Transcript Facilitating Early Communication Development in Children

Nancy Brady
University of Kansas
[email protected]
http://www2.ku.edu/~lsi/research/profiles/brady_nancy.shtml
Presented to Illinois Speech Language Hearing Association
April 1, 2011
 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
 Gestures
and vocalizations that precede speech
in typically developing children
 Occur in a developmental order
 Why
focus on describing, assessing and
teaching these types of behaviors?
 There
is great variability in the communication
skills of prelinguistic children
 Prelinguistic = before children are speaking or
signing or using another formal language
system
 “Perlocutionary”
= children communicate by
crying or acting on objects. Others assign
meaning to these behaviors.
 Next
sections:
• Vocalizations
• Coordinated attention
• Gestures
 Crying

and experimental sounds
and experimental sounds continued –
“Raspberries”
 Crying
 Canonical
babbling (reduplicated consonant
vowel babbling)
 Variegated
babbling (jargon babble)
 http://www.youtube.com/watch?v=-
5yIiGF8WGk.
 Crying
 Experimental
Sounds
 (e.g., raspberries, noncanonical babbling)
 Canonical Babbling
 Variegated Babbling
 Speech
 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?
3
month old:
http://www.youtube.com/watch?v=KMbKlOL8q5s
 9 month old:
http://www.youtube.com/watch?v=Lr_CmHq2vog
 How old?
http://www.youtube.com/watch?v=0r_H2kHREig
 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!
 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)?
 Differences
in prelinguistic quality and
quantity of vocalizations in children with
Down syndrome
 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)
 Lots
of variability
 Aka…joint
visual attention, line of visual
regard,
 What is it and why is it important?
 Within
routine, child is looking at object, then,
intersect gaze
 Verbally
prompt for eye gaze
 Specifically acknowledge the eye gaze
 Provide the desired object contingent on the
eye gaze
 Bring
toys up to face
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

 Illocutionary
or purposeful gestures
 What is the function?
• Behavior regulation = imperative
• Joint attention = declarative
• Social interaction
 Crais
et al. (2004) study
• Deictic vs. representaitonal
• Different functions
• What’s the developmental sequence?
 Contact
gestures = gives, leading by the hand,
showing. Gestures that are in direct contact
with an object or person.
 Example
of a contact gesture
 Distal
gestures = points. The index finger is
extended and other fingers are pulled back. The
gesturer is not in direct contact with the
referent.
 Example
of a distal gesture
 Head
nod and shake, shoulder shrug, open
palm request
 Depictive gestures such as pantomimes
 Sometimes
people combine gestures to convey
complex meanings
• Gesture + vocal combinations
• Gesture + gesture combinations
• Gesture + word combinations
 Examples
gestures
of children combining 2 or more
 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?
 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
 Form
and function
• Individuals with intellectual disabilities who only
communicate with contact gestures rarely communicate
“joint attention” (comments).
 Lack
of joint attention- example of boy with
autism
 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)
 Example
task.
of person pointing in a joint attention
 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)
 Example
of low rate communicator
 Example
of high rate communicator
 Children
who use only contact gestures try to
repair communication breakdown less often
than children who use more advanced gestures
 Input
 How
do children respond to gestures?
• Respond to joint attention
• Disambiguate messages
 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 1.16
words/month…or 167 word advantage by age 2
 Differences
in gesture type associated with
differences in:
• Communication functions (requests, comments)
• Frequency of communication
• Repairs of communication breakdowns
 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
 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
 Assessment
strategies for prelinguistic
individuals
 Intervention strategies for prelinguistic
individuals
• Increasing parent and peer responsivity
• Teaching joint attention
 Standardized
assessments are not very helpful
 Need to determine how a child is
communicating across environments
 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
 Parent/Caregiver
Questionnaires
 Direct Observation
 Assessment Protocols
 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
 Examples
of Questionnaires
• What do you use?
 Good
contexts to observe in
• Contexts indicated by the questionnaire as showing
high probability of communication
• Meal or snack time
• Contexts for vocalizations?
 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?
 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
 Adaptations
for older participants
 Assessment
protocols have been used in
research by Dr. Brady and colleagues to study
 Initiations
• Requests and Comments
 Responses
to Communication Breakdowns
 Example
of child initiation
 Example
of repair protocol item
 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”
 The
Communication Complexity Scale = CCS
 Example from current research by Brady &
Thiemann-Bourque

