Some of our clients with autism get well and truly stuck when it comes to improving expressive language. They can’t seem to get beyond putting a few words together and using echolalia. Looking at their stage one sentence types can tell us a lot about why they get stuck. Join us as we look at an eye opening case study and explore WHY this client was stuck.

—- Episode Links  —-

Stage One Sentence Types in the Free Resource Library
Story Champs – https://www.languagedynamicsgroup.com/

Music: Simple Gifts performed by Ted Yoder, used with permission

Transcript

Denise: So I had known for a long time that David’s typical two-word phrases communicated less than a typically developing child, but I didn’t know why. That’s one of those characteristics we see with some kids with autism without really understanding why that would be. Now. I think I know why, I’m developing a hypothesis, that this is why.

Welcome to The Mindful SLP, the show that explores simple but powerful therapy techniques for optimal outcomes. I’m Denise, here with co-host Dan, and today we’re talking about a way to help our clients with autism use their expressive language more functionally. This podcast has been a year in the making, and I’m really excited to share my ideas with our listeners.

Dan: Now wait a minute, we haven’t even been doing a podcast for a year, and this has been a year in the making? Unpack that. What do you mean?

Denise: Okay. A year ago I began using a method to improve the expressive language of one of my clients who has autism. Very quickly, I saw some really good results. But since this was a method I hadn’t ever heard of anyone using, I wanted lots of clinical validation before I started shouting it to the world. So when we started our podcast in July, this was immediately on my mind, but I wanted more, more clinical validation. Basically. I’ve been sitting on some really exciting, it’s thrilling, really, information for a year. And since April is autism awareness month, I decided it was time to go for it.

Dan: Tell me what’s so unique about what you found.

Denise: I don’t know for certain if it’s been tried to research before, I just know that I couldn’t find anything on it and I searched through ASHA’s literature. What I can tell you is that it’s based on solid research about language development, it’s developmentally appropriate, and it has worked super, super well for my client with autism.

Dan: Oh, wow. This sounds like a pretty marvelous method.

Denise: I hope you’re dying to know what it is. I am, but hang in there. So SLPs, you know, when you go to a conference and the presenter is scheduled to speak on the same topic before lunch. Get your lunch break then after lunch, I’m always that SLP who’s going, okay. I know they’re going to go over the etiology, I know, I know they’re going to go over the background. I really want to get to the meat of it. Okay. Well, tables have been turned on me because I am like that presenter. This is your before lunch presentation. I really need to set the stage so you know where I’m coming from.

Dan: Okay. So hang with us here, because this is, this is going to be good stuff. And definitely you’re getting to know what we’re talking about this week, but next week’s the big payoff, but let’s start with the stuff for this week. Tell us about what you learned.

Denise: So first I’m just going to describe the particular client that this works for, and then I’m going to tell you where he was in language and how he was topping out, and how I just couldn’t get past where he was topping out.

Then I’m going to describe an epiphany I had, why it’s important, why I missed things I wasn’t seeing earlier so that you can be reminded to look for these things too.

Dan: Tell us about the client.

Denise: I’m going to call him David. He was nine at the time and David is verbal. He could speak in complete sentences, often did not, often just communicated in one and two words. He used a lot of echolalia. He tended to repeat himself a lot, perseverate on the same topic, um, tell me the same story, and I use story in quotes, he couldn’t tell me a story, but the words that he would use…

Dan: Same thoughts. And it was multiple weeks, not just in the same session, it was multiple weeks.

Denise: I remember when we replaced the floor in the clinic waiting room. He talked about that for weeks. When he came in the same thing, he was really impressed that the new fort echoed. That being said, David could do a lot with what he had, he could tell his parents if he was sick or how he felt. And they got pretty good at intuiting what he wanted to communicate, just because they knew him so well. And he could sometimes tell you a sequence of events. He likes to talk, he likes to talk, and he still does, likes to be social. And he is really bright when it comes to math and puzzles and he can read far above what he can comprehend.

Dan: Okay. So he’s pretty expressive, but we have some problems.

