MULTIFOCAL THERAPY FOR SPEECH DISORDERS IN CHILDREN WITH AUTISM

The work details us the successfully recovery of a girl suffering from a severe autism disorder, which enjoyed long term and complex support together with psychological, speech therapy, pedagogical and medical drugs help. Family members and kinder garden and school personnel have constantly represented co-therapists.

The girl, aged 10 years and 2 months, was born on December 29th 2004 in urban area. She is a 4th grade pupil at one of the first 5 top schools in the city. She is able to keep up with her colleagues and school demands without a specially individualized curriculum.
She is a child without pathological condition neither before nor after her birth. The girl belongs to a well organized and solid family, with young, highly socially, culturally and professionally educated parents. Both parents are University graduates, being involved in specializing courses at the moment. She enjoys affectionate, civilized and relaxed family atmosphere, having an elder brother, in the 9th grade, and a younger sister, in the 1st grade. Nowadays the relationship between them is affectionate and encouraging but in the past, before the diagnostic recognition, there were a lot of conflicts caused by her aggression.
Life standards and study conditions are very good; every child has his own room, toys and books. Now, that she in the 4th grade, she expresses her will to work, to watch certain TV shows, to play with different toys, no matter were in the house. She can clearly express in whose room: her brother’, her mother’ or the pink room. She wants certain games, toys, showing constant interest in them.
Parents’ presence has always been a constant in her life. Even from the beginning when the girl rejected their hug, they tried to show her their love when she was screaming and crying, apparently without a reason. When she was 2 years and a half, her parents got worried because the visual contact started to diminish at the same time with her acquisitions, so far, and nonverbal interactions with the family members.
The girl wouldn’t talk, didn’t answer when she was called and was no longer interested in toys. She made sharp noises, looked around when she heard certain noises made by domestic devices (washing machine for instance) and clearly waved her hand; she used to get naked, with total lack of interest in the family members; she didn’t look a person in the eye, looking as if being retreated in a world of her own. Other times, she had unmotivated crises of psychometric agitation, preferring food in one colour only and refusing any combination. As a result, when she got 3, her parents took her to a neuro-psychiatrist for an evaluation.
The autism diagnostic (nowadays, according to DSM-V: autism spectrum disorder with severe impact on A and B criteria group) was a real shock for the family.
The diagnostic as based on the following criteria:
Criterion A:
Alteration of the quality of social interaction
Alteration of the communication quality
Limitative, repetitive and stereotyped behaviour, interests and activities

Criterion B: occurrence before 3 years old
repetitive movements and stereotyped language;
insistence and adherence to fixed / rigid routine and patterns ritualized through verbal and non verbal behaviour.
fix and very limited interested, of high intensity and concentration.
hyper or hypo reactivity to sensorial stimulus or unusual interest towards environmental sensorial aspects.

