Why is Speech and Language delay in ASD children treated different to SLD children?

[blueShark]

In desperation to find different/supplementary way to help my DS develop his speech and language further (with the lack of SALT), I got in touch with a friend who works in ICAN unit.

DS (4) was initially treated with SLD for a while until given ASD with speech and language as a primary issue this summer. At the beginning the SALT sessions seemed to be very frequent until he was dx with ASD and although in special unit no sign of SALT to do an assessment nor provide the visits every 2 weeks as per statement (which is another battle I now and school SENCO and I are taking action).

The friend that teaches at the ICAN unit is telling me she cannot give me any specific tips since her expertise is not ASD and speech delay in ASD children is treated different.

She also told me that kids that are in her unit are progressing beautifully with speech but when given ASD dx are moved to different unit. Also the SALTs are busier to deal with SLD children rather than ASD.

Anyone that is a bit more tuned in to explain why? Do I have to search for a private SALT specialising in ASD? Current SALT still recommends attention and listening games (turn taking, object passing etc) but DS started combining sentences with I want, I see, Give me etc and using them in context so what is wrong in asking for a guidance to extend the language whilst I still do the attention and listening exercise which I think he also benefits from?

I have found some excellent tips from you people here on MN which have been a great help and also read both Hanen books and any book I find recommended here.

Thanks for reading and sorry for the long post.

DS1 has standard SALT and ASD SALT. He has HFA. He has a speech delay and phonological disorder, but no language delay. The ASD SALT is using social groups and, I think, teaching him about why he needs to speak clearly. I get the impression that it's motivation IYKWIM. And because he's a passive child who genuinely doesn't care if people talk to him or not, he's never felt the need to make himself clearly understood. I think. Or a different answer. TBH, I'm not really sure.

Oh FFS the SLTs and anyone else should be using WHAT WORKS, not some wierd drummed up opinion of what 'should' work.

I'm having this very same battle at the moment. Aparently ds has Speech and Language problems because of his autism, and since his autism won't go away.......

I have read some research on SLT and autism and basically it says that SLT has largely been shown to have little effect on children with asd. This is the research that is behind the myth that LA's and NHS like to spout but it is flawed.

It is based on the belief that children with Autism are often very difficult to engage and get their focus in order to get them to do the exercises that they need to do, so SLT time spent with a child rocking under a table and refusing to come out is a waste of time.

It is further believed that to get a child to the stage where you can work with them will take years and years of autism specialist input, so SLT for early years is pretty much ruled out as impossible.

This is all bollocks imo but it is what is used to justify no slt in many places.

exactly Stark.

If SLT has little effect on children with asd how are they supposed to learn? Do all mums like me and many others here have to give up work, beg for advise anywhere they can, read all SLT books and pay for SALT privately?

When I pressed my friend for tips (even though I am sure she is trained to say SLT dont help asd much and dont know what to tell you) she said they are trying to build the single words vocabulary by topic, i.e. autumn, christmas, winter, beach, holiday etc besides the everyday functional words they use. Then they teach verbs. Finally she strongly suggested Makaton as most asd are visual learners so they should use signs as well as language to be understood by others. DS speaks very clearly what he knows to say and anyone can understand him without the signs, PECS etc.

How old is your DS LightlyKilled? Thx for the input.

He's 5.

It's insane. Humbly grateful as I am for the Social Skills group (and I am), it's 15 miles away, and I don't drive. So DS1 misses most of a day of school to get there by public transport, or else I pay £15 for a taxi and he only misses the afternoon. Just seems a bit mad to remove him from a real social occasion (school) to spend time in an arranged one. I don't know the answers, trouble is, I don't think the professionals do either.

Think this sort of thing must vary from area to area - DS got better input by being under the social communication disorder/learning difficulty SALT team than he would have done with his original NHS SALT....I get the impression with my city that it does try and share the limited resources fairly iyswim.

google for the mariposa school california, it's gone a VB manual online, with lots of useful structured info about the order in which to teach language. also worth looking at the winslow or taskmaster catalogue for ideas (even if products are too dear, the sort of things you can adapt a lot more cheaply)

thinking back to when DS was at that stage, at 4 plus, we worked on pronouns - he/she using photos, adjectives, and objects by function (something you can write with/something you can brush hair with) - using lotto boards for both. oh and sequencing - before and after type pictures.

what else - oh one thing signs can be useful for is question words, if your child has issues with muddling who/where/what type words - as you can back up the word with a sign or visual iyswim

As a SALT myself, I think most SALTs are not equipped to deal with ASD.