Denise: Yeah. Because you can’t tell you a lot with the number of words he uses. So I’ve been fortunate to work with David since he was in preschool. And I do have to tell you he had come a long ways to get to where he was a year ago. And by last spring, my main objective for David was to teach him to form more complete sentences on his own and be able to express cause and effect.

I had tried various methods, but nothing took hold. And I felt that if he did express a more complete thought during a session, it was because I had been working on it the whole session, I was providing a kind of artificial support that just collapsed when he wasn’t in speech therapy. On his own, he was back to using mainly one or two words.

Although, occasionally, like I said, he could form a complete sentence.

Dan: Wow, that had to have really left you with a where do I go from here feeling.

Denise: That is exactly right, because there does come a time with clients who have lifelong disorders, where you need to acknowledge that therapy is providing diminishing returns, where you’ve gone, as far as you can go with the conditions that exist. And I was beginning to wonder if that was the case with David. We were spinning our wheels in therapy. He seemed like he was topping out.

Dan: And you don’t want to just continue wasting parents’ money if you can’t help them, and yet you’ve got this professional. I want to help this kid.

Denise: Yeah, yeah, I know. You would see glimpses, like there’s that complete thought, there’s that complete sentence.

Dan: I should be able to do something with this. Right. So what happened next?

Denise: Well, I went to our state association conference and I heard Trina Spencer, one of the co-creators of Story Champs, presenting on how to implement it.

Dan: Oh, Story Champs, that’s what we talked about last week when we interviewed Doug Peterson, who is that co-creator.

Denise: Yes, that was a fantastic interview. And Story Champs is a fantastic product. I can’t say enough about it. Maybe you want to go listen to the podcast, actually two podcasts, we split into two. Anyway, back to Trina’s presentation. She showed a video of implementing Story Champs with a child who has autism and it was impressive.

Dan: Oh, and of course you instantly thought of David.

Denise: I decided to give it a try because Story Champs, besides building narrative language, it can also build sentence structure and understanding of cause and effect. So the reason I thought David might be ready for it was because of glimpses I saw of his ability to express complete thoughts and use complete sentences.

Dan: Unpack this a little bit here, why would you think that a person who could only communicate in one or two word sentences would be ready to have a complete story?

Denise: Let me tell you about a really, really good day I had in therapy with David. One of the things I like to do is read books with him and then cover up the words and have him describe to me what he’s seen in the pictures. And by the way, David can read far above what he can comprehend, it was exciting to me that he was actually describing in complete sentences what was going on in the book. And when we got towards the end, he said this sentence, the little bear is riding the bike. I was doing this happy dance, a complete sentence, a complete thought independently expressed, no prompts for me.

It was glimpses like that, that kept me going with David. So I thought, oh, okay. So maybe he just needs this story structure and that’s the missing piece. I can get these complete thoughts going.

Dan: And how’d that go?

Denise: He couldn’t grasp it. He couldn’t grasp how to describe the problem in the story, why they characters felt and reacted the way they did. Um, and part of the Story Champ protocol is to answer wh questions about the story. Yeah. Who was the story about, what was their problem? How did they feel? He really, really didn’t understand how to answer those questions. He was still stuck at talking about a series of events and partial sentences, couldn’t make it cohesive. Okay. And I suspect there are a lot of SLPs out there with similar clients with autism. I’ve had them in the past. David happens to be the only client I have with autism right now who’s in this particular stage, but I’ve had them in the past where they were kind of topping out with their language.

And you tend to think as an SLP, if I could just move them on to expressing a complete thought, then they could learn narrative language and the road would open up in really significant ways. And that’s what I wanted for David, but I was back to wondering, is this the end of the road? Are we done here? I can’t move them on to stories.

Okay. Well, obviously, since we’re talking about him, this isn’t the end of the road for David. What happened next?

Okay. Now that you’re all up to speed on where David was, I want to take you on a little thought experiment. Imagine you’re learning math, but you only have even numbers to work with. Could you write a pretty long equation?

Dan: I could write a long equation, but it wouldn’t really do anything.

Denise: I mean, eventually you’d hit a stopping point where you couldn’t do higher level math, even if you could make a pretty long equation, right?

