1. Intervention Strategies for Caregivers & Young Children Who Have Multiple Disabilities and Cochlear Implants: Research to Practice to Training Kat Stremel Thomas, The Teaching Research Institute, Western Oregon University

2. Objectives: Participants will increase their knowledge of: 1.… the demographics and outcomes for children with deaf-blindness and other disabilities, 2.…the critical aspects of cognition, social and communication development as they relate to receptive and expressive language development for children with cochlear implants and multiple disabilities, 3.… effective procedures to teach these children in natural environments, and 4.… effective adult learning strategies to teach caregivers to effectively teach their child.

3. Practice: What To Teach & How To Teach It

4. Considerations for Planning Intervention for Children Who Are Deaf-Blind (Multiple Disabilities ) The tremendous differences between the children – the need for individualization. The need for multiple disciplines planning and intervening – collaborative teaming. The need to teach caregivers specialized procedures for teaching the “What” and the “How” of intervention.

5. Influencing Factors for Individualized Instruction Age of onset of vision and hearing loss Severity of the disabilities/loss (vision, hearing, physical, motor, medical) Impact of concomitant disabilities Age of diagnosis and intervention Use of vision and auditory devices &AT Cognitive and social development Support and training of the family

6. How Are Children With Multiple Disabilities Different From a Typical Deaf Child? Lack of intentional behavior (causality) Low rates of social interaction/lack of initiation Limited actions on objects and toys (mouthing/throwing) Low rates of turn-taking Absence of prelinguistic communication Lack of clear behavioral responses to pure tone signals Lack of consistent wearing of hearing aids These children are often “dropped” from AV therapy due to lack of progress.

7. -Individualization- Facilitators/Inhibitors to Communication Development Motor Vision Hearing Cognitive Social Medical Hyper/hypo sensitivity

8. Individualization Any individual child’s motor, cognitive, perceptual, social and medical status must be considered in order to individualize a communication & language program and make future decisions for movement HANDOUT

9. Case Examples DOMAINS/ FACTORS Child “C”Child “E”Child “L” CHARGE MOTOR Rolls to move, little use of rt. hand Ambulatory & good fine motor skills Began walking 2 days after implant; good fine motor skills VISION Small field of light perception in one eye CVI-Progressive Improvement Good with correction at 12 inches HEARING Profound – Bilateral Implants CI & Hearing AidNot a full insertion COGNITIVE Limited actions on objects-increasing Very good interactions with objects Stereotyped behaviors, flipping, mouthing SOCIAL Positive response to others Beginning to coordinate object & people more Recognition of persons increasing/minimal MEDICAL GI Tube and eating; 7 months NICU Long NIU stay; No problems now Trach & multiple surgeries AGE AT IMPLANT 1year, 9 months 2 years, 2 months4 years, 9 months

10. Critical Components of “What” We Need to Target for Practice Related Social & Cognitive Behaviors Auditory Processing Receptive Communication Vocal Development Expressive Communication Receptive Language Speech or Augmentative Systems Expressive Language (morphology & syntax)

11. Assessments for Each Domain: A Strength Model- Not a Deficit Model Need to determine skills in each area Need to determine next skill to teach Need to use skills to teach new behaviors

12. Cognitive & Social Development: Impact on Communication & Language Development “ Language cannot get off the ground until some minimal set of cognitive infrastructures are finally in place, including cognitive structures that are necessary though (perhaps) not sufficient for the establishment of reference and predication” Bates et al., 1995 Perhaps intentional communication also cannot get off the ground without some minimal set of cognitive and social infrastructures. Stremel Thomas

13. Important Social Factors Reacting to the emotions of others Engaging in the social interaction, Joint attention Joint activity Turn-taking Awareness other’s communicative intent, Understanding the “theory of the mind” Imitation

14. Important Cognitive Factors Anticipation (Based on “cues” and repetition) Causality (Social and Physical) Means-End/Tool Use Object Use, Object Permanence, Spatial Relations Coordinating Objects and Persons Imitation Symbolism (Pretend Play & Representational Gestures) Understanding that specific symbolic gestures and words “stand-for” individual objects, locations, actions, and features.

15. The Critical Factors of Receptive & Expressive Communication- Considerations of Communication Before Language Forms = A way to communicate Intents/Functions = A reason to communicate Content = Something to communicate about Context = The social and physical environment in which communication takes place

16. RECEPTIVE COMMUNICATION & LANGUAGE DEVELOPMENT

17. Levels of Receptive Language (Geers & Moog, 1990: Examples Awareness that the mouth/voice conveys information Comprehension of a few words or expressions Ability to learn new word Ability to acquire new receptive vocabulary in phrases and sentences Comprehension of successive phrases and sentences * For children with multitple disabilities, other receptive “Communication” skills may be targeted as well….

18. Young children first begin to anticipate events and activities based on non- language forms: Young children begin to understand the meaning of others through facial gestures, intonations, pitch, movement, and touch when these behaviors are part of a familiar routine. Early in development, children also learn to associate certain objects, sounds, and smells with routine, care giving activities. What we teach needs to be meaningful.