This is probably because many kids with ASD are not motivated to use the communication skills they have beyond what is purely functional (ie to get them what they want).

The average SALT has no training in the highly technical field of motivation and reinforcement. For that you need a behaviour analyst. Your dream team is a behaviour analyst, a SALT who takes on board what the BA says, and Vice versa) and a methodical teacher who places data driven interventinos at the hear of all she deos.

A very tall order unfortunaltey and if even 1 of those 3 doesn't play ball it all goes pear shaped.

"I have read some research on SLT and autism and basically it says that SLT has largely been shown to have little effect on children with asd. This is the research that is behind the myth that LA's and NHS like to spout but it is flawed.

It is based on the belief that children with Autism are often very difficult to engage and get their focus in order to get them to do the exercises that they need to do, so SLT time spent with a child rocking under a table and refusing to come out is a waste of time."

I don't really agree that this is flawed, Stark, for the reasons that moondog outlines. A great many children with autism need quite intensive input with carefully structured and executed instructional programmes tailored to reinforce and motivate them in order to engage and focus. The majority of SLTs are not trained to do this. Quite a lot of teachers don't know how to do this.

If children with autism had access to adequately designed educational programmes, you would find SLT would improve immeasurably as they would be freed from having to deal with behaviour inadequately (due to lack of training) and could focus on the linguistic challenges presented instead. What we are trained to do is to understand language development, recognise disorder and explain how to break down tasks to manageable levels. We have basic levels of behaviour management skills which work fine with kids with other disorders who find stickers and praise motivating.

However, because the vast majority of SLT's do not work in a context where they have sufficient access to children with autism that does not merely involve "managing behaviour" (inadequately) to maybe have 5-10 minutes of attention in an hour long session, they never really get to know them and their unique linguistic profiles. However, as it is accepted culturally that the norm for people with autism is to have limited attention etc, the problem isn't even recognised.

I had six years of good quality ABA experience before I became a SALT. I had great ideas about how I would work with kids with autism but with the limited time I had with kids, it just wasn't possible to work at that level. To get a child with autism on board, you need to have learned what makes them tick: you need to pair yourself with reinforcers, work out what motivates and drives them and what is the function of their behaviour. I have a good grasp of the basics so I do okay but I am not a behaviour expert and I am not a teacher...the majority of my working life has been spent assessing, observing and writing reports not carrying out therapy. I am in the very lucky and very unusual position to have had the experience of being in a more intensive setting that has allowed me revisit teaching methodologies but if I'd never done ABA I wouldn't know to do this. I am trying hard to educate myself but I have to say that, without retraining, my skills will lie more in analysis than delivery.

The other point I would like to make is that SALT services are very shaped by education. For example, speech and language delay advice and training in our trust has been totally rewritten to fit in with the Early Years Foundation Stage so that practitioners in nurseries will be more likely to understand and act upon our recommendations. Our reports are colour coded in line with the EYFS: we use their terminology etc.

If expectations for children with autism were higher in education, I have no doubt that SALT would follow education's lead. If VB or ABA were the norm, SALTs would seek training in these areas more regularly and everything would be a lot better. However, as things are, most of the time just getting a setting to understand that a child with autism isn't being "naughty" when they have an overload and that screaming abuse at them is not an effective communication strategy is a hassle. This is even the case in some specialist settings, sad to say.

There are massive issues with SALT in this country but the root causes go far beyond individuals. It's easy to get annoyed with the apparent ineptitude of the person you are dealing with but if there is ever to be true change, there needs to be deeper changes: better educational methodology for all students, better pre-reg and continuing training for all health care professionals/people working with kids with SEN (as per Bercow), better multidisciplinary and interdisciplinary options, more money, more resourcing, more commitment, more research.

oh where do I find a SALT trained in ABA??? working9while5 is doing a maternity leave handover so no luck there...

Thanks all for the great input, got some ideas on where to go and once again got the ugly truth confirmed. What I dont get is, all ASD are unique individuals, yes the culture states they most lack attention and motivation to use language, what about those they do better in these things?

