Adapting the Sign to Talk Program

Using PECS (Picture Exchange Communication System) and signs form an integral part of therapy for a lot of speech language pathologists that work with children who are predominantly non-verbal and require a functional communication system.  For one little guy, who was diagnosed with Autism Spectrum Disorder,bubbles Severe Apraxia of Speech and a seizure disorder, I attempted the “Sign to Talk” program (Tamara Kasper, M.S., CCC-SLP, BCBA; Nancy Kaufman, M.A., CCC-SLP).  The program is offered as a “bridge to vocal communication for children that are not yet vocal imitators.”  The program consists of two sets of flashcards and instruction manuals.  The flashcards are pictures of the object or verb on one side and on the back they have the picture of the sign for the word.  On the back, each card also displays a series of ”successive approximations” of the target word based on least physiological effort, as proposed by Nancy Kaufman.


Each set costs approximately $150.  However, you can purchase the Sign to Talk app for the iPad for about $20.  While the flashcards are a lot easier to use during therapy, the difference in cost definitely tilted the scale in that direction for me.  Since my little guy had a hard time attending to flashcards in the first place, I began the program by selecting a group of objects/ toys that were motivating to him and used the objects instead of the flashcards.  We worked on the signs for several weeks until he could produce the sign with minimal prompts to request his favorite objects or make choices.  I then found pictures of the objects on “Google Images” and put them on index cards.  I didn’t put a picture of the sign on the back since both the parents and myself were now familiar with the target signs.  I also hand wrote Nancy Kaufman’s “successive approximations” on the back.  The advantage to making your own cards (apart from the obvious cost factor) was that I could include pictures that are not in the repertoire of the original set.  I did have to make my own “successive approximations” for those words, but it does get fairly easy once you’ve done a few.  If you are familiar with the Kaufman cards, it won’t be hard at all.  Since my little guy was by now comfortable using signs, I introduced the flashcards to see if he could produce the signs on demand.  As his consistency increased, I gradually introduced the speech portion, which is the successive approximation of the syllables.  Since we also use signs, it alleviates some of the frustration that used to follow speech imitation when it was attempted in isolation without signs.  Of course, I always use P.R.O.M.P.T (PROMPT Institute) along with the signs.  We are seeing significant progress in his speech imitation skills.  More importantly the frustration and behaviors that accompanied any speech imitation task earlier are now almost completely eliminated.

Treating Vowels: A Tactile Treatment Program (Part III)

The second part of Sam’s treatment for vowels was the speech production or articulation portion.  We began by targeting the round vowels such as /Ʊ/.  A lesson plan was created that included auditory bombardment, production of the sound in isolation with PROMPT and tactile cues, production of the sound in words using a functional or communication task, and production of the sound in a word using drills.

For the round vowels multiple tactile cues were provided to elicit the lip rounding.  The TalkTools Tactile Tubes were particularly helpful.  Since they come in different diameters, different tubes were used to elicit different sounds.  Initially the use of Renee R. Hill’s and Sara R. Johnson’s Ice Stick was also very helpful to elicit lip rounding.  The added thermal stimulation provided by the cold Ice Stick yielded some good results.  The Ice Stick placed horizontally was used to elicit lip retraction for vowels such as /i/.  In addition, two Bite Blocks placed between the molars simultaneously on both sides also assisted with stabilizing the jaw height while aiding lip retraction.

Following the principals of Hodson and Paden’s Cycle’s Approach, a vowel was targeted for a few weeks and then a new vowel was selected.  Once all the sounds were targeted, the same targets were then re-cycled.  The functional or communication tasks were the highlight of the session.  This portion is important since it gives us as therapists the opportunity to shape the sound in one phonetic context using multiple trials.  For example, when targeting the “ee” sound, I used the Honey Bee Tree game.  I worked on the words “tree” and “leaf” when Sam placed the leaves on the tree.  When he pulled the leaves out and the bees fell, I targeted the word “bee.”  I try to elicit the word at least 8-10 times per activity.  In a half hour session, I try to include at least 4-5 similar communication activities.  Apart from being able to target the same word through multiple repetitions, the communication task also gives the child an opportunity to use the sound in a meaningful way rather than simply naming pictures in a drill.

As a part of the generalization portion of the lesson, I would have Sam’s parent lead one of the activities in the clinic (so Sam can produce the target word with a person other than me) and I also provided the parents with a copy of the drill pictures to practice at home.

Treating Vowels: A Tactile Treatment Program (Part II)

When Sam began therapy he had difficulty tolerating any sensory input in or near is mouth. Bringing a toothette close to his mouth would lead to an involuntary tongue protrusion to resist any stimulation. Placing a bite block between his molars would lead to gag reflex. My first goal therefore was to decrease his tactile defensiveness, while building his proprioceptive awareness (knowing where his lips, tongue and jaw are in space) of his oral structures. The first step of course, was to build his trust and comfort level with me and the tools I would use. We named the toothette with the vibrator “Mr. Tickles.” Mr. Tickles would always start the session. Sam could tell Mr. Tickles where he wanted to be tickled. We would usually start with the palm of his hand or his arm and gradually work our way to his mouth. Within a few sessions, Sam could tolerate several minutes of stimulation with a toothette without any negative reactions.

vibrator-tootethOnce Sam’s tactile defensiveness was significantly reduced, my next goal was to stabilize his jaw and increase jaw grading (i.e. opening and closing of his mouth to various jaw heights without jaw sliding or jerking). Since Sam tended to “fix” his jaw at jaw height 1 (closed mouth position) during speech, my objective was to move him gradually through Sara R. Johnson’s Bite Block hierarchy. Unless Sam was able to lower his jaw to jaw height 3 or 4, production of vowels such as /Ɔ/ would be challenging. We started with Bite Block #2 and within several weeks were able to move to Bite Block #6, which requires considerable jaw opening. Sam can now hold a lower jaw position without sliding. As a part of a comprehensive oral motor or oral placement program, we also worked on lip rounding, lip seal and tongue retraction. Sara R. Johnson’s Horn and Straw Hierarchy’s were employed for this purpose. In addition, a tongue depressor with added “weights” (pennies taped to both ends) were used to build lip strength and lip closure.