functional communication intervention for individuals with developmental disabilities
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Functional Communication Intervention for Individuals with Developmental Disabilities. Lillian N. Stiegler, Ph.D., CCC-SLP [email protected]. 10 INTERVENTION PREMISES. THE SPECTRUM WITHIN THE SPECTRUM. INTENSITY! REDUNDANCY!. THE NEED FOR VARIABILITY. SPIRIT OF EXPECTANCY. - PowerPoint PPT PresentationTRANSCRIPT
Functional Communication Intervention
for Individuals with Developmental Disabilities
Lillian N. Stiegler, Ph.D., [email protected]
10 INTERVENTION PREMISES
THE SPECTRUM WITHIN THE SPECTRUM
INTENSITY! REDUNDANCY!
THE NEED FOR VARIABILITY
SPIRIT OF
EXPECTANCY
There is much more to
communication than the
expression of wants and needs.
COGNITIVEDIFFERENCES
HUMAN COMMUNICATION IS
MULTIFACETED
SENSORYDIFFERENCES
FEARAND
ANXIETY
THE CULTURAL PERSPECTIVE
Working with Nonspeaking Individuals
NOCOOKBOOKS
Why do people communicate?
Need fulfillment is the most basic reason.
To request good things…
…And to protest/avoid bad things.
What is the most CONVENTIONAL way to perform the functions of requesting and protesting?
TALKING!
But not talking alone… When people request or protest conventionally, they combine many aspects of communication:
gestures Eye gaze
Expressions
Body languageLoudness level
Touching
PantomimeWriting
If TALKING is not an available resource for the multi-modal system, human beings will rely on other components of the system, according to their own ability.
What are the factors that eliminatecommunication resources?
Social issues
Motor issues Cognitive issues
(Or a combination of two or more.)
So, it’s our job to help people move up the continuum from less conventional to more conventional.
While making this journey up the mountain of conventionality, it’s good to know what each individual already has in his/her “suitcase”…
…And then, to figure out what can be added to the “suitcase”throughintervention.
If there is motor involvement, some communication resources may be diluted or unavailable.
Speech?
Written language?
Gestures?
PANTOMIME?
Sign language?
It is still desirable to exploit every single item in a person’s suitcase to the fullest extent possible.
Multi-modal is ALWAYS better than uni-modal.
Speech Written Language Picture board/word board Echolalia Sign Language Familiar cultural gestures Physical manipulation Reenactments Proximity Idiosyncratic Gestures Facial Expressions Screaming Aggressive Behavior/Tantrums Self Injurious Behavior
CONVENTIONALITY
INTENSITY in intervention leads to CHANGE
FILLING THE CUP
By 12 months, the typically-developing baby understands about 50 common words and phrases!
And this increases rapidly…18 months = 100-150 words24 months = as many as 500 different words
During this part of development, the child typically understands about FOUR TIMES as many words as he/she is able to produce!
And development happens as a by-product of
EXPERIENCE!
Someone said, “Experience is the sculptor of the
brain.”
“Participatory learning activates all the senses and provides immediate feedback. Although a child can learn [the names of] farm animals from a book, a trip to a farm with participation in feeding the animals provides an unforgettable experience. More sensory and motor neurons are activated when the child becomes an active participant, and the connections between this learning experience and previously stored information are increased. When children are physically disabled, it is often more difficult to engage their active participation in [communicative] activities. Frequently, these children become observers rather than participants in learning and life.” (Morris, 1991)
Remember that the brain is an amazing structure.
New communication skills emerge in response to new skills in other areas
A COGNITIVE development results in a communicative development.
A SOCIAL development leads to a communicative development.
A MOTOR development precipitates a communicative development.
As interventionists, we MUST provide experiences…and we must strongly encourage families to do the same.
Experiences need not be (a) difficult or (b) expensive.
They DO need to happen VERY often.
Intensity of experience is what causes brain changes…new pathways…
Here’s an example of how to create an experience that can lead to social communication.
Start with a theme: SHOES
Has this person ever had the opportunity to wear…
Tap shoes?
Swim fins?
Fuzzy slippers?
Roller skates?
Cowboy boots?
Cleats?
Ballet shoes?
High heels?
Trying on shoes, with a peer, perhaps in front of a mirror, is an EXPERIENCE!
