Friday, October 22, 2010

Case presentation: The Beauty of Imitation

This is my first of what I hope will be many updates on a patient’s progress in therapy. It’s good for parents and professionals to see the beauty of progress, to keep them encouraged. I think it is very important therefore to share some stories. Due to confidentiality and other ethical principles we will call this patient Josh.

Josh is 5 years old and is Autistic. He is nonverbal, but he is so communicative by any other nonverbal means. I have introduced PECS with him and he is flying with it. He is one I wish I could video as an example to other parents, as he is doing so well. We jumped to symbol discrimination in about 3 weeks with only 1, 45 min session per week. Anyway this is not a PECS post, this is about his imitative skills. Children on the Autistic Spectrum are known to have weak imitative skills. I know this as a speech therapist and someone who has had interaction with children on the spectrum, but somewhere in my goal setting I think this got lost. However, thankfully not lost forever.

One day while working with Josh it hit me in the face. He is stuck between Stage 1 and Stage 2 of imitation. How was I expecting him to imitate sounds then. Yes, he could imitate me building blocks and knocking them down, he could imitate me pushing a car around, if I splashed a toy into the water he could do that, or if I jumped he would copy, but after that the breakdown occurred. I had to go back to the books. I remembered in my early development class learning about imitation being one of the key precursors to speech development. I went through my files and found a handout called “Imitation before Speech!!” Eureka! Where I was stuck was at level 3: Imitation of actions/gestures. As I’m also trying to use evidenced based practice a lot in my clinical work I went to some journal articles as well. I found some research which looked at the effectiveness of mand training techniques and motor imitation tactics to elicit first sounds in children. The result of this study was that 5 elementary school children with autism could be taught to vocalise when the instruction first started with a generalised motor imitation sequence. I was really fascinated by this research.

The next week I started a ‘copy me’ game. I needed to find a way to get Josh to try to copy me and then reinforce him for his behaviour. I started with clapping, but he didn’t imitate. He either watched me or when I said your turn he took my hands and tried to make me clap. I got his parent to sit behind him and prompt him to clap and then fully reinforced him with putting a “tic tac tony” chip into the space. After 3 tries he no longer needed the prompt from behind, and we have launched into a 6 week journey (so far) of “copy me”. Every week we have added one or two actions working outwards- in. We went from clap hands, tap table, wiggle fingers, touch ears, touch head, touch nose, blow a kiss (which was adorable), to peek a boo (which has been a bit difficult due to what might either be proprioceptive difficulties or some possible apraxic tendencies). He has been doing really well with these and catching on very quickly. He is my little superstar.

Last week started a big move, transitioning to stage 4: Imitation of face and mouth movements. I had to be very cautious with this since when a task becomes too challenging we tend to lose him. I started with a kind of lip trill where I rubbed my index finger down my lip and made a vibration while vocalising. He was so fascinated by this and watched closely a few turns before he finally gave it a try. However, there was no vocalisation with it. I was thinking ‘uh oh’ this is our brick wall…no sound. I rewarded him for the slightest ummph of a vocalisation and put lots of emphasis on my vocalisation in my model. This week I pushed for it, making lots of loud silly vocalisations. Then….he tried it and made a long, loud, brrrrrrrrrrrrrrr, and loved it. I almost cried! We played with that for a few turns then I introduced a new one ; what I call an “Indian call”, where you vocalise and keep patting an open palm over your mouth. He did this like it was nothing and I was the proudest speech therapist in the world.

These 6 weeks have been amazing with Josh’s progress and I think we will only keep moving forward and seeing greater gains. The next stage is more imitation of silly sounds and noises then after that is real words, which I’m very positive about. I’m going to continue to document our journey and I hope that it might help some professional out there who is wondering what’s the next step with a similar patient.

If you’re interested in the “Imitation-Steps to Speaking” handout feel free to email me at sharekab@gmail.com and I will share it with you.

The research article can be found at http://www.ncbi.nlm.nih.gov/pubmed/12553968

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