I just wish we parents didnt have to be reinventing the wheel, doing our own research and developing our own therapies. In my case its difficult to engage ABA regularly as DS in in school till 3.30 and can only do so much after school, but I am trying my best to fit in an hour every day and few more hours at weekends.

If it's any consolation, kids with SLD are given very little SALT in our area but especially as they get older. Not a consolation to me!

thanks for the info from the SALT side, moondog and 9while5. It has often struck me how much ground the initial SALT training has to cover - as I guess there is so much re:physical aspects of eating/swallowing, care of the elderly, dementia, stroke/neurological disorder in adults, phonological problems, dysfluency - that coverage of children with SN must be a fairly small element in the course.....

donkey - I assume the OP is using SLD to mean speech and language difficulties in this context

zzzzzzzzzz - interesting post, as I have a 6 year old who presents similarly, official dx was language delay with subtle social communication difficulties , I suspect SPD fits more closely.

blueshark - another useful site is the superduper inc site - think it's www.superduperinc.com - they have loads of free handouts on various areas of languge - you have to register, but it's free and undodgy, you just give your name and e-mail address

a couple of books I found useful - Julia Moor's book on Autism, Play and Learning, and the New Language of Toys by Schwartz and Miller - both have loads of practical ideas on toys and communication/language and yo may be able to find them in the library

people - you made my day with all the wonderful ideas and recommendations, I like it when I have lots to read, print, teach, meaning more help for DS and I dont take back the statement that I toughed him all he knows with some credit for the writing to his teacher.

I feel better now after the SALTs input and explanation on SALT for asd; I was wondering when we go past the listening and attention group stage...To me it looked cruel to have 6-7 asd children with parents in a room (most screaming their head off as they are not allowed to even go near the toys the SALT demonstrates for 30 mins). Good listener makes a better communicator!

blueShark, don't know what area you live in but if you could get a student SLT to work on your team that's a great way to get a mix in your team and get access to all the speech and language info. When I was a student, I only charged £5 an hour (which was the going rate for babysitting/respite at the time) as I valued getting the skills etc.

Of course, I wasn't a SALT so I didn't really know a lot but I could look things up and I acted as a liaison between the team and the SALT, explaining things (much as I do here) e.g. busting myths that ABA was all rote learning and similarly busting myths that SLTs thought they knew everything

anotherbrickinthewall, to give you an idea of the course content when I was a student it went a bit like this:

General Linguistics
Linguistic Analysis
Phonetics & Phonology for SLT
Clinical Practical Phonetics
Anatomy & Physiology for SLT
Child Studies
Adult Studies
SLT & Professional Issues
Clinical & Personal Skills
Research & Information for SLT
Theoretical Approaches to Language
Language Development
Psychology Across the Lifespan
Phonetics & Phonology for SLT
Clinical Practical Phonetics
Clinical Practice & Research
Medical Disciplines
Speech & Language Pathology & Management
Clinical & Personal Skills.
Placements
Speech & Language Pathology & Therapy
Counselling Skills
Clinical Analysis of Language
Professional & Interdisciplinary Issues Service Delivery
Theoretical Perspectives & Implications
Research Project on an area of relevance to speech and language therapy.

If you look at that, you will see that therapy itself is a very, very small portion of the course.

The "Speech and Language Pathology and Therapy" course consisted of weekly 3 hour lessons which usually consisted of a lecture about the topic (e.g Hearing Impairment, Cleft lip and Palate, Autism, Specific Lanuage Impairment, Aphasia, Language Disorder, Dyspraxia, Dysarthria, Physical Difficulties, Fluency etc), a practitioner coming to tell us about how their trust delivered service in this area and then discussion of different ways of managing this difficulty in a clinical setting/typical pathways etc.

So really, in a 3 or 4 year couse, the average SLT may have only had 3 hours tuition on ASD. They may even have been away that day

I think it's important to realise how little practical training SLTs have. The practical training is really carried out on placement so is wholly dependent on the quality of the SLT you get to supervise you AND varies between training institutions e.g my placements were usually one day a week whereas in some institutions they are in "blocks". In one of my placements, where I was for twelve weeks, I saw a grand total of three clients due to failures to attend! If you compare it to a teacher's training, it is unrealistic to expect SALTs to know how to teach all clients of all ages from cradle to grave. Speech, language and communication are hugely complex areas to grasp and master in a few short years: they are everything we know! The training structure would make more sense if it were more like a Clinical Psychologists training - it is too short and not in sufficient detail for the subject matter.