I. Behavior Regulation
•
•
•
•
•
•

Task 1:
Task 2:
Task 3:
Task 4:
Task 5:
Task 6:
2 wind-up toys (1 broken)
Food items placed in a container (with tight lid)
2 battery-operated hammer toys (1 toy switched off)
Train tracks and toy trains (child has only one track)
Sealed bubbles (2 bottles, one sealed)
Bumble ball (examiner switches off)
II. Joint Attention
•
•
•
•
•
•
Task 1:
Task 2:
Task 3:
Task 4:
Task 5:
Task 6:
Ball chute toy (one ball is too big to fit)
Spider mixed in with blocks in a container
Musical instruments
Pretend hot dog placed in a marker box
Book with altered pages (e.g., upside down, marked, ripped)
Foot controlled switch toy (in child’s line of vision)
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
 6a-
triadic eye gaze
 6b- dual focus + 1 PCB
 7- triadic eye gaze + 1 PCB
 8- triadic plus more than 1 PCB
 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
 How
would you score the following example:
 Example for a boy that uses lots of different
forms!!
 Average
of the three highest forms observed
 Can average within each function (joint
attention; behavior regulation)
 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
 Summarize
information regarding:
• Communication forms
• Functions
• Frequency/rate of communication
• Stage of prelinguistic development
• Initiations/responses/repairs
• Contexts
• Motivation
 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
 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
 Increase
the frequency and complexity of
requests and comments
 For both of these goals the first step is to build
routines
 Theoretical
reasons
• Occur developmentally
before symbolic
communication
• Thought to pave the way
for symbolic
communication
• Provide opportunities for
linguistic input
 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
 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
 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. 47-77). Baltimore,
MD: Brookes Publishing Co.
 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
 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
 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
 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
 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
http://www.youtube.com/watch?v=eR01qlXQ63g
 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
 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
 Vocal
play
 Imitation
 use
sounds within child’s repertoire
 Verbally
prompt for vocalizations
 Specifically acknowledge vocalizations
Vocalization + eye gaze + gesture
=
a clear, recognizable communication act!
 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
 Immediately
after the child produces the
targeted component (eye gaze, vocalization or
gesture), provide the appropriate consequence
and verbal feedback
 Children
with Down syndrome
 Children with autism
 Children with fragile X syndrome
 Children with multiple disabilities
 Children learning AAC
 Characteristics
to consider when planning
assessments and interventions
• Intelligibility
• Learning style (may not respond well to “Do/say ___.”)
• Persistence
 Exciting
new treatments in development!
• http://garnerlab.stanford.edu/DS_Research.html
 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
 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
 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
 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
 How
can AAC complement prelinguistic
interventions?
 How can prelinguistic interventions
complement AAC?
 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
 child
who is slow to acquire natural gestures
and vocalizations
 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
 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
 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
 Brady
and Bashinski (2009)
• research with deafblind children
• Results from 9 children who had relatively good motor
skills
• 2 children with severe motor limitations
 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
 Working
with partners to increase
responsiveness and decrease directiveness
 Goal is to promote a context where children
have a need and desire to communicate
 Increase
communication
 Play
 Social
interactions
 Video
demonstrating need
 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), 54-75.
 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, 141-154.
 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.
 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.
 Discussion
of topics
covered in reading;
direct instruction
 General
sensitivity to
parent issues of all kinds
 Parent
observation of
intervention sessions
 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
 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
FARB
10.00
9.00
8.00
Rate
7.00
6.00
Facilitative
5.00
Beh Mgmt
4.00
3.00
2.00
1.00
0.00
1
3
5
7
9
11
Week
13
15
17
19
21
23
KOBM
10.00
9.00
8.00
Rate
7.00
6.00
Facilitative
5.00
Beh Mgmt
4.00
3.00
2.00
1.00
0.00
1
3
5
7
9
11
Week
13
15
17
19
21
23
FARB
3.00
2.50
Rate
2.00
Different Words
1.50
1.00
0.50
0.00
1
3
5
7
9
11
Week
13
15
17
19
21
23
KOBM
3.00
2.50
Rate
2.00
Different Words
1.50
1.00
0.50
0.00
1
3
5
7
9
11
Week
13
15
17
19
21
23
 Top
3 suggestions….
 Observation
and discussion of video-taped
parent-child interactions
 Coaching regarding use of techniques
 Brainstorming about the use of responsivity
techniques in typical situations
 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.
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
Targeted
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
Skill is
Emerging
Mastered
 Need
to work with partners and children
 Should parents learn intervention strategies, or
to be facilitative?
 Need to measure changes in partners and
children

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), 663-667.

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),
1098-1113.

Capone, N., & McGregor, K. (2004). Gesture development: A review for
clinical and research practices. Journal of Speech, Language and Hearing
Research, 47(1), 173-186.




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, 678-694.
Cumley, G. & Swanson, S. (1999). Augmentative and alternative
communication options for children with developmental apraxia of
speech: Three case studies. AAC, 15, 110-125.
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), 526-547.
Hunt-Berg, M. (2001). Gestures in development: Implications for
early intervention in AAC. ASHA Division 12 Newsletter, June
2001.

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. 47-77). 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), 235-251.

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), 337-354.
 The
national Fragile x foundation:
http://www.fragilex.org/html/home.shtml
 Down
syndrome research:
http://dsresearch.stanford.edu/