(Maybe it is an experience that a child has never had.)
What else can be done with shoes?
• hide items in shoes• Simon Says game with shoes• shoe print painting• choices for self and others• shoes on dolls• kicking balls/balloons wearing differing shoes• visit a shoe store• big shoes/baby shoes
Factors that Discourage Active Participation
The reality that some individuals resist the unfamiliar
It is often easier to let a child “be”
It takes more physical and mental energy to insist on at least partial participation
A Common Intervention Cycle
A new activity is introduced...
Child resists...
Team memberfeels bad becausechild is unhappy...
Activityis withdrawn...
Child learns toavoid new activities...
What obstacles can you think of that would stand in the way of an experience like this?
Overcome them with adaptations.
Take pictures of the shoe experiences.
Make a “Chat Book” with the photos.
This is a good way to initiate topics in future interactions.
Create social scripts for both events:
1.The shoe experiences with peers
2. Telling people about it afterward
Then, be a facilitator!
INTRODUCING VARIABILITY
COMMUNICATION PARTNERS
Teachers, paraprofessionals and other interventionists sometimes DON’T make the best communication partners.
We get used to prompting,and we forget to progress beyond that level…
We don’t always EXPECT the student to initiate, and so we don’t WAIT for it!
And we forget that REQUESTING is NOT the only communicative function!
Requesting is good and powerful, but…
Don’t get stuck there!
There are many otherimportant functions of communication!
Labeling Answering Commenting Practicing Asking Calling Greeting Protesting
So…where do we find good communication partners?
PEERS: younger older
typically-abled differently-abled
Find “magnets” to help attract peers…
…and they can help you make great strides in communication!
Depending on the student’s needs, topics can be as familiar as…
The child’s own shoesThe water in the sink
The classroom door
An ordinaryspoon
Or as creative as…
A bug in a jar
Somebody’s pet snake
Something grossin the cafeteria
An injury
Use the community!
No matter where you live, it’s possible to have a different guest once a week…
…and get out of the school whenever possible!
The bottom line is…
The sky’s the limit when it comes to communication topics!
And even though predictable structure is necessary and calming for individuals with communication disabilities…
…once daily routines are established, little communication progress will occur unless those routines are violated.
Sensory systems
Compromised AuditorySystem?
Possible Invisible Concerns
Fluctuations in hearing sensitivity
Ear pain Tinnitus Slower processing
Distorted signal quality
Difficulty attending to one speech signal while screening out others
Difficulty holding speech information in memory
So…If the receiver is having trouble
within one modality, the sender mustCHANGE the signal!
Change the way the speech signal istransmitted.
Ways to Enhance Reception
Slow it down Pause more often Pause longer Change pitch Change loudness Shorten and simplify utterances
Be concrete
Check the room acoustics
Highlight important concepts
Talk in the “here and now.”
Use consistent word choices
Remember: Auditory systems can function differently from day to day!
Change the modality.
Visual Communication Enhancers
PointingOther GesturesFacial Expressions
ProximityMODEL the use of all augmentative communication materials
Use NONTRANSIENTS to allow a more permanent reference point
Use physical prompting, then fade as soon as possible
Should the following be targeted in intervention?
Gestures
The All-Powerful, Isolated Finger POINT!
Gaze Behavior
Mutual Gaze
Deictic Gaze
Reciprocal Gaze
Affective Signals
Fear and Anxiety
Fear/Anxiety Sources
Anything unknown• What will happen next• Time: how long an activity or a condition will last
• Location of familiar people and objects
Overstimulation
Being corrected
Nontransients are the best way to communicate what will happen next.
How can TIME CONCEPTS be communicated?
Timers
Personal Watches
Caution Lights
“Thermometers”
Blocks
Squares/Grids
We can elicit communicative behavior by offering many,
many, MANY interesting CHOICES…
Choice-making modes
Simple active/passive choice system with two options
Active binary choice using real objects in natural contexts
Active multiple choice using categorized groups of symbols
Prepared choice boards with various object/symbol orientations
Verbally presented choices
How many choice-making opportunitiescan be incorporated within a single day?
What if the student’s choices are not clear?
Try: Using real objects in a binary format Placing the objects farther apart Rearranging the orientation
What if a student is too passive to make a choice?