She was recommended a treatment program: ABILIFAY daytime doses and MILGAMMA, administrated during 3 months, without favorable effect, on the contrary, the child became more agitated, and with amplified stereotypes.
A speech therapy was considered necessary, moment when the child was presented to us. We conducted a complex examination by means of the interview with the parents and POTAGE test, taking into account the following: cognition, language, movement, social awareness, self service, playing activity. All the analyzed aspects registered results below the normal levels corresponding to the age of 1 year; total absence of the verbal communication and spontaneous playing, presence of certain mannerisms and movement stereotypes (hand waving, body straining).
After observation and assessment, we established a individualized speech therapy program.
All the lowest results obtained during the tests for every field mentioned above didn’t help us detail the speech therapy approach. The drug administration didn’t correct nor improve any of the problems: total lack of speech development, of spontaneous playing, the stereotyped and repetitive metrical mannerisms together with the lack of visual contact.
We ran tests in order to evaluate the functional and organic integrity of the speech system: symmetry, integrity, mobility and force of the lips and tongue, the shape and the bite of the dental apparatus, the shape of the under-jaw, the shape of the jaws arches, the existence of under hung, the shape, mobility, size and the tongue, the mobility of the tongue, the shape and the size of the soft palate, the mobility of the palace, the integrity and the place of uvula.
The examination was difficult as the girl didn’t keep eye contact, didn’t follow the movement of my lips, in front of the therapy mirror, in order to help her make certain exercises (with tongue, lips, and cheeks); she didn’t turn the head to see where certain noises came from.
That’s why the presence of her mother was a very big help for me as she constantly helped the girl, being close to her in every moment of the therapy. Even from the start I stressed the importance of parents’ presence during the entire therapy, as they were the persons who knew their child best; especially at the beginning of the therapy, when I had to learn the child’s habits. I strongly recommended them to continue speech therapy the same way every day after they leave my office. Many times, the feedback of the therapy was registered by the them, who told me that the child had made certain exercises several times after the time spent with me in the speech therapy session.
The speech therapy started with breathing and speech system exercises focused on tongue movements, soft palate’s rising and lowering, movement of mandible, lips and cheeks etc.
Given the fact that the therapy was severely blocked by the absence of cooperation with the girl, a new psychiatric examination was considered necessary in order to find a better therapy formula for a good contact. The treatment was changed and Zuclopentixol (Clopixol – 2 drops in the morning and at noon) together with Lithium carbonate 300 mg a day with regular control of lithemia. There was a clear and rapid improvement in establishing a contact with the child.
I had noticed variations in speech therapy even from the beginning, referring also to the prescribed drugs. She experienced psycho – motility agitation, nervousness and lack of cooperation, with me or with her mother, in front of the mirror or eye to eye with the person who was working with her. She could interact only for short time periods – of 1 second. All those things made me reconsider the drug administration and take into account another neuro-psychiatric assessment. The diagnostic was confirmed but a multifocal approache was thought to be necessary: CLOPIXOL (2 drops in the morning and at noon) and Lithium (300 mg a day). Lithemia level was checked and resulted under 0.
I mention that we had positive results when the emotional state of child improved. The medicine improved the contact with the child and allowed us to introduce therapies twice a week, doubled by continuous activity run by parents, especially by mother. Actually, mother trained and closely involved in the therapy becoming a co therapist and a good one, we can say, because she learnt how to understand what to observe and how to act in daily life routine.
Thus, I strongly recommend the family to participate in the therapy in order to stress every detail of either involution or improvement of the program.
Also, we analyzed smaller or bigger doses of drugs administrated to the girl and their effects on the contact quality and its steadiness. They were carefully adapted to the behavior changes caused by season, demanding level, necessity to be integrated in children groups etc.
Lithemia level was constantly verified and kept under control as its values oscillated depending on the season, demand and child’s involvement in different activities. Over the years, we noticed that the child’s acquisitions and behavior changes were related to the degree of lithemia body assimilation degree. The therapy also ordered the variations of clopixol doses, depending on the stress level of the therapy and involvement in different social environments of the child: kinder garden, walking alone, even from the beginning, playgrounds, parks.
Thus, the speech and psychological therapy helped to quick results: at the age of 4 she was accepted to a regular program kinder garden. It was not possible without the mother’s insistence and her presence during the first weeks. She slowly and progressively integrated.
The first exercises I managed to do together with the girl, not only by imitation but enjoying her cooperation, were those for the phono – speech system:
for the face movement: exercises for eye blinking, simultaneously, then by turns; filling my cheeks with air and then hitting them, letting her to hit my cheeks and me hitting hers, and then moving the air from one cheek to another, together with cheeks suction;
for the jaws gymnastics we did exercises to close and open the mouth freely and with resistance, exercises to push forward and back the inferior jaw, and biting exercises;
for lips: lips suction, lips tightly closed, lip pouting, laugh imitation, lips covering, by turns, lower lip on the upper lip and vice versa, blowing in soap balloons, blowing a feather or some paper pieces off the hand at different distances, blowing candles, which at first made her nervous, whistling, lip vibration;
for tongue: pulling out and drawing in, arrow or shovel like tongue, moving the tongue up and downwards and vice versa, lip or teeth wiping using the tongue, touching the teeth with the tongue, ditch like tongue inside the mouth (mother’s help was essential, as the child didn’t allow getting near her mouth or lips, strongly struggled and yelled)
for soft palate, larynx’s muscles: yawning and drawing the tongue and inferior jaw, deglutition exercises, coughing and snoring imitation

