The Tomatis Method and its impact on children with echolalia in the autism spectrum Nellie Torres de Carella SLP, CCC, RCTC
Summary • The objective of this research was to find out if the Tomatis Method for auditory stimulation was a significant variable to reduce the problem of echolalia in children diagnosed with typical autism (Kanner) and atypical autism (Pervasive Development Disorder, Not Otherwise Specified, PDD-NOS) who attend the Tomatis Centre in Puerto Rico. • In order to obtain the research results, a measuring instrument was created, consisting of 12 questions for the parents of children diagnosed with ASD who followed at least the first three intensive stages (62 hours) of the Tomatis Method.
Echolalia in children with ASD • There is more and more substantial evidence that proves that children with ASD show several levels of auditory dysfunction (Rosendallu, Nordinv, Vrantberg K, Gellberg C, 2003). This dysfunction is mentioned as the one that affects the typical characteristics of autism most negatively.
Echolalia in children with ASD • Some of the characteristics of children with ASD are the following: – They have difficulties to develop spoken language because the development of expressive language comes from the primary precursor which is the auditory processing of language (Rapin I, Dunn M, 2003). – They find it hard to be alert and conscious of the world around them. Hearing is the first sense that makes a person alert or attentive towards a stimulus (Fish L., 1970).
Echolalia in children with ASD • Cont. - Some of the characteristics of children with ASD are the following: – Attention deficit - they find it hard to focus on a main source of noise and ignore the sounds that compete with it. This affects their visual attention. (Medwestsky L., 2006).
Echolalia in children with ASD • Cont.- Some of the characteristics of children with ASD are the following: – Echolalic speech - immediate repetition of what they hear, although the repetition may be delayed and appear days, weeks or even months after they have heard the stimulus. Echolalia may be the repetition of a part of what they hear or identical repetition of what they heard, even with the same prosody. (Millar Koegel, Mendel, 1981).
Echolalia in children with ASD • Rappin & Dunn in 2003 said that 75% of children with ASD present echolalia, either immediate or delayed. • This characteristic has generally been considered a consequence of the language disorder; however since 1964 another theory was presented, which is still sustained in recent research – echolalia is caused by an auditory processing disorder.
Echolalia in children with ASD • Echolalia appears because they find it hard to recognise syllables that include the meaning or the variation of the morphological structure within a verbalisation. • When children begin to use sentences to communicate, (about three years old), it happens because they hear and recognise the strength of certain syllables in the language they hear and the divisions or separations between words in a verbalisation.
Echolalia in children with ASD • It is necessary to be able to recognise both elements – the key syllables and the boundaries between words, because at first the child will repeat syllables that will be reorganised after to be used in new contexts, thus varying the meaning. • For example, in Spanish, the perception of the last syllable in words like "comer", (to eat) "como" (I eat) or "comes" (you eat) makes the child aware of the fact that one syllable can change the meaning of a word.
Echolalia in children with ASD • Children with ASD who present echolalia do not perceive these two essential aspects to develop language, which makes them repeat segments of sentences or phrases without any order or reorganisation, so they cannot adapt them to new contexts (Brown y Bellugi, 1964). • Therefore, echolalia is not the problem in itself or the cause of the language problem – it is a symptom of the auditory processing disorder that is typical of autism. Echolalia is a reflection of how the child processes auditory information (Dawson, Philles, 1986).
Echolalia in children with ASD • A study carried out in Japan discovered that while children with ASD had a central auditory disorder, those with echolalia had a high incidence of dominance of their left ear, despite having dominance of their right hand (Hayashi M., Takamura I., Kahara H., Yamazaki K., 1989).
Research design • This research was exploratory because during the period of reading literature, little information was found on echolalia and no research was found on echolalia and therapeutic interventions using an auditory stimulation programme like the Tomatis Method. • The research was also descriptive because the aim was to describe the opinion of the participants on the impact of the Tomatis Method in children with echolalia in the spectrum of PDD.
