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Facilitating Early Communication Development in Children with Intellectual and Developmental Disabilities: Focus on Down syndrome and fragile X syndrome.

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Presentation on theme: "Facilitating Early Communication Development in Children with Intellectual and Developmental Disabilities: Focus on Down syndrome and fragile X syndrome."— Presentation transcript:

1 Facilitating Early Communication Development in Children with Intellectual and Developmental Disabilities: Focus on Down syndrome and fragile X syndrome Nancy Brady University of Kansas Presented to Illinois Speech Language Hearing Association April 1, 2011 Ask questions. Do you like video examples? I’ve got a ton of them.

2 Presentation Overview
Part 1: Overview of Prelinguistic development Why focus on stages of prelinguistic development? Typical and atypical developments Part 2: Assessment Strategies Part 3: Interventions Specific considerations for Down syndrome and FXS Part 4: Working with communication partners

3 Occur in a developmental order
What are prelinguistic gestures and vocalizations and when do they occur in typical development? Gestures and vocalizations that precede speech in typically developing children Occur in a developmental order

4 Why??? Why focus on describing, assessing and teaching these types of behaviors? Show clip from old Diane Ping tape

5 Stages of Prelinguistic Development
There is great variability in the communication skills of prelinguistic children Prelinguistic = before children are speaking or signing or using another formal language system

6 Some Examples “Perlocutionary” = children communicate by crying or acting on objects. Others assign meaning to these behaviors.

7 Prelinguistic communication
Next sections: Vocalizations Coordinated attention Gestures

8 Early Vocalizations Crying and experimental sounds

9 Early Vocalizations Crying and experimental sounds continued –“Raspberries”

10 Later Vocalizations Canonical babbling (reduplicated consonant vowel babbling) Who remembers about what age in typical development we expect to see canonical babbling?

11 Later Vocalizations Variegated babbling (jargon babble)

12 Three different people sent this link to me the last two days, so I’m sure I’m meant to share with you all. Who needs words??

13 Summary of Vocal Development
Crying Experimental Sounds (e.g., raspberries, noncanonical babbling) Canonical Babbling Variegated Babbling Speech Remember that babbling is important because it is highly correlated with first words.

14 Vocalizations in children with disabilities
Do we hear similar vocalizations in older children and adults with disabilities? Should we continue to encourage vocal development in older children and adults with disabilities?

15 Vocalizations in Down syndrome
3 month old: 9 month old: How old? Comment about best assessment contexts. When I was looking for some video examples, ones with the child engaged in object play had less vocs. What differences in vocal qualities do you notice?

16 Why differences in vocal qualities?
Anatomical differences Vocal folds High palatal vault Larger than typical tongue in relation to the oral cavity Weak facial muscles General hypotonicity Is babbling delayed in DS? Not much!

17 Quantitative differences in vocalizations by children with DS
Recent study by Thiemann-Bourque, Warren and Brady: How do children with Down syndrome differ from an age and SES matched sample of typically-developing children in regards to their home language environments (i.e., adult words, child vocalizations, and adult-child conversational turns)?



20 Matched on age, gender and maternal education


22 Vocal summary Differences in prelinguistic quality and quantity of vocalizations in children with Down syndrome

23 Vocalizations in autism
Discriminative vocal characteristics could be used to help identify children at risk for ASD Automated vocal analysis of naturalistic recordings from children with autism, language delay, and typical development Oller, Niyogic, Grayd, Richards, Gilkerson, Xud, Yapaneld, and Warren (2-10) Differences in vocalizations were detected in children as young as 16 months that were later identified as having autism Differences in pitch, prosody, tone and phones.

24 Children with FXS Lots of variability

25 Coordinated Attention
Aka…joint visual attention, line of visual regard, What is it and why is it important?

26 Why is eye gaze important?

27 Strategies for increasing eye gaze
Within routine, child is looking at object, then, intersect gaze

28 Increasing eye gaze continued
Verbally prompt for eye gaze Specifically acknowledge the eye gaze Provide the desired object contingent on the eye gaze

29 Increasing eye gaze continued
Bring toys up to face

30 Eye gaze shift Step 1. obtain the child’s attention (e.g., move face in front or call their name) Step 2. Look in direction of a “target even” (e.g., remote control car or fan) Step 3. Activate the target event -repeat Steps 1-3 many times- Step 4. Gradually increase the time interval between the shift in the gaze and activation of the event. (This creates opportunities for the child to anticipate and look in direction that interventionist is looking) Activity: practice teaching eye gaze shift with a friend From upcoming chpt by Reichle and Brady

31 Gestures Illocutionary or purposeful gestures What is the function?
Behavior regulation = imperative Joint attention = declarative Social interaction

32 Crais et al. (2004) study Deictic vs. representaitonal
Different functions What’s the developmental sequence?

33 Contact Gesture Communication
Contact gestures = gives, leading by the hand, showing. Gestures that are in direct contact with an object or person.