Dan: It just would be window dressing, but it wouldn’t have the meaning.

Denise: But someone who saw you work an equation that only required even numbers, they might be deceived about your ability.

Dan: Right, until they really got in found out oh yeah, he’s just, he’s he’s and he’s not all there.

Denise: Then you might think you were ready for math that you weren’t ready for. And it’s not that you couldn’t learn it, it’s that you would need to learn about the odd numbers. Right?

You see where I’m going with this? The question for me was what was David lacking and could he learn it? Well, I think I figured out what it is. And it all came from reading a Facebook thread, Facebook, one of the SLP language sites. You remember how I said, David couldn’t comprehend the wh questions in the Story Champs. Right. So an SLP commented that when her clients had trouble with wh question comprehension, she always looked at Brown’s grammatical morphemes to see what was missing and their language structure.

Dan: Now Browns grammatical morphemes. What’s that? Oh, that’s a lot of syllables, must be a speech therapy term.

Denise: Okay. Uh, grammatical morphemes are grammar we use to change or add meaning to words like adding an ING ending, plurals, possessive S .There are 14 stages of morpheme development and they go in developmental order. So what’s really cool is generally as children increase the number of words they use, they add an increasing number of morphemes and they go in this kind of order.

And I knew David had some morphemes he used regularly, but I thought, Hmm, I haven’t looked at that. So I immediately Googled handy-dandy morpheme chart to see what stages he might be missing when my attention was drawn to stage one, which I haven’t thought about in years.

Dan: Okay, what’s special about stage one?

Denise: Stage one is just sentence types. Now, let me explain that a little bit. When you put two words together, you’re putting two ideas together. We call that semantic relations. If a child holds up a sock and says, mommy, sock, that’s expressing possessor possession. This is mommy’s sock. If a child says dolly bed, that’s expressing entity and location, the dolly is on the bed.

If a child says, daddy, go that’s agent action. Daddy’s the agent. And go as the action. There are several different stage one sentence types, and those are just examples of three of them.

Dan: Okay. So there’s lots of different ways, but there’s only two words. So it’s not a complete thought.

Denise: It’s a complete thought, it’s not a complete sentence. Mommy socks, not a complete sentence, but it is a complete thought, which is what’s so interesting to me, it’s what’s really important. Um, stage one has two parts. I just want to say the semantic relations I just talked about, but also the operations of reference are really important.

Operations of reference are ways to express recurrence. Like more, again, it’s a ways to express negation. Something’s gone, it’s not there, it didn’t happen. That’s, they’re equally important. The semantic relations and operations of reference. These are what make our language complex. It’s what makes someone able to make their language complex.

And so what I thought was, I don’t think David has a lot of the semantic relations or operations of reference. I had never even looked at it. So what we normally see, um, many children come to us with only one or two words, preschoolers, or maybe they have 10 words, you start doing some therapy, you start playing with them. They start putting words together. And these stage one sentence types emerge on their own. Okay. I know because I’ve checked. I thought I missed this with David, did I miss it with some of my others, clients, you know, I was looking at him. No, no, just as I started putting words together, it started happening.

So normally as SLPs were focused on stages two through 14, We do have to work on those.

Dan: But level one is, it comes along so automatically normally, it’s easily to just jump right over it.

Denise: And not even think about it. And I think this is really specific to autism. That’s my hypothesis. And that’s part of the reason why their language sounds so, um, Yeah, why the language sounds so stilted and kind of unnatural and why some of the words they put together don’t really give us a lot of information.

So by the way, I am going to have a chart of the stage one sentence types in my free resource library. So go there, go to SLP proadvisor.com/free, and you can download those sentence types. Stage two through 14 are easy, easy to find on the internet, stage one’s not quite so easy, so that’s why it’s going to be in my library.

So with this idea in my mind about where David was with the stage one sentence types. I took a language sample in free play with him. I wasn’t supporting his language at all. I analyzed it and he was almost 90% one kind of sentence type, agent action. He only had one kind of negation, a very, very simple kind of negation that he used in very particular ways.