Measuring instrument • For this study the researcher designed a questionnaire with 12 questions for parents, guardians or tutors of children with ASD (typical or atypical), who followed the Tomatis Method for at least 62 hours (3 intensive stages) and who presented echolalic speech before the intervention began. • The aim of the questionnaire was to describe the opinion of the parents, guardians or tutors on impact of the Tomatis Method in children with ASD who present echolalia.
Results
• It important to say that out of 51 questionnaires, 14 were returned. Out of these 14, 6 were ruled out.
Results • The following information was obtained from the 8 questionnaires that were accepted for the study: – Sex. Out of the 8 questionnaires, 62.5% of the participants were parents of boys with ASD and 37.5% were parents of girls with ASD. – Age. The age of the boys went from 3 to 9
years old (3, 4, 5 and 9 years old). The age of the girls was 3, 4 and 6 years old.
Results – Diagnosis. 75%, most of the children, were
diagnosed with Pervasive Developmental Disorder - Not Otherwise Specified (PDDNOS or atypical autism). 25% of the children had typical autism. – Hours of Intervention with the Tomatis Method. 50%, most of the group, completed 110 hours of intervention over a year. 25% completed 78 hours (three intensive stages and a reinforcement step of 8 days or 16 hours), and the remaining 25% completed 62 hours of treatment (three intensive stages of the Tomatis Method).
Type of echolalia in children before beginning the Tomatis Method 100% 80% 60% 40% 20% 0%
87,50%
12,50%
Immediate echolalia Delayed echolalia
• 100%, most of the children, presented echolalia before beginning the Tomatis Method. 87.5% was immediate and 12.5% was delayed, 3 cases presented both.
Frequency of echolalia in children before beginning the Tomatis Method 100% 80% 60% 40% 20% 0%
Frequent echolalia
50%
Low echolalia
37,5% 12,5%
Most of their speech is echolalic
• 50%, most of the parents, described their children as frequently echolalic. 37.5% described them as not very echolalic. 12.5% said that most of what the children said was echolalic.
Impact of the Tomatis Method in the children's echolalia 100% 80% 60% 40% 20% 0%
TM helped quite a lot TM helped a little
37,5% 37,5% 25%
After the TM, their echolalia had disappeared
• 37.5% of the parents said that the Tomatis Method helped reduce the echolalia quite a lot, although in some cases it causes it. 37.5% said that it helped a little, but that the children still have it (echolalia). 25% said that their children's echolalia disappeared after following the Tomatis Method.
Reduction of echolalia in stages 100% 80% 60% 40% 20% 0%
En F1 Between S2 and S3
37,5% 37,5% 12,5%12,5%
In R1 Between R1 and R2
• 37.5% said that they observed a reduction in the second and third stage or after 46 to 62 hours. 37.5 % said they noticed it in the first or second reinforcement. 12.5% said they saw changes during the first reinforcement and 12.5% of the parents said that the children's echolalia started to disappear in the first stage.
Therapy followed before the Tomatis Method Speech and Language 100
90
Occupational
80
Change in the Diet 70
60
Intro vitamins and nutrients
50
ABA 40
30
20
10
0
Begin at a specialised school Others
Therapy followed before the Tomatis Method • Speech and language – 100% of the children was following speech and language therapy before they began with the Tomatis Method from 2 to 3 sessions a week. • Occupational – 87.5% of the children was undergoing occupational therapy before following the Tomatis Method from 1 to 3 sessions a week. • Diet – 50% eliminated gluten and casein (a protein in cow milk) from their diets before following the Tomatis Method, and they also reduced the amount of sugar. 50% included vitamins and minerals (complex B, omega 3 oils).
Therapy followed before the Tomatis Method • Applied Behaviour Analysis (ABA) – 25% followed ABA before the Tomatis Method. • Starting at a specialised school – 37.5% of children attended specialised schools before starting the Tomatis Method. • Others – 25% received AIT (Auditory Integration Therapy or Berard), kinesiology y horse riding before the Tomatis Method.
Therapy followed before the Tomatis Method • 75% of the mothers said that they had tried to get rid of or reduce echolalia with other therapies before beginning the Tomatis Method. • Out of that 75% , 50% said that the therapies improved their echolalia a little, but that they still have it.