34 Examples of Contact Gestures
Example of a contact gesture

35 Distal Gestures Distal gestures = points. The index finger is extended and other fingers are pulled back. The gesturer is not in direct contact with the referent.


37 Examples of Distal Gestures
Example of a distal gesture

38 Other Conventional Gestures
Head nod and shake, shoulder shrug, open palm request Depictive gestures such as pantomimes

39 Gesture combinations Sometimes people combine gestures to convey complex meanings Gesture + vocal combinations Gesture + gesture combinations Gesture + word combinations

40 Examples of Gesture Combinations
Examples of children combining 2 or more gestures

41 A Continuum of Prelinguistic Development
Prelinguistic Stages Perlocutionary Contact gesture+ Distal gesture+ Other conventional+ A Continuum of Prelinguistic Development

42 Activity Work in pairs or groups
One person act out the title of the song from the paper Partner guesses the title Discuss the types of gestures you used to convey the title What titles seemed easier and why?

43 Why is it important to know about prelinguistic stages?
Other child behaviors correlate with these stages Intervention strategies may differ for children at various stages Stages are like “milestones” that indicate to parents and teachers that children are progressing

44 Correlates of Prelinguistic Stages
Form and function Individuals with intellectual disabilities who only communicate with contact gestures rarely communicate “joint attention” (comments).

45 Form and Function Lack of joint attention- example of boy with autism

46 Persons who communicate with contact gestures and distal points frequently communicate joint attention Significant differences between contact and distal gesture users reported in: Brady, Marquis, Fleming & McLean, 2005; Brady, McLean, McLean & Johnston, 1995; McLean, Brady, McLean and Behrens, 1999; McLean, McLean, Brady & Etter, 1991)

47 Joint attention Example of person pointing in a joint attention task.

48 Differences in children with Down syndrome? Legerstee and Fisher (2008)
Get reference

49 Frequency of communication
Individuals who communicate with only contact gestures communicate significantly less often than children who communicate with more advanced gestures Findings reported in Brady et al.,2008; Brady et al., 2001; 2004; McLean et al., 1999)

50 Low Rate of Communication
Example of low rate communicator

51 High Rate of Communication
Example of high rate communicator

52 Differences in Repairs of Communication Breakdowns
Children who use only contact gestures try to repair communication breakdown less often than children who use more advanced gestures

53 Gesture comprehension
Input How do children respond to gestures? Respond to joint attention Disambiguate messages

54 Gaze following plus pointing
Brooks and Meltzoff, 2008 JCL Gaze following, as measured by length of looking at object adult looked at, significantly predicted vocabulary 11 month olds who pointed had an additional words/month…or 167 word advantage by age 2 Here’s the paradigm, experimenter facing infant and something is in the perifery. Experimenter turns to look at the something. Will infants follow that gaze? Infants that did so and looked longer had greater vocabulary growth, and infants that did this and also pointed had an even greater effect on their vocabulary growth. Share story about human spark from PBS

55 Summary Differences in gesture type associated with differences in:
Communication functions (requests, comments) Frequency of communication Repairs of communication breakdowns

56 Looking ahead at implications for Intervention Strategies
Are different intervention strategies better for children at different stages of prelinguistic development? Examples Teaching children to use natural gestures Outcomes from teaching words or other symbols to individuals at different stages of communication development

57 Milestones Individuals progress in communication even if they have not yet begun using words or symbols Progress in: Frequency of prelinguistic communication Use of points and other advanced gestures Diversity of communication functions Repairs of communication breakdowns

58 Preview of Upcoming Sections
Assessment strategies for prelinguistic individuals Intervention strategies for prelinguistic individuals Increasing parent and peer responsivity Teaching joint attention

59 Assessment Strategies
Standardized assessments are not very helpful Need to determine how a child is communicating across environments Standardized assessments may be helpful if you need to use them to qualify a child for services or to receive a particular diagnosis, however they are not very useful for determining intervention goals

60 Why is it important to assess prelinguistic behaviors?
Early identification of a language problem Early identification of a developmental disorder Predictive value for later language Provides information for identifying intervention goals, monitoring progress Responsiveness to prelinguistic behaviors provides linguistic input

61 How to assess prelinguistic communication?
Parent/Caregiver Questionnaires Direct Observation Assessment Protocols The CSBS Parent/Caregiver Questionnaire is a good one.