As the market demands, the training is heavily geared towards: a) linguistic and phonological analysis and b) working in the NHS as it stands e.g. Service Delivery talks about how things are and might be done when you are working.

at the scope of course! so I guess a very lot ends up being learnt postqualification...

Dd2 has ASD and severe language delay, at the age of 2.5 she was sent to see SALT, she was refered by SALT to a SN nursery which had more expereance of ASD and its own SALT's on site. She's now almost 5 and has had 3 SALT's (2 at nursery and now one the visits her at ms school), only one of those really had any idea about ASD.

Dd2 has improved a lot over the past 2 years, she has gone from being non-verbal to being very verble (but on her terms).

Working Probably the research isn't flawed in it's findings, but I think it is in it's assumptions i.e. children with asd don't have the attention skills to benefit from SLT.

They do, or at least they CAN do.

I am quite interested in your suggestion though of SLT being a part of the education rather than a specific difficulty that needs to be address by a SLT (is that what you said?).

DS SLT said something quite similar. She said 'he doesn't have a delay or a disorder. his language is very good, but his autism is getting in the way. As such his language is disorganised'.

This made me a bit because our independent SLT said that if we could sort out his language difficulties many of his autism symptoms would disappear, but I suppose it it plausable that both are correct.

I 'think' what you are suggesting is a model a bit like this: the child has specialist ASD input that is 'in charge' of behaviour and motivation and learning style etc. and that is the context within which they 'access' other specialist services to support any difficulties. Would that work?

This is why I need an independent SALT right? So I can do the 'teaching' following the specialist advice of 'what' I am to teach.

In some respects, it probably is true that many autistic children do not have the attention span to do conventional speech therapy exercises so that in itself does not concern me that much. What I do want to know though is where is the advice on building motivation and attention span ? I feel we got nothing out of our involvement with NHS SALT but presumably they are getting money in their budget to cover ASD children. Why can they not either admit they cannot help and stop getting money, and/or direct parents to therapies that can help.

Thanks for the list and the breakdown on SALT training, I do appreciate they have a lot to cover and a lot to offer in the right circumstances.

This is a very interesting thread. I have had similar experiences with NHS SALT. I have however found a reluctance even in an independent SALT to adapt resources and go with the child's interests. I also found the SALT too focused on presenting materials to the child, child can't do task SALT says oh she can't do that WITHOUT any teaching. After following ABA principles where you teach the child, this seems to be madness. Yes, ASD children need a different approach, but I don't accept that it isn't possible to teach language in a different way. With dd she only started to learn single words when the reinforcement was v high and the labels were meaningful to her. It doesn't require alot of extra time to do this just willingness. Put frankly will the SALT jump up and down with the child, sing bob the builder fifteen times and get very excited when the child identifies the name of the correct character? Not often it seems. This started dd off to learn loads of single nouns, but I don't think she would have learnt any by just blowing bubbles and looking at black and white line drawings of simple everyday items.

doh, sorry!

My ds attends an I Can provision (he's just started reception) and they deal with children not with just delayed speech, its usually a specific impairment, which my ds has. They have a completely different way of leaning language, and my ds hardly had a vocabulary up to the age of 3 and a half. They made a point of checking he wasn't autistic before accepting him tho as the I Can setting wouldn't be suitable if he was

Willowthecat, to give you an idea of costings for NHS SALT, the reference cost for one hour is £70. This is publicly available info, but can't find it.. . Obviously, this includes NHS property, light and heat, management, training etc - I am NOT getting anything like this!

My ASD caseload last year varied from 66 - 100 but overall I "processed" about 75 kids in 3 sessions (a day and a half) a week or 141 sessions a year. Thats 493.5 hours for that caseload, or a total of 6.58 hours a child (working on a 47 week year to account for mandatory NHS training/annual leave etc).

That's a cost of (approx) £460 per child for:

• 2 assessment sessions
• phonecall to school and any other necessary professionals (EP, Clin Psych, School nurse etc)
• Report writing (Diagnostic report about 4 pages long with full assessment results)
• Attendance at Multidisciplinary meetings (sometimes 2-3 for a "tricky case"
• Observations in school
• Travel to school/MDT etc

I would say an average of about 10 "bits of work" for each child, so about £46 for each "bit" (again, including overheads and management etc here). Some would have more, some would have less..