Treatments or therapies that the children followed outside the school at the same time as the TM • 100% of the parents answered that the children received speech, language and occupational therapy, 50% stopped consuming gluten and casein in their diets and 62.5% took vitamins and nutrients.
Therapy that parents believe helped to get rid of or reduce the echolalia the most 12,5% Tomatis Method
12,5% 75,0%
ABA
Combination of all of them
• 75% of the parents said that the Tomatis Method is the treatment that helped reduce or get rid of echolalia the most. 12.5% of the parents answered ABA and 12.5% answered a combination of all of them (including the Tomatis Method).
Progress during the Tomatis Method 50,0%
50,0%
During the three first intensive stages (62 hours)
During reinforcements (78 94)
• 50% of the children began to improve their echolalic behaviour during the first three intensive stages (stage 1 - 3, 62 hours), while 50% began to show progress during and after the reinforcements (78 - 94 hours).
Progress during the Tomatis Method • Two of the questionnaires were not used in the research to obtain these results. They were ruled out from the group because in both cases the parents said that the children were practically nonverbal when the Tomatis Method began and they did not respond to spoken language. • They started speaking after beginning the Tomatis Method, but they also used echolalia. Both children currently speak a few words, spontaneous speech, but in both cases the parents describe them as 'frequently echolalic’.
Progress during the Tomatis Method • Based on the results of the latest research on auditory processing in children with ASD and taking into account the Tomatis Theory, the process through which these two children are going. Both children did not use to process language, they did not hear it before the Tomatis Method. • They both followed traditional therapy and diets, and took nutrients, like the rest of the group, before and during the Tomatis Method.
Progress during the Tomatis Method • Language appears thanks to the Tomatis Method, because the hearing process increases, but they are still perceiving the divisions between words and key syllables, which results in echolalia. • One of the parents says that the more the child understands spoken language, the more spontaneous vocabulary appears and verbalisation gets longer, and of course echolalia appears less, although it is still frequent, both immediate and delayed.
Progress during the Tomatis Method • The second child did not talk at all when the Tomatis Method began, and began to talk later on, but with echolalia. Currently, after 110 hours of intervention, the child is still frequently echolalic, but produces spontaneous language and answers simple questions properly. • This is not necessarily the usual process in all non-verbal children with ASD who receive the Tomatis Method – more research is required in this sense.
Progress during the Tomatis Method • Such positive data cannot be ignored for non-verbal children with ASD, because they could respond positively to the Tomatis Method regarding the development of language.
Conclusion • If we go from the fact that echolalia is a problem that is secondary to an auditory processing disorder, the statistical results obtained should not be a surprise, but a logical consequence of the use of a programme or method that stimulates auditory processing (Brown y Bellugi, 1964).
Conclusion • We observe that the absolute majority (100%) underwent several therapeutic services before and during the Tomatis Method, from at least 6 months to 4 years with an average of 2 sessions a week. Likewise, a high percentage of them (50%) were following biomedical alternatives (changes in the diet, vitamins).
Conclusion • They were significantly worried about echolalia because 75% of these approaches tried to eliminate it. Only one of the children had received auditory integration training, AIT, but the echolalia was not reduced until the child received the Tomatis Method, and now the child presents irregular echolalia. • Both the cases that reported the complete disappearance of echolalia had followed traditional therapies before and during the Tomatis Method. Regarding diets and nutrients, one of them did not follow a diet or take special nutrients.
Conclusion • The parents only eliminated casein (milk) from the girl's diet and cut sugars, however she still ate food with gluten, as well as other vitamins and special nutrients, which she already did before starting the Tomatis Method. The boy overcame his echolalia during the first intensive stage of 15 days (30 days) and the girl did between the first and second reinforcement, after 78 hours.
Conclusion • The Tomatis Method consultants must integrate auditory lateralisation in the programme for echolalic children with ASD. This does not mean that it should be included right from the first intensive stage, because the dysfunction in auditory processing is so severe that both ears need to begin to process or improve the processing of spoken language.