62 Parent/Caregiver Questionnaires
Characteristics of a good parent questionnaire Questions about here and now Use recognition memory (vs recall) “What does your child do when he or she needs help (e.g., opening a container or getting a toy to work)?” How to use information from parent questionnaire

63 Examples of Questionnaires
What do you use? Inventory of potential communicative acts The caregiver questionnaire from the CSBS

64 Direct Observation Good contexts to observe in
Contexts indicated by the questionnaire as showing high probability of communication Meal or snack time Contexts for vocalizations? Story of Lena issues with shirt on backwards,

65 For our research…. Also using Lena to narrow in on the most vocal contexts to listen too.

66 Activity 1. list student characteristics-age, setting, likes, dislikes, sensory abilities 2. list two or three good activities/contexts to observe and why 3. Describe what communication behaviors to record and how. How could you summarize your observation?

67 Assessment Protocols Tests designed to see if the individual will communicate with whatever means available in order to request, comment, etc. If no communication noted in Direct Observation, need to see if they will do it when provided a specific opportunity to do so Example from Cottonwood- young man who only said a few phrases and we wanted to measure his intelligibility for a reading project and we went in with a picture book and he blew us away…. Similar example of boy at Parsons who demonstrated elaborate play when given a chance, the materials etc. Also in dynamic assessment type paradigm

68 Examples from Assessment Protocols
Adaptations for older participants

69 Assessment protocols continued
Assessment protocols have been used in research by Dr. Brady and colleagues to study Initiations Requests and Comments Responses to Communication Breakdowns

70 Examples of protocols used in research
Example of child initiation

71 Examples of protocols used in research
Example of repair protocol item

72 Activity: Construct assessment activities
Case 1, boy with fragile X syndrome Assess two things-rejecting (or protesting) and repair Case 2, girl with Down syndrome Assess indicating preference of different items Case 3, boy with autism: Assess use of PECS and gestures to indicate joint attention (commenting) functions) Case 4, individual your group previously “created”

73 How to Score Protocols? The Communication Complexity Scale = CCS
Example from current research by Brady & Thiemann-Bourque

74 12 Scripted Interaction Tasks
I. Behavior Regulation Task 1: 2 wind-up toys (1 broken) Task 2: Food items placed in a container (with tight lid) Task 3: 2 battery-operated hammer toys (1 toy switched off) Task 4: Train tracks and toy trains (child has only one track) Task 5: Sealed bubbles (2 bottles, one sealed) Task 6: Bumble ball (examiner switches off) II. Joint Attention Task 1: Ball chute toy (one ball is too big to fit) Task 2: Spider mixed in with blocks in a container Task 3: Musical instruments Task 4: Pretend hot dog placed in a marker box Task 5: Book with altered pages (e.g., upside down, marked, ripped) Task 6: Foot controlled switch toy (in child’s line of vision)


76 Items 1-5 Pre-intentional
1 - single orientation only– toward an object, event or person 2 - single orientation only + 1 other PCB 3 - single orientation only + more than 1 PCB 4 - Scanning- eye gaze shift between objects 5 - dual focus– shift in focus between person and an object

77 Items 6-8 Intentional non-symbolic
6a- triadic eye gaze 6b- dual focus + 1 PCB 7- triadic eye gaze + 1 PCB 8- triadic plus more than 1 PCB

78 Items 9-12 Intentional symbolic
9- one-word verbalization, sign or AAC symbol 10- two word verbalization, sign or AAC symbol 11- three-word verbalization, sign or AAC symbol 12- four-word or more verbalization, sign or AAC symbol

79 Activity How would you score the following example:
Example for a boy that uses lots of different forms!!

80 Proposed Scoring Average of the three highest forms observed
Can average within each function (joint attention; behavior regulation)

81 Summary Assessments are designed to determine how and why a prelinguistic child communicates Gather information from interviews, direct observation, and assessment protocols Assessment protocols can be constructed to provide opportunities for particular behaviors of interest Repairs, communication with peers, use of AAC

82 Summarize information regarding:
Communication forms Functions Frequency/rate of communication Stage of prelinguistic development Initiations/responses/repairs Contexts Motivation

83 Interventions aimed at…
Increasing prelinguistic communication Gestures Vocalizations Eye gaze Increasing communication across multiple contexts and with multiple people Facilitating transition into symbolic communication Speech, sign language, pictures

84 Operational Principles
Create contexts where children communicate naturally Follow the child’s lead but address specific communicative targets Use the least intrusive prompts necessary to promote communication targets

85 Goal of Intervention Increase the frequency and complexity of requests and comments For both of these goals the first step is to build routines

86 Why teach natural gestures?
Theoretical reasons Occur developmentally before symbolic communication Thought to pave the way for symbolic communication Provide opportunities for linguistic input Gestures occur developmentally before symbolic communication and often it’s easier to learn developmentally earlier behaviors, like crawling before you walk or run etc., Thought to pave the way for symbolic communication. In fact there is a chapter by Butterworth in a book all about pointing titled “pointing is the royal road to language.’ I like this because it’s not the only way to language but many folks who are engaged in theoretical discussions of early communication and language development contend that gestures convey the early thoughts that are later mapped by languge Gestures also provide opportunities for linguistic input, so when a child points at something we almost always label it and we know from Tomasello’s work and others that children learn words best when they are jointly engaged with the referent and person and this is clearly the case when they are gesturing, in fact if you work with kids who are entering that vocabulary burst period, they seem to be activiely recruiting that input in activities like joint book reading by pointing to the pictures and waiting for you to name them.

