functional communication intervention for individuals with developmental disabilities

Functional Communication Intervention

for Individuals with Developmental Disabilities

Lillian N. Stiegler, Ph.D., CCC-SLPlstiegler@selu.edu

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 !