Speech Issues in Autism
Just because a child doesn’t speak, it doesn’t mean they have nothing say. Providing your child with an effective means to communicate their thoughts, opinions, experiences, feelings, and knowledge is essential to creating a meaningful life for them. We have learned from children who later were able to gain speech or find a way to communicate that they understand much more than people think they do, many understand everything.
A person with autism can have a receptive language delay, expressive language delay, or both. Receptive language delays occur when someone struggles to understand and process the information they are receiving. Expressive language delays occur when someone struggles to express their meaning or message to other people. Either way, it is important to know that your child is listening to you and has thoughts and feelings they need to express. Presume competence.
Approaches to Helping Non-Speaking Children Communicate
There are two different approaches to developing speech:
- Therapeutic Approach: Includes speech and behavioral therapies as well as alternative communication methods.
- Medical Approach: Involves treating underlying medical issues that impede speech.
Both of these approaches are essential to developing speech. Many of our kids have co-occurring medical issues that cannot be remedied with therapy alone. As one mom put it, “No amount of time spent in speech therapy can prevent my kid from having seizures.” It is essential for parents to utilize both approaches in order to achieve the best possible outcome for their child.
Developmental Speech Delay or Apraxia?
Knowing the difference between a developmental speech delay and apraxia can help you determine which therapeutic and medical approaches are the best fit for your child.
A developmental speech delay is when a child is following a “typical” path of speech development, but at a rate that is considered slower than normal.
Apraxia is a motor speech disorder which makes it difficult to formulate sounds into syllables and words. People with apraxia understand language and know what they want to say. The muscles involved with speech aren’t weak, but rather have trouble performing because the brain has difficulties with directing and coordinating the muscle movements involved with making sounds to formulate words. Find out more information about apraxia, including what makes speech therapy different for children with apraxia at Apraxia Kids.
Therapeutic approaches include alternative communication options and can be provided by speech therapists, behavior therapists, or both. Many parents report success with a team approach, where both speech and behavior therapists are consulted for input related to their specific area of expertise. When services approach skills in completely different ways, they can inhibit your child’s ability to master those skills. Make sure your providers are on the same page.
Therapists use a number of different methods (approach or way of teaching) and modalities (ways, other than speech, a person can use to express their voice) to help children with autism improve functional communication skills. They perform evaluations to assess strengths, challenges, and needs and then help develop goals based off of the results of that evaluation. Speech therapists also work with motor planning and Augmentative and Alternative Communication (AAC) needs.
Below you will find a brief description of some therapeutic methods and modalities. Please keep in mind that this list is not exhaustive – it contains just some of the options that are available. Furthermore, what works for one family may not work for your family. In order to determine which option will best match your child’s learning style and needs, it’s important to work with a qualified professional who knows about all of the different methods and modalities that are available.
Discrete Trial Training (DTT)
DTT is a technique that breaks down skills into small, “discrete” or distinct components. Instead of teaching an entire skill at once, it is broken down and “built-up” using discrete trials that teach each step, one at a time.
Functional Communication Training (FCT)
FCT is the use of positive reinforcement to motivate the child to communicate rather than engaging in problem behaviors.
Facilitated Communication (FC)*
FC is a method of AAC that involves a facilitator who uses physical and emotional supports to encourage a person to communicate by pointing letters, words, or pictures. The goal is to gradually fade physical supports out as the communicator becomes more independent. For more information about FC, please visit Syracuse University's Institute on Communication and Inclusion and the Wellspring Guild.
Prompts for Restructuring Oral Muscular Phonetic Targets (PROMPT)
PROMPT is a multidimensional approach to speech production disorders has come to embrace not only the well-known physical-sensory aspects of motor performance, but also its cognitive-linguistic and social-emotional aspects. PROMPT is about integrating all domains and systems towards positive communication outcome. It may be used (with varying intensity and focus) with all speech production disorders from approximately 6 months of age onward. To achieve the best outcome with PROMPT it should not be thought of or used mainly to facilitate oral-motor skills, produce individual sounds/phonemes, or as an articulation program, but rather as a program to develop motor skill in the development of language for interaction. Find out more about PROMPT here.
Rapid Prompting Method (RPM)*
Developed by Soma Mukhopadhyay, RPM is a method that is used to teach academics and communication is also taught in the process. Despite behaviors, the academic focus of every RPM lesson is designed to activate the reasoning part of the brain so that the student becomes distracted by and engaged in learning. You can find out more about RPM here. If you're looking for an RPM provider, there is a private Facebook Group called Unlocking Voices which has a list of trained and certified SomaRPM providers. The folks at Unlocking Voices work with Soma to maintain this list. They also have good information on tutorials and other resources.