We have a tool that can help…
Try a simple active/passive choice system with two options…Student gets Choice A
when passive – this is the default, and should be fairly neutralStudent gets Choice B when active – this should be something highly motivating
Choice B continues for a predetermined time period – maybe 3 minutes – then reverts back to Choice A until the student is active again
Choice A
Choice B
What if something that used to be a choice is no longer a choice?
Communicate the facts – typical students are told “no” sometimes.
If something is NOT currently a choice…
Should the object/symbol be removed? Should the object/symbol be covered? Should the object/symbol be replaced? Should unavailability be indicated using the international “NO” symbol?
Should the individual be redirected to make an alternative selection?
Should a team member verbally explain why the item is not a choice?
Sometimes our task is to help decrease unwanted communicative behavior…
This requires some CAUTION
Individuals MUST be allowed to make refusals or rejections…
It is the only way they can feel truly safe.
But, challenging behavior can become a vicious cycle that systematically robs a student of all his/her communication opportunities.
Results of challenging behavior:
Being left out of school activities and field trips
Being dismissed from services
Spending more “down time” than learning time
Being viewed as “crazy”
Being viewed as stubborn, unpleasant, lazy…
Being left at home while the rest of the family goes out
So it’s a vicious cycle…some peoplecommunicate with behavior…
Thebehaviorremoveschancestoimproveskills...Without experience, communication does
not improve...
Behaviorcontinuesas the only availablestrategy.
We definitely have to establish a symbol system!
What do these symbols mean to you?
Symbols should be of high interest to the student:
TAKE ME TOILET
Symbols should have potential for frequent use:
MORE, MOM YOGURT, BED
Symbols should denote a range of communicative functions:
See EAT
Symbols should reflect the here and now:
COOKIE THINK
Symbols should have potential for later multi-symbol use:
GET DRINK
Speaking of symbols…
The hierarchy of “GUESSABILITY”
identical object
colored photograph
pencil
black and white photograph
pencil
Miniature object
colored line drawing
pencil
black and white line drawing
pencil
pencil
written word
What about signs? Advantages:
Easily shaped by the interventionist Sometimes very guessable Not an inhibitor to eventual speech
Disadvantages More transient than pictures Need an interpreter Difficult to form with motor issues
Tangible symbols for individualswith dual sensory impairmentsand cognitive issues
Context Size Light/dark contrast Smell Taste Sound Weight
WeightTemperatureTexture Movement Orientation Braille symbol Manual sign
By using functional symbols, you pack more stuff into someone’s conventionality suitcase!
CHOOSING A FIRST LEXICON
First lexical symbols should be …
• FUNCTIONAL
• LEARNABLE
• POWERFUL
What motivates this person?
Food?
Music?
Movement play?
Sensory input?
Looking at photos?
Water play?
Certain objects?
An animal?
Recurrence?
Termination?
Concrete nouns?
Action words?
GO!
Jump!
Fly!
The First Lexicon
Word classes/ Parts of Speech:
Nominal-specific – Mama, Mimi, Daddy Nominal-general – ball, cup, book Action words – go, up, ride Modifiers – big, yucky, dirty Personal-Social – No!, Hi!, Please Functional – This, what, where
Substantive Words/Fringe Vocabulary
Relational Words/Core Vocabulary
more
mine
this
no
all gone
Notice: These are difficult to picture!
that
there
big
up here
Social Vocabulary
thank you
bye
please
hi
What kinds of vocabulary words are conspicuous by their absence?
Word Combinations
Transitional utterances (12-18 mos.)2-element structures (18-24 mos.)3-element structures (24-30 mos.)4-element structures (30-36 mos.)
But length is not nearly as important as diversity of function!
TRAINING WHEELS
Signs
Visuals
When they’re no longer needed…
LITERACY
PICA BEHAVIOR…
Vigilance for Unconventional Communication
Try hard not to miss communicative attempts, as unusual as they may be!
EMOTIONAL CONNECTIONS
When intervention is accompanied by laughter and playfulness, new patterns of communication are established more easily in memory. Fear and anger also create strong memories, but it is not desirable to have these negative memories attached to communication patterns. (Morris, 1991)
Upping the Ante
What can the child do all by herself? What can she do if somebody helps? What can she NOT do right now, even with lots of help?