87 Why teach natural gestures?
Practical reasons May be easier to teach than some forms of symbolic communication No extra equipment needed Gestures are readily understood by members of community Can be used across many different contexts Easier to teach: I’ll show you examples of physically prompting gestures and fading these prompts and I can tell you it’s a lot easier to prompt a gesture than a speech sound– could mention PROMPT Another practical reason is that you don’t need extra equipment, now I’ll continuously make a point that we want kids to communicate symbolically with AAC systems as much as they can, but there are many many times when equipment isn’t available or vocabulary doesn’t match a ontext, and the child needs to have a means to communicate when they can’t access their equipment, Another selling point for gestures is that they are readily understood by members of a community. It’s obvious that this guy want help with the bubble jar. Now if he walked up to you and went “sign bubbles.” unless you are familiar with signs, you aren’t going to know what means. I have a brother who communicates primarily with sign language and he has a pretty big vocabulary, combines into sentences etc. but he can only use it with people who know sign and he relies heavily on his gestures when he’s out and about So, he can use his gestures across many different contexts and with different partners, unlike his signs.

88 When to teach gestures? Gestures as one part of communication intervention Early phase of expressive communication As augmentative forms when other forms of communication are not available or are not working e.g., SGD not available e.g., communication partner doesn’t know sign As I said, gestures should be targeted as PART of a communication system. For some learners who don’t have any discernable expressive communication, it would be the primary focus, for others, gestures may be a back up when those other systems aren’t available, or to bridge into more complex communications.

89 How to Teach Natural Gestures
Principles described in Prelinguistic Milieu Teaching (PMT), see Warren et al., (2006) Warren, S., Bredin-Oja, S., Fairchild Escalante, M., Finestack, L., Fey, M., & Brady, N. (2006). Responsivity education/ Prelinguistic milieu teaching. In R. McCauley & M. Fey (Eds.), Treatment of language disorders in children (pp ). Baltimore, MD: Brookes Publishing Co. I’m going to go over the main steps and show you some examples. More information is available in a recent chapter by Warren,, Bredin-Oja, Fairchild Escalante, Finestack, Fey & Brady Book also includes a cd with more video clips of these and other procedures

90 Step 1: Find objects/activities/people that participant will be motivated to communicate about
Different for every individual Preference assessments or questionnaires Examples of activities: toy box, snack activities, motor activities like swinging, Range to match development and interests The first step is common to all interventions aimed at teaching children to ask for things but is absolutely essential for kids with severe disabilities and for using this approach. You have to find thinks they like, a lot. Differ for every child. I bet many of you already have systematic ways to find what will drive a kid to communicate. What are the? observations’ Preference interview with family and teachers, a great thing to do at initial meetings or IEPs. Best 30 seconds of the meeting. Direct assessment procedures like forced choice procedures. Whatever means you use, you need to identify a range of activities the kids really enjoy and reassess this frequently throughout intervention. If something’s not working any more, time to think, OK is this activity still motivating. And for some kids this changes frequently so you got to rotate and change things up often.

91 How to Teach Natural Gestures
Step 2. Develop turn taking routine(s) involving activities identified in step 1 Examples: Rolling a ball Putting colored discs on a light box Pretend cutting food Turning on and playing with any battery operated toy More elaborate routines can be used with children who have advanced play skills Next, you need to figure out some back and forth turn-taking activities involving the objects and activities that the individual really likes. You have to think of an activity that can take the form of first I do something then you do something etc. Almost any toy or activity can be made into a turn taking activity. Some thing have obvious turns associated with them, like a ball, where you roll the ball back and forth. But there are other fun things you can do with a ball too, like little bounces and big bounces, and roll it zig zag etc. Some of the activities are going to vary by child’s sensory status too. We’re finishing up a study with children with hearing and vision losses in addition to intellectual disabilities, and for a couple kids with limited vision, they loved the light box, and you might wonder well what kind of turn taking routine could you do with a light box but he loved putting different colored discs on the light box so he and the interveentionist took turns putting different discs on to create an interesting pattern. These are very easy, basic activities. For children with more complex play skills, you can use pretend play, like cutting up pretend fruit, velcroed together.