And then I started to think about that sentence, the little bear is riding the bike. Huh, not her bike, which would express possession, or not on the bike, which would present vocative(?) location. And I started to, yeah, think about all the way he, the way he was putting words together and how they didn’t give me a whole lot of information. I thought…

Dan: Yeah, and when you break it down, it is a very simple sentence with lots of words, but simple.

Denise: Yeah. It’s long deceivingly long, like adding up all those even numbers, but without complexity and I remembered what he said when we were playing this matching game, it’s called Who Lives Where, we have to figure out if the animal you have in your hand is under this roof. If that’s his house, where they live, where they live. And so he had chosen like the duck when it was really the bunny’s house. And he just said the duck and the bunny, because he didn’t have negation to express that’s not the Duck’s house that doesn’t fit, that doesn’t match.

Oh, wow. Just he could only see the duck and the bunny.

Dan: Oh, my brain is going explosions right here. Imagine yours was too.

Denise: Yeah. And I thought, well, of course he can’t tell stories. How many stories have problems that involve being able to express negation?

Dan: All of them.

Denise: Not all of them, not all of them, but a lot of them can’t find, didn’t have.

Dan: That’s the real conflict.

Denise: How many of them expressed possessor and possession? Like she’s got my toy. I can’t find my shoes, stuff like that. Oh. And that reminds me of a story. David would tell me about his Cougar hat falling in the river. So you just ought to know that David is a huge BYU Cougar fan, that’s a sports team down here and he has a hat, he has a Cougar hat. He adores the Cougars and he adores his hat. So when he told me about it, he said the Cougar fell in the river because he didn’t have what we call entity plus attribute. Right? The entity is the hat, the attribute is the Cougar. He just said, he said the Cougar fell in the river and someone who didn’t know him would have no idea what he was talking about.

So contrary to how most children develop language, David’s language didn’t increase in complexity as his MLU, that’s what we call mean length of utterance, increased. So he’s not following that sort of developmental chart.

Dan: Just adding on words, be didn’t add on any meaning.

Denise: And in fact, you could argue that his MLU really didn’t increase very much because he was still mostly using one and two words. It was a kind of a, one-off a rare occurrence when he put lots of words together. And in fact, his word combinations often lacked clear semantic relations as I started to analyze, and I’m like, not really sure what he means there. There’s two words there, but there’s not two ideas connected. So I had known for a long time that David’s typical two-word phrases communicated less than a typically developing child, but I didn’t know why. That’s one of those characteristics we see with some kids with autism without really understanding why that would be, and now I think I know why, I’m developing a hypothesis, that this is why.

Dan: Okay. So we’re going to have to wrap this up for today and kind of leave you hanging. Of here, but yeah. What, what, what do we do about this? What’s the takeaway for this week?

Denise: The takeaway is that complete thoughts come before complete sentences. Let’s not be too focused on complete sentences with these clients who are like this, let’s be focused on, do they have the ability to relate ideas that make a complete thought, to put words together that express these operations of reference and these semantic relations. That’s what we should be looking at.

Dan: Complete thoughts before complete sentences.

Denise: Again, when you master the simple, the complex takes care of itself.

Dan: Come back next time, cause we’ve got a lot of really exciting stuff. So as Denise explained, go have your lunch, come back after lunch, and we’ll have some even more exciting information about how she took this and turned it into the actual therapy.

And how did David respond? But in the meantime, go sign up at SLP proadvisor.com/free, so you can get the free materials and including this list of level one, stage one, stage one. So you can get the stage one sentence types. I should be making you say this. But that’s an important thing. There’s a lot of other tools out there on the free resource library that will help you every day, and in your therapy. We appreciate you coming and listen to us today. Talk to you next time.

Thank you for listening to The Mindful SLP. We hope you found some simple tools that will have optimal outcomes in your practice. This podcast is sponsored by SLP advisor. Visit SLP pro-advisor dot com for more tools, including Impossible R Made Possible, Denise’s highly effective course for treating those troublesome Rs. A link is in the show notes. If you enjoyed this podcast, please give us a five-star rating and tell your fellow SLPs, and please let us know what you think. Join the conversation at SLP pro-advisor dot com.