19. Points: We need to determine what aspects of a communication exchange the child comprehends A child with multiple disabilities may have different receptive and expressive systems. We need to assess how children anticipate and begin to understand meaning. Comprehension precedes production fairly dramatically with typical children. We need to use this information in designing communication & language production for children with disabilities.

20. Determining what receptive forms will support auditory perception of words The child’s vision and cognition play an important role in determining supportive cues, Initially, these cues will be used for communication, Later, they can be used to support the learning of “receptive verbal words.”

21. Forms of Receptive Communication & Support Stage 1: Contextual cues Stage 2: Tactile cues Stage 3: Object cues Stage 4: Gesture cues Stage 5: Tangible symbols cues Stage 6: Sign Language Stage 7: Speech

22. Contextual Cues A combination of auditory, visual, movement, smell or taste stimuli may serve as a cue if these have been used in frequent, motivational routines. -Participants give examples-

23. Touch or Tactile Cues Cues that do not include objects. The touch cues should be as natural as possible and be part of an interaction, as in “up” in which the mother may slide hands up the child’s outer rib cage; or rub their hand. - Participants provide examples-

24. Object Cues Initially, Object Cues should be real objects that are naturally used in frequent routines. We need a means to determine if the child understands the “meaning” of these cues. Later, Object Cues, may “stand for” a part of an activity (as a chain link on a swing) - Participant Examples-

25. Deictic Receptive Gestures These gestures establish reference and provide our intentionality to the child Initially and for children with no vision, these gestures will be “contact” gestures (may overlap with touch cues). Examples: “up” “give me” “take this” “look” “all done” “push away”

26. The Importance of Gestural Development Initially, children begin to understand deictic gestures, such as “up” and “want. ” Representational gestures are important for learning “symbolic” communication. Young children often begin to understand verbal words that are paired with gestures.

27. Representational Gestures These gestures may initially include objects and later may include the shape of the hand/object, the function or action of the object; or an action in a game. These gestures may include tactual gestures for children with little or no vision. Examples might include “drink” “open door” “drum” “pour” “car”

28. Other Types of Tangible Symbols Part-Whole Pictures Line drawings Raised symbols Abstract symbols (texture/shapes)

29. Sign Language Visual Tactile Words Word combinations (beginning ASL) ASL grammar

30. Speech As more and more children receive cochlear implants, we need to focus on the sequence of auditory perception and speech comprehension. Early behaviors may include responding to motivational environmental cues and toys sounds. Verbalizations of different pitch, tones, duration, patterns within social games; using the child’s name, simple directions in social interactions.

31. Auditory Perception Auditory perceptual activities can be implemented while the child is working on receptive communication

32. Detection – Use of Listening Cue Non-Speech Sounds Environmental sounds Toy sounds Animal sounds Speech Sounds Accentuated pitch contours Slower cadence Repetition (paced) Elongated vowels Key words exaggerated Simplified semantics Nancy Mellon (2000) in J.K. Niparko (Ed)

33. Discrimination Discrimination between environmental sounds (door bell, door, microwave) Discrimination between voices Discrimination between inflections that express different functions (no, teasing, directive, descriptive talking)

34. Embedding Opportunities in Routines ComponentsLunch RoutinePlay Routine DetectionMicrowaveToy sounds LocalizationMom’s voiceChewy to right/left DiscriminationMicrowave/doorbell Mom’s/Nurse’s voice Chewy vs. Shake, shake,shake, shake IdentificationGet spoon, milk, bibGet you chewy vs. shoe ComprehensionBib offMy turn

35. Children begin to interpret the “intent” of their caregiver as: You want to play with me (joint activity) You want me to turn to my name (calling) You want me to stop doing what I am doing (protest/rejection) You want me to respond to you You want me to give you this object You want me to look at something (joint attention)

36. Later, children understand the meaning of simple phrases by the way the words are ordered, “more milk, ” “no milk, ” “pour milk” “pour juice”

37. Expressive Communication The means by which we interact with others, express feelings, likes/dislikes, messages and intents to others. There are many forms of expressive communication other than speech or manual signs.

38. Intentional Communication Acts Intentional communication acts include: an orientation to the other person, a clear message, a clear intent, and continued acts to get message across

39. Levels of Expressive Language Skills (Geers & Moog, 1990) Awareness that vocalizations are used to communicate Ability to use a few syllables, words or expressions Ability to learn new expressive vocabulary Ability to acquire new vocabulary fairly readily Ability to join 2-3 words together Ability to combine verbs and nouns in phrases and sentences Ability to use sentences with more than 1 type of modifying word…. * What children with multiple disabilities may need to learn before these skills….

