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Slide 2 Nancy Brady University of Kansas nbrady@ku.edu http://www2.ku.edu/~lsi/research/profiles/brady_nancy.shtml Presented to Illinois Speech Language Hearing Association April 1, 2011 Slide 3 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 Slide 4 Gestures and vocalizations that precede speech in typically developing children Occur in a developmental order Slide 5 Why focus on describing, assessing and teaching these types of behaviors? Slide 6 There is great variability in the communication skills of prelinguistic children Prelinguistic = before children are speaking or signing or using another formal language system Slide 7 Perlocutionary = children communicate by crying or acting on objects. Others assign meaning to these behaviors. Slide 8 Next sections: Vocalizations Coordinated attention Gestures Slide 9 Crying and experimental sounds Slide 10 Crying and experimental sounds continued Raspberries Slide 11 Canonical babbling (reduplicated consonant vowel babbling) Slide 12 Variegated babbling (jargon babble) Slide 13 http://www.youtube.com/watch?v=- 5yIiGF8WGk. http://www.youtube.com/watch?v=- 5yIiGF8WGk. Slide 14 Crying Experimental Sounds (e.g., raspberries, noncanonical babbling) Canonical Babbling Variegated Babbling Speech Slide 15 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? Slide 16 3 month old: http://www.youtube.com/watch?v=KMbKlOL8q5s http://www.youtube.com/watch?v=KMbKlOL8q5s 9 month old: http://www.youtube.com/watch?v=Lr_CmHq2vog http://www.youtube.com/watch?v=Lr_CmHq2vog How old? http://www.youtube.com/watch?v=0r_H2kHREig http://www.youtube.com/watch?v=0r_H2kHREig Slide 17 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! Slide 18 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)? Slide 19 Slide 20 Slide 21 Slide 22 Slide 23 Differences in prelinguistic quality and quantity of vocalizations in children with Down syndrome Slide 24 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) Slide 25 Lots of variability Slide 26 Akajoint visual attention, line of visual regard, What is it and why is it important? Slide 27 Slide 28 Within routine, child is looking at object, then, intersect gaze Slide 29 Verbally prompt for eye gaze Specifically acknowledge the eye gaze Provide the desired object contingent on the eye gaze Slide 30 Bring toys up to face Slide 31 Step 1. obtain the childs 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 Slide 32 Illocutionary or purposeful gestures What is the function? Behavior regulation = imperative Joint attention = declarative Social interaction Slide 33 Crais et al. (2004) study Deictic vs. representaitonal Different functions Whats the developmental sequence? Slide 34 Contact gestures = gives, leading by the hand, showing. Gestures that are in direct contact with an object or person. Slide 35 Example of a contact gesture Slide 36 Distal gestures = points. The index finger is extended and other fingers are pulled back. The gesturer is not in direct contact with the referent. Slide 37 Slide 38 Example of a distal gesture Slide 39 Head nod and shake, shoulder shrug, open palm request Depictive gestures such as pantomimes Slide 40 Sometimes people combine gestures to convey complex meanings Gesture + vocal combinations Gesture + gesture combinations Gesture + word combinations Slide 41 Examples of children combining 2 or more gestures Slide 42 Prelinguistic Stages PerlocutionaryContact gesture+ Perlocutionary Distal gesture+ Contact gesture+ Perlocutionary Other conventional+ Distal gesture+ Contact gesture+ Perlocutionary Slide 43 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? Slide 44 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 Slide 45 Form and function Individuals with intellectual disabilities who only communicate with contact gestures rarely communicate joint attention (comments). Slide 46 Lack of joint attention- example of boy with autism Slide 47 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) Slide 48 Example of person pointing in a joint attention task. Slide 49 Slide 50 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) Slide 51 Example of low rate communicator Slide 52 Example of high rate communicator Slide 53 Children who use only contact gestures try to repair communication breakdown less often than children who use more advanced gestures Slide 54 Input How do children respond to gestures? Respond to joint attention Disambiguate messages Slide 55 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/monthor 167 word advantage by age 2 Slide 56 Differences in gesture type associated with differences in: Communication functions (requests, comments) Frequency of communication Repairs of communication breakdowns Slide 57 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 Slide 58 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 Slide 59 Assessment strategies for prelinguistic individuals Intervention strategies for prelinguistic individuals Increasing parent and peer responsivity Teaching joint attention Slide 60 Standardized assessments are not very helpful Need to determine how a child is communicating across environments Slide 61 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 Slide 62 Parent/Caregiver Questionnaires Direct Observation Assessment Protocols Slide 63 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 Slide 64 Examples of Questionnaires What do you use? Slide 65 Good contexts to observe in Contexts indicated by the questionnaire as showing high probability of communication Meal or snack time Contexts for vocalizations? Slide 66 Slide 67 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? Slide 68 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 Slide 69 Adaptations for older participants Slide 70 Assessment protocols have been used in research by Dr. Brady and colleagues to study Initiations Requests and Comments Responses to Communication Breakdowns Slide 71 Example of child initiation Slide 72 Example of repair protocol item Slide 73 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 Slide 74 The Communication Complexity Scale = CCS Example from current research by Brady & Thiemann-Bourque Slide 75 