92 Other types of routines
Meal times Getting ready to go outside Play with a certain toy or object Songs with repetitive lines and actions The type of routines will vary with the child’s play skills

93 How to Teach Natural Gestures
Step 3 (for teaching requests) Interrupt the routine in order to provide an opportunity for the child to request For example: hold on to the ball, or pause the swing, or turn off the battery operated toy…. May add an expectant look So we’ve identified some awesome activities and turn taking routines involving those activities/objects and you’ve already seen the rest of these components but I’ll highlight them with some more examples. The third step, at least for teaching requests, is to interrupt that routine that you’ve just established in order to provide an opportunity for the child to ask for more. So in the peg board routine, how did Susan do this? The light ball, does this on it’s own, it turns itself off, and in the amazing barrel rolling routine, when was the interruption? 1 before he starts rolling her, and also before she flips. For kids with good vision, in the beginning stage an “expectant” look can often help. I call this the confused or dumb look and it can be an extra cue for the child that you’re waiting for something.

94 How to Teach Natural Gestures
Step 4: wait Step 5: if necessary prompt the targeted response Physical, hand over hand prompts Model prompts Verbal prompts Fade prompts as quickly as possible Clip from Super Nanny Along with the interruption and the expectant look, there’s a wait. And the length of that wait time is going to depend on the child’s motor skills and motivation and you the interventionists familiarity with the child’s communication repertoire. If a child has a slow response time in general you will have to wait longer. If you know that she has the response of searching out and tapping your hand strongly in her repertoire, you’re more likely to hold out and wait for that response. However, if it’s pretty new and fragile, you might only wait a few seconds before the next step which is prompting. But I want to emphasize how important the wait time is. When your first starting to use these procedures it may be helpful to even do a silent count in your head just to make sure you’ve given enough time. So, offer the pegs or the ball and then count 5-10 seconds or so. If you wait too long, you’ll know because they’ll lose interest and give up or tantrum. Next time shorten it a bit. But if you don’t wait, they don’t have a chance to show you what they can do. If you don’t get the response you’re looking for during that pause—and you should always have a response in mind– then you need to use a prompt and we rely on physical prompts for our learners with hearing and vision losses, but I think they are best for all beginning communicators. They are easier to fade out than verbal prompts and the kids are more likely to become initiators rather than responders quicker with physical prompts. You can model gestures like points, although it’s hard to model giving for help or open palm requesting unless you’re completely double jointed. You want to fade the prompts as quickly as you can so the child doesn’t become prompt dependent, but, in my experience, you often have to give little booster prompt sessions, maybe at the beginning of each session for awhile. So if you’ve faded a prompt it doesn’t mean it’s gone for good for a long time.

95 How to Teach Natural Gestures
Step 6: continue the routine/activity. This reinforces the child’s behavior. General pointers Shorter routines provide more opportunities for communication Change activities when child just begins to lose interest This last step may seem like a “no brainer” but you need to finish up a turn with the activity so they get to experience the fruits of their labor. Sometimes this can be just a few seconds of the ball light or hearing music, for some kids and some activities they need more time but I try to always be conscious of the fact that the longer they are getting to to experience to reward, the less time they have to ask for it again. So you want to make it worth their while, but not too long. This gets to the first general pointer– shorter routines provide more opportunities. So the examples you’ve seen so far provide lots of turns, lots of opportunities, in contrast, if you had a routine like dress up and teach the child to ask for the box of clothes then spend 10min. Putting on the clothes, that’s only one response in 10 minutes and that’s not enough teaching opportunities. During this skill acquisition period, you need more dense opportunities. We work with the kids for a long time, 45 min. to an hour and so we go through a number of activities and if you are having to do more prompting than usual or the child is getting whiny or falling asleep then you have probably stayed with a particular activity too long. Learn to read subtle signs that they are just beginning to lose interest and change at this time. “Leave em wanting more.” is what we strive for. Change up some motor, some sensory toys, some snack activities, keep it interesting for the child and you. If you’re bored it’s not a good sign either. Try to keep up a good energentic but not frenetic pace.

96 Intervention: Role Play exercise
One of you is teacher, other is student Using the steps we just discussed….Teach student to do one of the following: Point to blinking fan Open palm request for yummy treat Give to request more bubbles Vocalize to continue a social routine Reverse roles

97 Specific strategies to increase vocal production
Vocal play Imitation

98 Specific strategies to increase vocal production, continued
use sounds within child’s repertoire

99 Specific strategies to increase vocal production, continued
Verbally prompt for vocalizations Specifically acknowledge vocalizations

100 = Combining components Vocalization + eye gaze + gesture
a clear, recognizable communication act!

