SP4 when the child's speech-language therapy focused substantially on the use of the speech generating device. Conversely, during the third sampling period (SP3) when the child had no access to or therapy with the speech generating device, a minimal change was observed in the overall number of his CAs.

Figure 2 depicts the child's percent of total gestures. The child used no gestures for expressive communication during SP1 (0%). During SP2, 3.2% of his expressive CAs was gestural while 6.6% of his expressive CAs was gestural during SP3, and 10.1% of his expressive CA's was gestural during SP4. These data suggest that when provided with speech-language therapy and consistent, ongoing use of the speech generating device, the child's use of gestures steadily increased.

Figure 3 shows the child's percentages of recorded natural verbalizations and synthetic verbalizations produced by the speech generating device from each sampling period. During SP1, the child did not use any natural verbalizations (0%) as CAs. During SP2, 20.1% of his expressive CAs was natural verbalizations. A total of 35% of his expressive CAs was natural verbalizations during SP3, and 27.7% of his expressive CAs was natural verbalizations during SP4. Results also show that during SP1 and SP3, no data were available for synthetically produced CAs since the speech generating device was not used by the child. During SP2 and SP4, the child used the speech generating device to produce 84% and 67.7% of his expressive CAs, respectively.

Figure 4 shows the total number of different words the child naturally verbalized in each sampling period. In SP1, no verbalizations were observed. In SP2, the child naturally verbalized seven different words. This number was equal to the number of words verbalized during SP3 when the speech generating device was not used by the child. During SP4 the child's number of naturally verbalized words dramatically increased to 28 different words. The data indicated that each time the speech generating device was utilized the child's number of different words naturally verbalized increased.

Figure 5 shows the types of words naturally verbalized by the child in each sampling period. As previously defined, a representational word was an abbreviated natural verbalization representing a word (i.e., "/m/" for more). A functional word was a word articulated with adequate accuracy for correct interpretation (i.e., "more"). In SP1, the child produced no natural verbalizations. In SP2, the child naturally verbalized seven different representational words which remained constant during SP3. During SP4, the child's natural verbalizations increased to 22 different representational words. Similarly, no functional words were noted in any sampling period until SP4 when six different functional words were naturally verbalized.

Discussion

The results from this study indicated the training and ongoing use of a speech generating device positively impacted the child's ability to expressively communicate. Specifically, the results revealed that the child's communication acts (CAs) per obligatory context (OC) per minute increased for both sampling periods during which the speech generating device was utilized. The CAs per OC per minute appeared to plateau when the speech generating device was not being utilized during the two-year time span labeled as SP3. However, when the speech generating device was reintroduced, along with adequate training and support in its use, there was a demonstrative increase in the CAs per OC per minute. Results further suggested that as the child's verbal skills increased he relied less on the speech generating device to produce CAs. Finally, results suggested that the speech generating device facilitated the child's verbal communication skills. Specifically, during both sampling periods in which a speech generating device was being used, data indicated an increase in the number of different words verbalized, as well as an increase in functional word usage.

Current results support the findings from previous studies that suggested that the use of a speech generating device improves an individual's ability to expressively communicate with others (Ahlsen, Sandberg, & Thunberg, 2009; Malandraki & Okalidou, 2007; and Romski et al., 2001). Likewise, current results are in agreement with results from previous studies suggesting that the use of a speech generating device facilitates the acquisition of natural speech communication for individuals who have significant speech impairments (Kouri, 1988; Lloyd& Kangas, 1994; Malandraki & Okalidou, 2007; Romski & Sevcik, 1996; and Scruggs, Mastropieri, & Casto, 1987).

The nature of case studies does not provide sufficient validity or reliability to draw strong conclusions nor make inferences across the entire population of persons with ASD. Still, the unique nature of the circumstances under which this case study was completed does provide a modest level of scientific support for using a speech generating device for some individuals with severe ASD. Perhaps the most interesting findings from this case study for these investigators were 1) the lack of language progress in all communication behaviors tracked in this investigation during the two-year sampling period in which the child did not have access to a speech generating device, and 2) an increase in all targeted expressive communication behaviors after the reinstatement of the speech generating device when paired with guidance and support from the speech-language pathologist.

This case study does have important implications for using a speech generating device to improve the communication skills in some children with ASD. The findings from this study strengthen the theoretical proposition that speech generating devices can be effective tools for enhancing communication competence (Ahlsen, Sandberg, & Thunberg, 2009; Malandraki & Okalidou, 2007; and Romski et al., 2010) and facilitating the acquisition of speech communication for individuals who have significant speech impairments (Kouri, 1988; Lloyd & Kangas, 1994). Clearly, more rigorous randomized controlled trials are needed to delineate the impact of speech generating device usage on communication competence and the facilitation of verbal communication in individuals with ASD.

References

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RICHARD A. NEELEY

Arkansas State University

MARY HANNAH PULLIAM

Westside Public Schools, Jonesboro, Arkansas

MERRILL CATT

Jonesboro, Arkansas

D. MIKE MCDANIEL

Arkansas State University
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Author:Neeley, Richard A.; Pulliam, Mary Hannah; Catt, Merrill; McDaniel, D. Mike
Publication:Education
Date:Mar 22, 2015
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