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 childs line of vision) Slide 76 Slide 77 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 Slide 78 6a- triadic eye gaze 6b- dual focus + 1 PCB 7- triadic eye gaze + 1 PCB 8- triadic plus more than 1 PCB Slide 79 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 Slide 80 How would you score the following example: Example for a boy that uses lots of different forms!! Slide 81 Average of the three highest forms observed Can average within each function (joint attention; behavior regulation) Slide 82 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 Slide 83 Summarize information regarding: Communication forms Functions Frequency/rate of communication Stage of prelinguistic development Initiations/responses/repairs Contexts Motivation Slide 84 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 Slide 85 Create contexts where children communicate naturally Follow the childs lead but address specific communicative targets Use the least intrusive prompts necessary to promote communication targets Slide 86 Increase the frequency and complexity of requests and comments For both of these goals the first step is to build routines Slide 87 Theoretical reasons Occur developmentally before symbolic communication Thought to pave the way for symbolic communication Provide opportunities for linguistic input Slide 88 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 Slide 89 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 doesnt know sign Slide 90 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. Slide 91 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 Slide 92 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 Slide 93 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 childs play skills Slide 94 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 Slide 95 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 http://www.youtube.com/watch?v=eR01qlXQ63g Slide 96 Step 6: continue the routine/activity. This reinforces the childs behavior. General pointers Shorter routines provide more opportunities for communication Change activities when child just begins to lose interest Slide 97 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 Slide 98 Vocal play Imitation Slide 99 use sounds within childs repertoire Slide 100 Verbally prompt for vocalizations Specifically acknowledge vocalizations Slide 101 Vocalization + eye gaze + gesture = a clear, recognizable communication act! Slide 102 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 Slide 103 Immediately after the child produces the targeted component (eye gaze, vocalization or gesture), provide the appropriate consequence and verbal feedback Slide 104 Children with Down syndrome Children with autism Children with fragile X syndrome Children with multiple disabilities Children learning AAC Slide 105 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 Slide 106 Slide 107 Slide 108 Slide 109 Slide 110 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 Slide 111 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 Slide 112 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 Slide 113 Research isnt 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 Slide 114 How can AAC complement prelinguistic interventions? How can prelinguistic interventions complement AAC? Slide 115 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 Slide 116 child who is slow to acquire natural gestures and vocalizations Slide 117 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 Slide 118 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 Slide 119 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 Slide 120 Brady and Bashinski (2009) research with deafblind children Results from 9 children who had relatively good motor skills 2 children with severe motor limitations Slide 121 Slide 122 Slide 123 Slide 124 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 Slide 125 Slide 126 Working with partners to increase responsiveness and decrease directiveness Goal is to promote a context where children have a need and desire to communicate Slide 127 Increase communication Play Social interactions Slide 128 Video demonstrating need Slide 129 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. Slide 130 It is very hard to change a persons 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. Slide 131 Work with partner to increase: following the childs 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 childs actions. Imitate the childs actions and sounds. commenting about childs actions, etc. Slide 132 Discussion of topics covered in reading; direct instruction General sensitivity to parent issues of all kinds Parent observation of intervention sessions Slide 133 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 childs lead providing simplified input Slide 134 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 Slide 135 Slide 136 Slide 137 Slide 138 Slide 139 Top 3 suggestions. Slide 140 Observation and discussion of video-taped parent-child interactions Coaching regarding use of techniques Brainstorming about the use of responsivity techniques in typical situations Slide 141 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. Slide 142 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. Mothers Name_____________________ Childs Name ______________________ Should be Skill is Skill is Targeted Emerging Mastered How would you rate your skills in responding to your childs communication in the areas of Responding to Gestures Responding to Vocal Initiations Responding to Verbal Initiations (Words, Signs) Following Your Childs Focus Within Activity Slide 143 Need to work with partners and children Should parents learn intervention strategies, or to be facilitative? Need to measure changes in partners and children Slide 144 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. Slide 145 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. Slide 146 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. Slide 147 The national Fragile x foundation: http://www.fragilex.org/html/home.shtml http://www.fragilex.org/html/home.shtml Down syndrome research: http://dsresearch.stanford.edu/ http://dsresearch.stanford.edu/