Keep the conversation going.
The more communication turns you can hook together, the better chance of improvement.
Never give up…giving up is the worst case scenario!
Unconventional Verbalizers
UNCONVENTIONALVERBAL BEHAVIOR
Just as all other characteristics of autism are on a spectrum, verbal behavior may be demonstrated in a variety of forms.
The important thing is to try to identify the communicative FUNCTION of the verbal behavior, no matter how unusual it seems.
Echolalia comes in many forms:
• Immediate – Pure• Immediate - Mitigated• Delayed – Pure• Delayed - Mitigated• Interactive• Non-interactive
And echolalia serves a large variety of communicative functions…sometimes several at once!
Sometimes verbal behavior is perseverative – what might this mean?
Incessant questioning is another very common unconventional verbal behavior. Possible causes include:• Anxiety about what will happen• Desire to maintain an interaction• Desire to control an interaction to ensure predictability• What about over-modeling of question forms?
How can interventionists identify the communicative functions of unusual utterances?
Even when verbal behavior is more generative, it can still be used in unconventional ways……one example is interrupting…
…another example is saying particular words at inappropriate times …
Remember: Our job is to help people add more strategies to their communicative repertoires, and to help facilitate the move from less conventional to more conventional communicative behavior.
Indirect Intervention when echolalia is being used…
Inform all team members about functions of echolalia Modify environment to avoid confusion Simplify language input to enhance comprehension Allow the child to take the lead often Model conventional, functional utterances Look for signs of mitigation
ModelingStrategies
Try NOT to model any verbalizations in the child’s presence (especially during crisis times) that you wouldn’t want to hear later…
Model a variety of communicative functions
Use the child’s perspective.
Use quiet carrier phrases for deictic terms
Direct Intervention when echolalia is being used…
Try to respond to the utterance’s intent.
Nonfocused: Clinician redirects attention by providing additional instruction about the activity
Clinician: (Holding straws) “Do you want a blue one?”Child: (Looking away) “Want a blue one?”Clinician: “Ben, here’s your straw. Let’s make our boat.”
Turn-taking: Clinician provides a demonstration that helps the child comprehend critical vocabulary
Clinician: “We need to stick it in the soap.”Child: (Looking at clinician) “Stick it in the soap”Clinician: “Watch, I’m going to stick the straw in the soap.”
Declarative: Clinician models an appropriate linguistic form to match the child’s expressed intent
Clinician: “We need the glue.”Child: (Reaches for glue) “Need the glue”Clinician: “Ben will get it.”
Rehearsal: Clinician confirms that the child’s participation is successful; a time delay is inserted to allow information processing
Clinician: “Let’s use a crayon to draw the eyes.”Child: (Chooses crayon) “Draw the eyes” (in a whisper)Clinician: (After a brief time delay) “That’s right, you’re making the eyes.”
Self-regulatory: After completion of the task, clinician confirms that the motor task is correct and successfully implemented
Clinician: “Now you have to cut the paper.”Child: (In a low intensity voice) “Cut paper. Cut paper.” (repeats as he continues to cut the paper)Clinician: (After completion) “Good job, look how you cut the paper.”
Yes-Answer: Clinician provides additional information relative to the conversational topic
Child: “What’s that?”Clinician: “That’s a paper cup.”Child: (Picks up cup) “A paper cup”Clinician: “We’re going to use the cup to make a flower.”
Request: Clinician complies with child’s request and provides a model for possible future use
Clinician: “What do you want?”Child: “What you want a cookie.”Clinician: “Ben would like a cookie.”
PERSEVERATION
PERSEVERATION
PERSEVERATION
PERSEVERATION
PERSEVERATION
PERSEVERATION
INCESSANT QUESTIONING
Facilitating Comprehension& Social Understanding
Cognitive Picture Rehearsal Social Stories Power Cards Child-Specific Books or Videos Schedules/Mini-schedules/Calendars Task Organizers People Locators Pre-Fab Social Skills Lessons
More Generative Verbalizers with ASD
Let’s talk about some people I know…
I correspond by email with a 27-year old man with autism…
He is verbal!
He is literate!
He has a high school diploma!
He is also unemployed…
…and he has no friends outside his family.
Also, I correspond by snail mail with a 40-ish woman with autism…
She is verbal!