40. Understanding How Children with Disabilities May Initially Communicate Children with disabilities often communicate in unique ways Children may send messages using one form and receive messages using another form. Children are most likely to learn to communicate their wants and needs Children are most likely to communicate in their own natural environments Children first communicate in the “here and now” Children need routines within their natural environments to learn to communicate

41. Children’s receptive communication usually precedes the development of their expressive communication. Caregivers begin to “interpret” the meaning of their student’s smiles, vocalizations, facial gestures before children have any “intent” of impacting the caregiver. Children demonstrate “intentional motor behaviors” prior to the development of “intentional communication.” Early “intentional” communication occurs in many forms prior to the development of speech and language.

42. Receptive & Expressive Communication Research may use the terms: Comprehension and Production The differences in rate of acquisition should play more a part in our decision-making than it does. Typical children may understand 50-200 words and use only 5-10 words expressively! (Bates et al., 1995) – we often do not use these guidelines when teaching signs.

43. Expressive Communication Forms 1. Affective Communication 2. Contingency Communication 3. Instrumental Communication 4. Conventional Communication 5. Emerging Symbolic (Adaptive) 6. Symbolic *

44. Affective Communication Infant Affect -playful -smiling -expressive -interested -calm -sad -fearful Caregiver Affect -playful -happy -inviting -observing -comforting -responsive

45. Contingent Communication Child is intentionally acting on toys Child uses general excitement as a “causal” action Child imitates action and vocal sounds already in repertoire Child repeats interesting actions on objects Increase in joint activity & attention Parents provide a linguistic mapping

46. Forms of Contingent Communication General excitement Body movement Vocalizations Facial gestures

47. Instrumental Communication Intentional communication becomes more apparent Criteria for communication is present There is an intent to impact another person Child terminates signal when goal is achieved or failure is realized Forms: Touching persons & objects; Manipulating persons & objects, AT devices

48. The Critical Development of Gestures Comprehension and production of gestures is an early means of expressing intentionality Deictic gestures – Establish reference and can only be interpreted by the content. They can be used with a variety of objects and events. Early deictic gestures may be contact and then more distal, such as open –handed reaching; reaching to be picked up.

49. Conventional Communication Child coordinates objects and persons Gestures change from reaching to giving to showing to pointing Children increase their rate of prelinguistic communication acts Child applies social actions to objects Tool use and imitation also are occurring Forms: Extending objects, giving, pointing, simple gestures as mine, no, all done.

50. Development of Representational Gestures Symbolic gestures or representational gestures establish reference and indicate a particular semantic content. Symbolic gestures can be object related or conventional to represent some concept or action

51. An Assessment to Examine the Development of Gestures Based on research by Crais, Watson & Baranek (2009) HANDOUT

52. Emerging Symbolic Communication Representational gestures increase Vocalizations become “proto words” Gestures are defined more by the culture Child begins to use representational play Children may use more precise movements if CP is present (eye blinks for yes) Pictures or other tangible symbols may be used. Rate of communication acts increase

53. Symbolic Communication Child maintains sustained attention to both the adult and the object/shift back and forth Children are using at least 1 communication act per minute in an engaged activity Children may have 50-100+ words receptively Types of 1-word utterances: existence, rejection, recurrence, action, state verb First words may represent the entire context

54. Variation in the Rate of Development Gesture & word comprehension Gesture & word production First word combinations (children go thru a prolonged period of using single words before combinations or inflections – 50-200 single words): Implications! First stages of grammar (goes from rote to rule)

55. Expressive Communication Functions Early Functions Calling or accessing people Protesting Requesting continuation of an activity once it’s started and then discontinued Requesting an object Requesting from a choice of 2 objects or activities

56. Expressive Functions Later Developing Functions Social greeting Offering or transferring objects Repeating Answering questions Naming or labeling

57. Even Later…. Replying Requesting information Additional (joking, lying, convincing, etc.)

58. Communication Mapping Select a “sample” child with whom you work Determine facilitators and inhibitors for this specific child Fill out only the “Receptive (top)” forms of communication on the Communication Map & then fill in the “Expressive forms” (bottom) and “functions” (middle section) of communication. - Handout & Participation Activity-

59. MacArthur-Bates Communicative Development Inventories (CDI) Fenson et al., (2007) Paul H Brookes, Publisher Words and Gestures (Infants: 8-16 months) Gestures, Actions on Objects, Representational Play, and 396 Vocabulary Items across 10 semantic categories Words and Sentences (Toddlers: 16-30 months) 680 items based on 22 semantic categories and grammar

60. Auditory Lead-Wait-Support-Auditory Follow-up 1. Lead with speech! Say it 1-2 Times (NO MORE)! 2. WAIT (1 second for narrative description; 5-7 seconds for directives for which you expect a response) 3. Support with Tactile/Touch Cue prompt while repeating the word (1 time) 4. Say it again – end with speech only, “Bite.” Example: (a) Say, “Bite”; Say, “milk” while providing touch cue, repeat, “bite…yum-yum.” Later, “You took a bite!” Assist Child if no response is made within 7 seconds.