Spelling to Communicate (S2C)*
S2C teaches individuals with motor challenges the purposeful motor skills necessary to point to letters to spell as an alternative means of communication. The goal is to achieve synchrony between the brain and body. Skilled and rigorously trained communication partners teach purposeful motor skills using a hierarchy of verbal and gestural prompts. As motor skills improve through consistent practice, students progress from pointing to letters on letterboards to spell to typing on a keyboard. Accordingly, communication moves from concrete to abstract as motor skills progress. More about S2C can be found here. Furthermore, if you are interested in being trained as a communication partner, you may want to look into I-ASC (they are affiliated with S2C and there is hope they will expand to other modalities).
Communication Modalities (Tools)
Augmentative and Alternative Communication (AAC)
Augmentative and Alternative Communication (AAC) includes all forms/modalities of communication a person can use to express needs, wants, thoughts, and ideas without talking.
Before we go further, let’s address some common myths about AAC.
- Myth: If I give my child an AAC option, they will no longer be motivated to talk.
Fact: AAC will NOT stop your child from using or developing verbal speech. Research has repeatedly shown that AAC encourages and improves natural speech development.
- Myth: My child is too young or doesn’t possess the skills to start using AAC.
Fact: An individual can never be too young to enhance communication. Research has shown that it:
- Myth: My child lacks the cognitive skills needed to learn how to use AAC.
Fact: There are no prerequisite skills to use AAC. In fact, development of language skills can lead to functional cognitive gains.
AAC Screening and Selection Process
Finding an AAC provider can be a bit tricky because it overlaps into multiple disciplinary fields (OT, PT, Speech, etc.). Typically a speech therapist with a specialty in AAC will screen your child to determine if there is a need for it. However, that is not always the case, so don't be afraid to look for professionals outside of a speech setting for help. You may also want to check out this blog from PrAActical AAC which has good information about finding a qualified provider.
Many schools and service providers use Assistive Technology Specialists for augmentative communication evaluations and trainings. It is important that you convey your specific want when requesting an “Assistive Technology Assessment" through the school. If you are wanting an Augmentative and Alternative Communication (AAC) evaluation you should convey this. Not all AT evaluations include AAC.
Once the need for AAC is determined, your AAC service provider will involve you in deciding which AAC system will work best for your child. They will also train everyone on how to use it, document progress, and make changes when necessary. Please keep the training piece of this in mind when dealing with your school district - teachers need to be trained on how to properly use your child's AAC system too.
AAC modalities can be aided or unaided, low tech or high tech. A person can also use a combination of many different modalities. What matters is finding the right AAC system that works for your child. Below is a chart with some examples of AAC modalities.
|No-tech||Low Tech||High Tech|
• Body Language
• Facial Expressions
• Sign Language**
|• PECS Picture Exchange Communication System|
• White Board
• Communication Boards
• Pen and paper
**Because sign language requires advanced fine motor planning abilities and coordination, it is not a viable option for many people with autism.
Both an evaluation and device/materials should be provided by the public-school system from age 3-22. If written into the IEP properly, your child will have access to the device or materials 24 hours a day (to be used at school, at home, and in the community) so that generalization and continuance of program and goals can be followed through. Medicaid also provides funding for evaluations and devices.
If you need further resources for funding, TACA’s private Facebook group for parents, Hope and Help for Autism, has some great threads with tips from parents who were able to successfully troubleshoot and get their child’s device covered. This article might help as well.
Again, the methods and modalities mentioned above are not the only options available. There are websites and blogs that contain pages and pages of information dedicated solely to this topic. If you wish to continue researching, links to a few resources that many TACA families find helpful can be found at the end of this article.
Back to Presuming Competence
When we talk about presuming competence, that doesn’t mean we are presuming that our kids already know everything. It means we are presuming that they have the desire and ability to learn age appropriate material, especially when using their preferred communication modality(ies), accommodations, and teaching strategies. As David Beukelman says, “Having a communication device doesn’t make you an effective communicator any more than having a piano makes you a musician.” Simply having access to all of the right tools is not enough. Your child needs to be taught how to use those tools with a method that meets their individual learning style and needs. Ensuring your child has access to both the tools and the teaching methods in the classroom and the community, will enable them to have a voice and lead a full, purposeful life.