101 Strategies for combining gesture, eye gaze and vocalizations
Time Delay If the child produces one or two components of a communication act, wait expectantly (i.e., use time delay) to prompt the second (or third) component. Ask, “what do you want?” or another general prompt and wait again

102 Strategies for combining gesture, eye gaze and vocalizations
Immediately after the child produces the targeted component (eye gaze, vocalization or gesture), provide the appropriate consequence and verbal feedback

103 Considerations in working with specific populations
Children with Down syndrome Children with autism Children with fragile X syndrome Children with multiple disabilities Children learning AAC

104 Children with Down Syndrome
Characteristics to consider when planning assessments and interventions Intelligibility Learning style (may not respond well to “Do/say ___.”) Persistence Exciting new treatments in development!





109 Fragile X syndrome Fragile X syndrome (FXS) is the leading inherited cause of mental retardation Delayed language typical in boys Profiles: relatively weak in Short term memory Processing sequential information Directing and sustaining attention Co-occurrence of ASD in about 10-40% boys

110 Children with Fragile X Syndrome
Characteristics to consider when planning assessments and interventions Wide range of variability of communication Many autistic-like characteristics Mothers may be shy or reticent in their interactions Oral needs Exciting new developments Drug trials Newborn screening Children with Fragile X syndrome have many of the symptoms and characteristics of children with autism. They seem to feel most comfortable in a structured, predictable environment with few distractions and some chance to rest and escape from demands.

111 Adaptations for Children with sensory limitations
Input includes sign and touch cues Directionality of communication act, indicated through whole body orientation (not just eye gaze) Routines emphasize tactile and vestibular stimuli Prompts are physical rather than verbal

112 When is it appropriate to target symbolic forms of communication?
Research isn’t available yet to guide this decision We start working on words when children are communicating prelinguistically at a rate of more than one communication per minute Start sooner with children who have severe physical impairments

113 Combining AAC and Prelinguistic Interventions
How can AAC complement prelinguistic interventions? How can prelinguistic interventions complement AAC? How many of you work with children that you think will need to use, at least for some period of time, augmentative communication? If the children are prelinguistic, we feel many of the principles used in PMT of can be used in early AAC intervention. We have been thinking about this a lot. So I wanted to discuss blending AAC with prelinguistic modes and teaching strategies, particularly for two scenarios, first for kids who, for whatever reason pick up at least a few signs or graphic selections more readily than natural gestures and vocalizations. And second, for kids who demonstrate all the prelinguistic skills we target, but are having a very hard time acquiring speech.

114 Considerations AAC does not slow down acquisition of speech communication Blishak (2000); DiCarlo et al. (2001); Kouri (1988); Shepis et al. (1982); Yoder & Layton (1988) Acquisition of prelinguistic behaviors may follow a different course for some children with severe disabilities Parents are eager for children to communicate symbolically We know that learning to communicate with AAC does not retard speech acquisition and it may even promote speech acquisition. Secondly, although I’ve spent a lot of my career describing stages of prelinguistic communication development, such as starting with contact gestures, progressing to distal gestures and then more symbolic gestures and speech, I’ve met many children who don’t seem to follow this pattern. They skip around, and we don’t know that mastery of gestures and prespeech vocalizations are necessary to acquire before symbolic communication in all cases. Every parent is waiting for that first word, whether it’s spoken, signed or selected on a communication device. Parents may be more excited participants in their children’s interventions when a sign is targeted than when a natural gesture is targeted.

115 Scenario 1: child who is slow to acquire natural gestures and vocalizations Some kids, for some reason, acquire a few signs or other AAC responses more readily than natural gestures. We’re going to look at some clips from a little girl who participated in 6 months of intensive PMT intervention with an excellent interventionist –Shelly Bredin-Ojay, a doctoral student working on our addition to her early intervention services received through infant/toddler services. In terms of her PMT goals, we’re still trying to get her to combine eye gaze with gestures and vocalizations to produce clear communicative signals. However, she’s learned one sign along the way, I bet you can guess what it is... “More.” In this clip we’ve got a cup banging routine set up and I’m waiting for her to request the blocks so she can bang them some more. Watch clip She uses this sign as a general request, quite appropriately. At the time of this videotaping, she’s 4 years old, and everyone, including myself is thrilled that she has learned a clear communicative signal that is recognizable by her immediate caregivers. Her parents are probably more thrilled that it happens to be a sign than a natural gesture.