These exercises were everyday activities, focusing on every organ and way of execution so that it should be correctly acquired and eliminate dyslalia by altered production of sounds. All these exercises helped me when I taught her every sound, doubled by a letter afterwards (using exercises for general mobility).
After that there were exercises for phonemic hearing, in order to help her differentiate sounds and syllabic field and then words perception:
exercises to imitate sounds of nature (onomatopeia), which at first were whispered and after that uttered loudly, using different rhythms
snake: s-s-s-s together with the sound and imitative snake movement by moving the index and hand; when hearing the sound, the girl also had an image of the snake in front of her so she could perceive the aspect and the twined shape of the snake
the bee: bzz! bzz!
Verbal explanations, in front of the mirror or with eye contact were accompanied by the sound “b”, using exercises to cover lips by closing the logoped’s cheek to the child’s and by putting the palm on the larynx of the child and the child’s hand on the logoped’s larynx in order to feel the sound vibrations. At the same time there were exercises for sound “b”, by blowing candles, feathers, making soap balloons without vibrations.
While she was blowing, I closed her mouth, lips, on short, successive intervals by using the thumb and the index until the correct imitation of the sound.
The cheeks were filled with air, hit on their side, so it was also a game.
Train: sh- sh-sh-sh ; the way to produce ‘sh’ sound. The lips were round and slightly pulled forward, the teeth were slightly opened, the tongue flat tip is raised behind the upper gum, without touching the hard palate. The tongue creates a narrowness. The tongue margins are up and get tightly closed to the upper molars. The back side of the tongue is raised and together with the hard palate creates a second narrowness and a cup is formed on the tongue. The air passing through the glottis and the mouth produces a resonance amplified by the lips cone, forming sound ‘sh’. The girl was explained the creation of this sound step by step, by detailing and repeating each step with short breaking.
cat: miau, miau. Each sound was examined and explained separately, by imitation and being helped for the different lip movements.
sheep: beee, beee (in Romanian)
whining: Vai! Vai! Vai!
goose: ga!ga!ga! (in Romanian)
frog: oac – oac – oac. Explanations on the sounds production have been accompanied by the movements imitating frog leaps
duck: mac-mac-mac. After my explanations on sounds, there were also hands and body movements to imitate duck movements.
cow: mu-mu-mu. After sounds production we imitated the cow’s horn by using the two indexes as if she had had horns on temporal sides
exercises to produce some series of counter syllables, taken from paronyms, to train her sounds analyzer. There were sounds like: p, b, d, t, s, z, f, v, etc
exercises to make the difference between the sounded and unsounded consonants:

p – b
pun – bun pupa – buba
pata – bata pompa – bomba
paie – baie
para – bara
pile – bile
t – d
tata – data
toamna – doamna
cot – cod
roate – roade etc