She is literate!
She has a high school diploma!
She also has held a job for over 20 years…
In addition, she has many domestic and leisure skills, AND fulfilling relationships within and outside her family!
Knowing that a student with ASD is “more able” may be viewed as a mixed blessing…
…as one mother put it: “The good news is he’s high functioning, and the bad news is he’s high functioning!
Sometimes, professionals are “blinded by the strengths” of these students.
Higher functioning individuals with ASD tend to have strengths in language FORM…
…but relative weaknesses in language FUNCTION.
Put another way, they often possess grammatical competence…
…but not COMMUNICATIVE COMPETENCE!
Sometimes verbal students with ASD have communication difficulties that are much more subtle and more difficult to pinpoint and address in intervention.
Often, these students are denied services based on test scores that only reflect a measurement of language FORM.
A mother said, “My 9-year-old high-performing autistic son is in his public school’s gifted and talented program. He learned to read at 3 years and 5 months of age and read 26 phonics readers within the next month. On the other hand [he] has no imagination, and takes everything he hears literally. He is rigid and impulsive. He has frequent tantrums. He plays with his saliva a lot. He has no friends, due to his lack of social skills.”
We have some useful constructs for discussing communication issues in verbal students with ASD.
First, we can say that difficulties in the area of PRAGMATICS are common.
“Pragmatics” is sometimes defined as the social use of language.
Skills such as: responding to greetings turn-taking topic initiation topic maintenance and topic termination all fall under the pragmatics umbrella
We can also consider the types of speech acts that students with ASD may or may not use...Requesting
Protesting Commenting and/or
expressing opinionsNegotiatingCalling
Repairing
We can think about the ways that students with ASD apply the rules of discourse.
Neurotypical people follow the rules of discourse unless they have a good reason…
Rule 1 states that in conversation, people should say just enough to be appropriate…not too little, and not too much!
Rule 2 states that people should tell the truth, except in certain situations…
Rule 3 is that speakers should be relevant in what they contribute to a conversation.
Rule 4 states that speakers should make their contributions in ways that are easy for conversational partners to understand.
How do your students measure up to those conversational rules?
In addition, cognitive style differences greatly affect communication…
Some professionals believe that individuals with ASD lack a THEORY OF MIND (Baron-Cohen)…that is, they can’t understand that other people have their own plans, thoughts, and points of view.
This graphic shows a typical child with a functioning “theory of mind.” She is able to imagine what the other person is thinking.
Sometimes the inability to know the thoughts of others is described as MINDBLINDNESS.
Mindblindness makes it difficult to understand humor, fiction, figures of speech, white lies, sarcasm, and many other aspects of socialization.
…So people with ASD may appear “lost” in our social world.
The THEORY OF CENTRAL COHERENCE (Frith) is another way to describe the cognitive and learning differences of people with ASD.
It states that typical people have a natural tendency to draw together diverse information to construct higher level meaning in context – they can easily jump to the main idea of a story (or situation), and forget many minor details.
People with ASD will instead focus on tiny details, and not be able to comprehend the real meaning of the story or situation.
A helpful metaphor for central coherence is a large river. Imagine that within each typical person is a river of meaning, and each new piece of information that is learned ultimately seeks to become part of the large river.
People with ASD may acquire many bits of information, but they only form many tiny streams. They have difficulty getting these streams to join together to form a large river of meaning.
So…what do we have in our intervention toolkit?
1. We can promote competence in play.
”foster successful transactions in supportive contexts”
Effective interventionists arrange peer-rich situations and act as coaches or mediators, not directors.
One author stated: “The longer children with ASD are involved in play groups, the more difficult it becomes to tell them apart from their peers.”
2. We can teach game structure…
…and that it’s fun to win, but it’s okay to lose.
3. We can offer conversational role plays to practice application of learned strategies.
4. We can provide scripts that will work in common settings.
5. We can structure activities in the form of joint action routines.
6. We can think in terms of guided participation and partial participation.
7. We can work on expression and recognition of affect.
8. We can model appropriate gaze, but allow it to develop on its own!
9. We can promote literacy by providing/celebrating high interest reading materials and writing opportunities.
Remember…talking, listening, reading and writing are all part of the same “communication iceberg”
10. And the most important thing we can do is have high expectations !