116 Scenario 2: Child who meets/exceeds goals of PMT but is slow to develop speech. Use typical naturalistic teaching strategies such as incidental teaching, mand model and delayed prompts to teach AAC and spoken verbal utterances Now, let’s shift slightly to thinking about children who communicate at a high rate with their gestures and vocalizations, including canonical vocalizations and they are getting older, but they aren’t acquiring spoken words yet. I have met many kids like this lately. They have labels like severe expressive language impairment or developmental apraxia of speech. These kids are getting lots of modeling etc. of speech and usually some speech therapy outside of our setting too but are making minimal progress learning to speak. For these kids we can use typical naturalist teaching strategies such as incidental teaching, mand model and delayed prompts to teach production via AAC and concurrently modeling verbal utterances. And continue to honor and encourage children’s use of gestures and prespeech vocalizations to communicate. Some nice examples of including AAC strategies such as remnant books, vocas, and signs are presented in three case studies in the Cumley and Swanson 1999 article in AAC.

117 Conclusion Incorporate AAC within prelinguistic interventions
In beginning AAC instruction, focus on communicative foundations such as directing behaviors toward partners and use of gestures Research is needed to identify optimum strategies for combining prelinguistic intervention and AAC PECS and spontaneity example Bottom line/take home message is that those of us who are focused on teaching prelingustic behaviors such as communicative gestures and canonical vocalizations, we need to be open to incorporating AAC into this instruction , and for those of us who are more inclined to think about teaching children to produce alternative modes such as sign language and graphic selection/exchange modes, need to be mindful of teaching the communicative foundation including eye gaze, directionality, gestures, vocalizations with the use of AAC and at other times as well. And we need research to help zero in on how best to combine AAC and PMT and when it makes the most sense to do so, that is, identifying what type of learner profiles would benefit most from this combined approach.

118 What is the evidence base?
Evidence that children increase their use of communicative gestures Yoder, Warren and colleagues studies: Effective for children in low-responsive environment Fey, Waren, Brady, Finestack, Bredin-Oja and Fairchild (2006) Significant increases after 6 months of intervention Warren, Fey, Finestack, Brady, Bredin-Oja (2008) Effects did not maintain over time Possible differences in effects for children with Down Syndrome So far, we know that this type of intervention does increase children’s communication. They learn to gesture and vocalize more after participating in this type of intervention than participating in a control group.

119 Brady and Bashinski (2009) research with deafblind children
Results from 9 children who had relatively good motor skills 2 children with severe motor limitations

120 Data obtained from videotapes collected aproximately ¼ intervention sessions, later coded from the videotapes. We take lots of data on the forms and functions etc. but we’ve graphed just the initiations and responses (combined) and the prompted responses here. Note the increases in the initiations and the decreases in the prompted responses. The triangles are structured probes that are mini tests like the CSBS.



123 Brady & Bashinski Summary:
All 9 kids with adequate motor skills increased their initiated communication Mostly requests Effects did not generalize to different contexts Less effective for children with severely limited motor skills What else should we take data on? Communication functions, use in other contexts, with other people…..

124 Questions and comments?

125 Increasing communication by working with partners
Working with partners to increase responsiveness and decrease directiveness Goal is to promote a context where children have a need and desire to communicate

126 Peer based interventions
Increase communication Play Social interactions

127 Do we need to teach peer interactions?
Video demonstrating need

128 Why focus on responsivity?
Warren, S., Brady, N., Sterling, A., Fleming, K., & Marquis, J. (2010). Maternal resposivity predicts language development in young children with fragile X syndrome. American Journal on Intellectual and Developmental Disabilities, 115(1), Brady, N., Herynk, J., & Fleming, K. (2010). Communication Input Matters: Lessons From Prelinguistic Children Learning to Use AAC in Preschool Environments. Early childhood Services, 4,

129 Changing Adult Behavior
It is very hard to change a person’s behavior. It is usually easier to learn a new behavior than to change an old one. People must be highly motivated in order to change behavior and maintain that change. It is very hard to change a person’s behavior, our own of someone else’s. It is probably harder to change an adult’s behavior that has been in use a long time than a child’s behavior. It is harder to change a behavior than to learn a new behavior. A newly learned behavior however may be substituted for an older behavior, especially if the new behavior is seen to be better or more effective in achieving the function of the behavior it replaces. When we want to teach a child with a disability a new behavior to replace an old less acceptable behavior, we need to learn what motivates that child and be ready to provide that reward when the child performs the behavior. We also need to be sure that the new behavior is at least as effective in accomplishing the function of the old behavior as the old behavior was. Our function here today was to provide information, not so much to try to change behavior. You students know that you can be highly motivated to learn, demonstrate and perhaps change a behavior or skill when you begin your practicum experiences and are observed by your instructor or supervisor.

130 Enhance partner responsivity
Work with partner to increase: following the child’s lead waiting for the child to respond listening to the child Play with the child face to face, placing few demands or constraints on the child’s actions. Imitate the child’s actions and sounds. commenting about child’s actions, etc.