Conclusion • It is necessary to discuss whether behaviour modification techniques are the right therapeutic approach to get rid of echolalia in these children. • Using this approach to try to reduce or get rid of echolalia could cause the child to stop speaking. • In most cases, echolalia has a pragmatic or communicative-social function.
Conclusion • Language is a part of the sensory stimulus that the brain needs; therefore, echolalia is not a behavioural problem – it has a communicative and sensory-linguistic purpose. Echolalia can be a stage in the process of spontaneous language development in children with ASD, while their auditory processing is increasing. • 37.5% of the parents reported that the Tomatis Method helped the children to improve the echolalia quite a lot, although in some cases they still have it, generally when they are asked questions.
Conclusion • The main difference in Spanish between an interrogative sentence (question) and a declarative sentence (gives information) is generally the variety of the inflection of the voice that pronounces it. • The inflection is a suprasegmental aspect of language which is processed on the right side of the brain, opposite to the decodification of language which happens on the left side.
Conclusion • This implies that there should be information transfer between both cerebral hemispheres at the same time in order to be able to process the auditory stimulus of a question properly (Medwtsky L., 2006). Children with ASD have symptomatology that shows that the information does not transfer properly between both cerebral hemispheres, which makes it hard for them to understand questions.
Conclusion • We deduce that if the information transfer between hemispheres is improved, the children will not present echolalia when answering questions. • Lastly, it is necessary to clarify that the progress observed in this group of children was not exclusively limited to echolalia.
Conclusion • This problem was isolated because it is so pragmatically inappropriate, but the children's progress was significant in all the development areas, that is, in language development (receiving and expressing), in their sensory integration skills (development of the motor functions, muscle tone, body image, visual following, praxis and balance among others) and attention, both visual and auditory.
Recommendations •
•
Carrying out research to find out if it is normal for non-verbal children with typical and atypical autism who follow the Tomatis Method to go through a stage of echolalic speech before developing spontaneous speech. Carrying out research to determine which is the Electronic Ear programme that has the most impact on information transfer between hemispheres, and therefore that helps the development of suprasegmental aspects of language in children with PDD.
References • Ayres, A.J. (1979). Sensory Integration and the Child. Los Angeles, CA: Western Psychological Services. • Bauman, M.L., & Kemper. T.L. (1994). The neurobiology of Autism. Baltimore: John Hopkins University. • Bellugi, U, Brown R, John Hopkins U.P. (1964). Tree processes in the child’s acquisition of syntax. Harvard Educational Review.
References • Dawson G, Finley C., Galbert L., Phillips S. (1986). Hemispheric Specialization and the Language Abilities in autistic children. Child Development, 57 (6), 1440 – 1453. • Fisch L. (1970). The selectivity and differential vulnerability of the auditory system. GEW Wolstenholm: J Knigh. • Hayashi M., Kohara H., Takamura I., Yamazaki K. (1989). A neurolinguistic study of autistic children employing dichotic listening. Tokai J. Exp. Clin Med. 14 (4) 339-49.
References • Madaule P. (1994). When listening comes alive. Canada: Moulin Publishing. • Loveland K.A., Landry S.A, Mc Evoy R.E. (1988). The functions of immediate echolalia in autistic children: A Developmental perspective. Journal of autism and Developmental Disorder, 18 (4), 657-68. • Medwtsky L. (2006). Spoken language processing: a convergent approach to conceptualizing (central) auditory processing. The ASHA Leader, 11 (8), 6-7, 30-31,33.
References • Rapin I. (2003) Update on the language disorder of individuals on the autistic spectrum. Brain Development, 25 (3) 16672. • Brantberg K., Gillberg C, Nordin V., Rosenhall U. (2003). Autism and auditory brain stem responses, Ear Hear, 24 (3) 20614. • Sollier P.(2005). Listening for wellness. California: The Mozart Center Press.
References • Shaw W. (2002). Salud, metabolismo y nutrición. Kansas: The Great Plains Laboratory. • Tomatis A. (1990). El oído y el lenguaje. Hogar del libro SA. • Koegel R., Mendel M., Westhersby A. (1981). Central auditory nervous system dysfunction in echolalic autistic individual. Journal of speech and Hearing Research, 24, 420-429.