There are many underlying medical issues that can impede speech. Below you will find a list of things to research when helping your child to develop speech. A good doctor, who is familiar with treating medical conditions common to autism, can help you on this journey.
Cerebral Folate Deficiency
Cerebral Folate Deficiency (CFD) is a relatively newly identified disorder in which there is low 5-MTHF (5-methyltetrahydrofolate) in the cerebrospinal fluid but normal or even elevated 5-MTHF in the blood. Symptoms include developmental delay including speech problems, among other symptoms. Treatment options for CFD include folinic acid and a dairy-free diet as mammal’s milk blocks folate receptors. More about CFD can be found here.
More common in autism than many realize. Approximately 41% of ASD kids will have seizures by the time they are adults. Seizures are often undiagnosed as a 30-minute EEG doesn't catch most seizures, and it definitely won’t catch seizures a child is having in their sleep. This is why it is recommended that every child with autism have at least a 24-hour EEG.
Symptoms can vary. They include, but are not limited to, GI distress, headaches, fatigue, oxidative stress, clumsiness, slow cognitive performance, slow processing speed, developmental delay or delay in growth, seizures and more. With a mitochondrial cocktail given at proper doses, many kids with autism improve greatly.
Decreased Blood Flow to Speech Areas in the Brain
Hyperbaric Oxygen Therapy (HBOT) helps with this & also reduces inflammation.
Study: Hyperbaric treatment for children with autism: a multicenter, randomized, double-blind, controlled trial
Vitamin and Nutrient Deficiencies
The body requires certain amounts of specific vitamins and nutrients in order to function. Speech is no exception to this rule. The good news is that these can be easily addressed through modifications to your child’s diet, including supplementation. Years ago, parents and clinicians were ridiculed for reporting that the gluten free, casein free (GFCF) diet was the most helpful intervention for speech. Thankfully, that is no longer the case. Studies like this one, support their clinical experiences. Not to mention the studies that explain the science behind them. A couple of examples are:
- Cerebral Folate Deficiency, mentioned above, which is treated by eliminating dairy from the diet and supplementation with folinic acid.
- B12 Deficiency in the Brain - B12 connects the folate cycle to the methylation cycle and is used to treat redox abnormalities. Studies like this one show that Methyl B12 helps with speech, sleep, energy, processing speed (cognition), focus, and attention in some kids with autism.
Nutritional and Dietary Interventions
Given that nutritional and dietary interventions are so helpful when it comes to speech, we’d like to provide you with a list of options to consider with your child’s doctor.
Gluten Free Casein Free Diet
The gluten free, casein free (GFCF) diet is the single most parent-reported therapy that gets children talking. The GFCF diet is merely a change of food, so it’s not invasive, dangerous, and it’s only as expensive as you choose to make it. Not only has it been shown to help with speech, but cognition, sleep, focus, anxiety, behavior, and gastrointestinal issues too.
Furthermore, a GFCF diet can alleviate issues associated with Cerebral Folate Deficiency. As mentioned above, dairy blocks folate receptors, but wheat can play a role in blocking them too. Most wheat products are fortified with folic acid. It is known that kids with autism have a hard time breaking down folic acid. They have polymorphisms that do not allow the body to properly break it down. Folic acid is the oxidized form of folate (folate is the form found naturally in food). If folic acid is not properly broken down, it may end up floating around in the blood and can actually block folate receptors.
Supplements That Have Been Proven to Help with Speech in Autism
L-Carnosine, is a naturally occurring amino acid found in high concentrations in muscle, heart and brain tissues. It has been used to treat liver disease, Alzheimer’s disease, and cancer. In the study below, children with autism who were given L-Carnosine showed significant improvements in behavior, socialization, and communication, as well as increases in language comprehension.
Study: L-Carnosine and Autism: Improving Language and Behavior in Children Diagnosed with Autistic Spectrum Disorder (ASD)
Creatine is an amino acid that supplies energy to muscles through the blood. By contrast, Creatinine is a biological waste formed by the metabolism of creatine and excreted from the body in urine. If creatinine is low, it is possible that creatine is low.According to Dr. Ben Lynch, if you have a child that is low muscle tone, not gaining weight, is low energy, and has a speech or developmental delay, then check their GAMT SNP. If they are ++ on this SNP, they may have a creatine deficiency. More info from Dr Lynch here.More information about creatine deficiency and its association with autism and speech delays can be found here.