Thus, the speech therapy and psychological support led to quick results and progresses:
– speech appeared at 5 years and evaluated each year being doubled by emotional involvement when she uttered certain words. Different categories of animals, birds, fruits, vegetables were introduced to her meaning substantives with intuitive support in order to become aware more and more of the word she learnt to say, and then to point it in a certain image, an animal, a bird, a vegetable, and later to be able to say it. After a time, adjectives were introduced, asking the girl to say how the apple is: red, big, small; or the raisin: round, yellow.
And thus colors were presented to her together with geometrical figures. The game LOGI II was very useful, teaching her at the same time, geometric figures, colors, sizes: wide, thin, neat, coarse, having the possibility to feel the figures, to take them with fingers and to put them in their right place. Small muscles of hand were thus activated, preparing the gestures for the drawing activity. A series of exercises focused on movement – sight coordination are made: to take beans by using the first 3 fingers in a bottle, held with the other hand; to wind up a ball of thread which at first was a paper, then crumpled, with one hand, without help from the other hand or the leg. We imitated the dance of the rain drops, using one hand or both hands at the same time or by turns. All these game shall be important for the graphic activity and they shall be done always before the beginning of it.
After the above mentioned exercises, graphic elements were added to the recovery therapy, essential for learning letters and number knowingly.
The autistic child uses very well each graphic element part of a letter or number when she learns it. For instance, in order to learn letter A capital, first she learnt vertical lines. She started with vertical line drawn from two points, then she continued with coupling the two points, later she learnt to draw a fence ^^^. The letter was also made up using fire matches, modeling clay, kinetic sand box, fingers or pencil. Each time I verbalized the way the letter was formed and its graphic elements.
There were breaks between the writing periods in order to relax the muscles, by different games: “The wind blows the leaves!”, “The Stone Bridge”, stressing on touching and fixing of left hand fingers on the right hand fingers; “Windmill” – by correctly rotating the hand wrist.
After the letter and sound A were learned, words starting with it were made up. Then letter A in different parts of a word: initial, middle, final. After that, there were sort phrases. And the same happened with every sound and letter of the Romanian alphabet, the child learnt the words typical for communication competence in the preprimary and primary school.
We were working at the same time with the preschool and the primary school curriculum. The capacities for kinder garden and school were adjusted using 2 plans: bio-psychical and training – educative. And at the end, the 5 year therapy approach led to successful results: 1st place at the end of 1st grade and 1st place at the school contest SMART, edition XIV: 2011-2012.
Her capacities- sensorial, mental and social – adapted step by step, starting with kinder garden where she went, as we have already mentioned, without being accompanied. The girl went to kinder garden alone since she had been 4 years old.
She started school, 1st grade, at the age of 6.
At school, she was accompanied by her mother for 2 years, making her easy to adapt to each subject demands. She adapted to the inherent difficulties of the typical psychological profile step by stem but with constant important progresses. The progress was constantly psychological and pedagogical supported by her mother and the qualified personnel together with the medical drugs she continued to be administrated as repetitive attempts to interrupt, even during holidays, didn’t prove to be recommended.
Now in the 4th grade, we can talk about a school adjustment according to each school subject requests. Besides the textbooks homework, the girl does exercises from different auxiliaries, being able to pass from one book to another, during the same hour, without refusing or having an undesirable behaviour.
While being at school, some problems appeared such as small refusals to work according to school master demands. She chooses either the textbook or the extra exercises book, refusing to use both of them during the same class. That’s why we started to work at home using the same requests as the school master at school, which made her more cooperative.
Also she hardly accepted the school master getting close to her desk when she was asked to give an answer. There were moments when she was bothered by a certain way the school master talked. The school master was explained the nervous outbursts the girl had had during certain classes. The voice tone and the distance between them two, while interacting, were elements with great impact on the girl. The school master slowly became co therapist. Thus, the answers during classes with problems began to be favorable, with progressive improvements.
The girl attends the courses of a mass general school of Constanta, without a specially individualized curriculum, without supporting persons but with teachers who accepted her particular behavior.
It was necessary to acquire the objectives of each school curriculum (1st grade, 2nd grade, 3rd grade and 4th grade), together with growing more and more autonomous: going to bathroom alone, to go to the school playground “with my colleagues”, as she says, to buy food from the school store; she dresses and undresses alone.
At the beginning, going to school troubled her physiological balance by having nervous outbursts with negative consequences on her school training activity.
Every day routine and concentration, graphical activity which requires certain speed: dictation, exercises done in a set time period, all these are possible by combining carefully the psychological, pedagogical measures with drug administration. All this time, the family has to be active, to fight with hardships, with moments of breakdown, inherent to such situation, has to be supportive and to understand each step that they began 7 years ago.
I mention that is a long term study with linear intervention and permanent support of the family from the age of 3. They accepted time and material sacrifices. Therapies are individual but require the presence of a group and group therapies.
Nowadays, she accepted food diversity, being able to prepare her school bag for next day.
Certain stereotyped movements are still kept at school but of low intensity. I noticed that nervous behaviour appeared when new exercises or demands appeared, so we prepare at home the lessons that are to be taught at school, by explaining her and using as many possible situations, notions she doesn’t understand. Thus, tensions are avoided during school program.
Each year the progresses are more a more closed to the curriculum demands. During holidays, we set clear information that had not been understood during the daily school routine.
Emotional and school adaptability is more and more closed to normality.

Conclusion:

It is the case o a girl with severe autism disorder, largely recovered, who is able to go to mass school in spite of some modest typical particularities for which she needs continuous psychological and pedagogical support together with medical drug administration. The favorable result was also possible due to constant, complex and individual support psychological, speech therapy and medicinal, where family and school personnel were permanently co therapists.

REFERENCES

American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders 5
Milea Stefan (1989) – Lithium carbonate in the treatment of infantile autism. In Psychiatry today Accomplishments and promises VII Word Congress of Psychiatry Exerpta Medica. International Congress Series 899, pg 432.
Milea Stefan (1997) Lithium carbonate in the treatment of autism. Romanian Psychiatry Pedo-psychiatry and Medical Psychology Magazine no 2 -3, pg 59-60.
Milea Stefan (1997) – Clopixol in the treatment of autism. First Meeting of Romanian Psycho-pharmacology College, focused on: New psychotic stages. Bucharest.
Milea Stefan (1998) – Chemo-therapy in autism disorders. Tome – 21st National Neurological Child and Youth Psychiatry Session, Targu Mures, 325
Partal Fanuta (2007) –Guide of Speech Therapy – Theory and Therapy program – Romanian Dutch Rondo Project
PORTAGE – Psychological and Motility Development Sheet
School curricula for 1st – 8th grades
Stanica C. Vrajmasu E (1997) – Therapy of Speech Disorders, House of Didactic and Pedagogical Publishing, Bucharest
Soimita Anca Gherle (2010) – Small guide of Speech Therapy. I want to speak correctly too!, University Publishing