In reality, the £450 per child per year is probably an overestimation in my trust. There are additional things that soak up time like workshops or groups or training for education professionals/colleagues/parents that are not specific to individual children. EarlyBird. Elklan etc.

Comparing this level of service to an ABA programme isn't really comparing like with like which is why I am dubious about a lot of research. Really, I don't get paid to do therapy at all. I get paid to assess children within a very tight time frame, keep waiting lists down and put some cut and paste suggestions at the end of a report... and more or less, that is what therapists like me do (usually working in their own time to make up for general NHS inefficiencies that slow things down further like computers that never work!).

I am leaving this part of my job now so I can work in a highly specialist setting only with a smaller, much more defined caseload. However, the annual cost per child in this unit (with 2-3 sessions of therapy a week and assistants etc is about £7K a year, so still much less than many ABA programmes).

Stark re:
"This is why I need an independent SALT right? So I can do the 'teaching' following the specialist advice of 'what' I am to teach."
Yes, absolutely. You will still need a SALT who understands that language development in ASD has a much more behavioural component than other disorders SALTs deal with, who is willing to work within ABA frameworks etc.

I guess what I'm really saying is that I think that SALTs are expected to understand behaviour/teaching/motivation when thats not what they're trained to do.
I am not trained to analyse or treat behavior and a good deal of ASD-related SALT in particular relies on behavioural principles. Yes, behaviour is communication and there are some therapists who pursue good training in behaviour as a result as they recognise that SALT training is not enough to really allow them to adequately address this aspect of communication development(e.g. moondog!). This is something I hope to do more of in future.

On the other hand, even though ABA is a hugely effective teaching methodology, I do not believe that theories of behaviour alone can ammeliorate all the language and communication difficulties that children with autism experience. I think the methodology can be used for anything but there are skills that lie below the level of observable behaviour that may need to be targeted - e.g. phonological awareness skills are not always "obviously" behavioural but there is good research they are associated with literacy outcomes and programmes to tackle this underlying skill CAN be behavioural. However, if we relied just on treating observable behaviours we might miss things that need to be tackled. Amberlight gives really good examples to demonstrate that there are processing difficulties and that we must continue to strive to work out what's going on. I am doing my MSc on deficits in gesture comprehension that may reduce understanding of speech in kids with autism. If research proves this to be an issue as I feel it will, then programmes can be designed to improve gesture comprehension etc etc.. and if I find that my hypothesis is accurate I will of course do that.. but autism is such a complex, diverse heterogenous disorder that you need many, many perspectives.

I think there is a general problem with many professionals that they don't understand their own limits and think they have the answer to things they barely understand.
This is as true of ABA professionals as SALTs. I have seen some dodgy ABA language programmes with children with more advanced and/or disordered language where what's going on hasn't really been adequately addressed.

So much more I could say but must stop writing essays!

cansu - if an independent SALT won't plan/individualise targets, they are probably just crap.

Some independent SALTs become independent as they want more planning time and to offer more quality intervention etc. Others become independent because they just can't hack the pressure of the NHS. I have met amazing independent SALTs and some pretty crap ones. Depends on their motivation, I guess? Sorry you got a crap one!

Oh working Please DON'T stop writing essays if you have more to say and you feel able to. Honestly your words over the last few weeks have been soooo valuable to me in trying to work out a way forward for ds.

We're in a bit of a unique situation I feel, in that we've ABA'd ds who has been an incredibly fast learner. We have his attention, his focus, his words and millions of them but the professionals don't seem to have caught up with us. Under 5's SLTs round here all seem to never experience their caseload children to progress past the bubbles stage.

No usual 3yr old on 92nd percentile for verbal comprehension would even GET SLT, let alone one with autism and WEEKLY too! The SLT works in the Jnr SLT base so I feel she is used to working on higher level difficulties (which I am pleased about), but with 8yr olds, not 3yr olds. I think she is a bit thrown, and add to that having to work with such a known to be difficult and challenging parent.

It would appear that I am asking a lot of her. Not in terms of my rights (or my ds' rights to be correct) but in terms of what she knows, perhaps to be fair in terms of what she is usually EXPECTED to know.

I suppose I can only hope that she can be honest about this with me and we can work together to move forward. Defensive professionals bring out the absolute worst in me.