- Omega 3 Fatty Acids
These have been shown to help speech and focus.
Meta-analysis: Supplementation of omega 3 fatty acids may improve hyperactivity, lethargy, and stereotypy in children with autism spectrum disorders: a meta-analysis of randomized controlled trials
Article: Fish oil capsules help children with speech disorders find their voices
Improves mitochondrial function, thereby possibly improving speech. It can be prescription or over-the-counter.
Study: A prospective double-blind, randomized clinical trial of levocarnitine to treat autism spectrum disorders
Article: Researchers investigate possible link between carnitine deficiency and autism
- Folinic acid or 5MTHF (methyltetrahydrofolate)
See the above information on Cerebral Folate Deficiency.
Study: Folinic acid improves verbal communication in children with autism and language impairment: a randomized double-blind placebo-controlled trial
Ubiquinol is the bioavailable form of CoQ10. In the study mentioned below, data results showed a 21% improvement in verbal communication with supplementation of ubiquinol.
Study: Ubiquinol Improves Symptoms in Children with Autism
The study cited below showed a 42% increase in verbal communication on Sulforaphane.
Study: Sulforaphane treatment of autism spectrum disorder (ASD)
- B6 (p5p) and magnesium
Study: Improvement of neurobehavioral disorders in children supplemented with magnesium-vitamin B6. II. Pervasive developmental disorder-autism.
- Methyl B12
Below is a study showing remarkable improvements with B12 and folinic acid treatment. On average, skills were improving drastically in only three months. For instance, six months of language improvement in 3 months.
Study: Effectiveness of methylcobalamin and folinic acid treatment on adaptive behavior in children with autistic disorder is related to glutathione redox status
Study: Randomized, Placebo-Controlled Trial of Methyl B12 for Children with Autism
- Vitamin D
Many children with autism have a vitamin D deficiency. Knowing your child’s Vitamin D level is important as it should be between 50-80. In the study linked below, the autism symptoms of children improved significantly following 4-month vitamin D3 supplementation.
Study: Randomized controlled trial of vitamin D supplementation in children with autism spectrum disorder
Iron plays an important role in cognitive and motor development. Iron deficiency may increase the severity of autism symptoms, including a lack of speech. Too much iron can be toxic, so you should NOT begin iron supplementation unless you’re under the care of a physician who is monitoring levels of both iron and ferritin (iron stores).
Study: Iron deficiency parameters in autism spectrum disorder: clinical correlates and associated factors
- Butyrate (a short chain fatty acid)
Butyrate is a short chain fatty acid. It has been shown to improve mitochondrial function, thereby possibly improving speech.
Study: Butyrate enhances mitochondrial function during oxidative stress in cell lines from boys with autism
- Kelly Dorfman’s Apraxia Protocol
A combination of phosphatidylcholine, Vitamin E, and Omega 3s has helped many kids with speech. Her protocol can found here
It is an understatement to say that navigating through this aspect of the autism journey can be tremendously challenging. But, remember, challenging does not mean impossible, and TACA is here to help, so you certainly don’t have to navigate it alone.
Additional AAC Resources:
- PrAACtical AAC is a great place to find resources and strategies to improve communication and literacy abilities.
- Communication First is a nonprofit organization dedicated to protecting and advancing the civil rights of people of all ages in the United States who, due to disability or other condition, are unable to rely on speech alone to communicate.
- United for Communication Choice is a grassroots organization established in support of the human, civil, and legal rights of people with disabilities to choose their most effective methods of communication.
- USSAAC (United States Society for Augmentative and Alternative Communication) is dedicated to providing information and support on the issues, technology, tools and advancements within the world of AAC.
- The University of Nebraska-Lincoln’s Department of Special Education and Communication Disorders.
- Closing the Gap empowers educators, professionals, parents and users with the latest research, tools and resources to deepen their assistive technology knowledge, best practices and implementation strategies.
- ABLEDATA provides unbiased, comprehensive information on products, solutions and resources to improve productivity and ease life’s tasks. Although ABLEDATA does not sell any products, they list the companies that do.
*We stand with United for Communication Choice in their request that ASHA withdraw their flawed position statements against RPM, S2C, and FC.
All content of this article was created for informational purposes only and is not intended to be a substitute for professional advice, diagnosis, or treatment. Always seek the advice of your physician, therapist, or other qualified health provider with any questions or concerns you may have.