131 Parent Education Strategies:
Discussion of topics covered in reading; direct instruction General sensitivity to parent issues of all kinds Parent observation of intervention sessions

132 Example 1: Families with FXS
Working with families that have a child with FXS Pilot study: 4 families Ten sessions were held approximately 1 week apart. Each session followed the Hanen curriculum but lessons were individualized. Key components of the intervention included teaching parents to wait for their children to initiate interactions recognizing communication attempts following the child’s lead providing simplified input

133 Results: Three mothers showed increases in facilitative interaction style behaviors Three mothers decreased their number of utterances per turn Two children increased the number of different words produced

134 Changes in mothers


136 Changes in children


138 Activity: identify some strentgths and goals
Top 3 suggestions….

139 Observation and discussion of video-taped parent-child interactions
Coaching regarding use of techniques Brainstorming about the use of responsivity techniques in typical situations

140 Mothers helped select the goals for themselves and their child for the intervention.
Mothers changed their behavior when the interventionist was present and coached them, but did not seem to maintain their skills. This is important for what some colleagues have called “buy in” We got more buy in when mothers identified what they felt they needed to work on most.

141 Excerpt from Checklist of Skills
Mothers’ Checklist of Skills When a skill is introduced, write the date in the Targeted space. When the skill is used at least part of the time, write the date in the Emerging space. When the skill is used during 80% of the opportunities provided, note the date under Mastered. Mother’s Name_____________________ Child’s Name ______________________ Should be Skill is Skill is Targeted Emerging Mastered How would you rate your skills in responding to your child’s communication in the areas of Responding to Gestures Responding to Vocal Initiations Responding to Verbal Initiations (Words, Signs) Following Your Child’s Focus Within Activity A sample of the first page and the first several skills on the checklist. There are 30 skills in all. We worked with the mothers until they felt they had mastered or were close to mastering all the skills. The intervention was more intensive at first, 2 or 3 30-minute sessions per week, and gradually decreased to once per week, then once every other week, and then once per month for the last two months that constituted the maintenance period. We were always available by phone to the mothers if they had a question between sessions. However, they typically called only if there was a need to cancel or change a session time or date.

142 Summary Need to work with partners and children
Should parents learn intervention strategies, or to be facilitative? Need to measure changes in partners and children

143 References Blishak, D. (2000). Increases in natural speech production following experience with synthetic speech. Journal of Special Education Technology, 14, 47-57 Brady, N., Marquis, J., Fleming, K., & McLean, L. (2004). Prelinguistic predictors of language growth in children with developmental disabilities. Journal of Speech, Language and Hearing Research, 47(3), Brady, N., Steeples, T., & Fleming, K. (2005). Effects of prelinguistic communication levels on initiation and repair of communication in children with disabilities. Journal of Speech, Language and Hearing Research, 48(5), Capone, N., & McGregor, K. (2004). Gesture development: A review for clinical and research practices. Journal of Speech, Language and Hearing Research, 47(1),

144 References continued Crais, E., Day Douglas, D., & Cox Campbell, c. (2004). The intersection of the development of gestures and intentionality. Journal of Speech, Language and Hearing Research, 47, Cumley, G. & Swanson, S. (1999). Augmentative and alternative communication options for children with developmental apraxia of speech: Three case studies. AAC, 15, Fey, M., Warren, S., Brady, N., Finestack, L., Bredin-Oja, S., & Fairchild, M. (2006). Early effects of prelinguistic milieu teaching and responsivity education for children with developmental delays and their parents. Journal of Speech, Language and Hearing Research, 49(3), Hunt-Berg, M. (2001). Gestures in development: Implications for early intervention in AAC. ASHA Division 12 Newsletter, June 2001.

145 Warren, S. , Bredin-Oja, S. , Fairchild Escalante, M. , Finestack, L
Warren, S., Bredin-Oja, S., Fairchild Escalante, M., Finestack, L., Fey, M., & Brady, N. (2006). Responsivity education/ Prelinguistic milieu teaching. In R. McCauley & M. Fey (Eds.), Treatment of language disorders in children (pp ). Baltimore, MD: Brookes Publishing Co. Warren, S., Fey, M., Finestack, L., Brady, N., Bredin-Oja, S., & Fleming, K. (in press). Longitudinal effects of low intensity responsivity education/prelinguistic milieu teaching for young children with developmental delays. Journal of Speech, Language and Hearing Research. Warren, S. F. (1992). Facilitating basic vocabulary acquisition with milieu teaching procedures. Journal of Early Intervention, 16(3), Yoder, P., & Warren, S. (1999). Facilitating self-initiated proto-declaratives and proto-imperatives in prelinguistic children with developmental disabilities. Journal of Early Intervention, 22(4),

146 Resources The national Fragile x foundation: Down syndrome research:

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