Meet Sean. Sean is 3 years old and transitioning out of Early Intervention into Early Childhood. I have had the pleasure of working with Sean and his family for the past 4 months. Sean has a medical diagnosis of autism spectrum disorder. He also has complex communication needs. He displays full body dyspraxia when initiating many activities of daily living, and generally needs full physical prompting to follow single step directions. Sean also demonstrates many sensory seeking behaviors in order to satisfy his oral motor and movement needs.
Initially when I began working with Sean 4 months ago, I knew that Sean was a smart little boy who didn’t have a functional means to communicate. Sean’s complex needs, especially his sensory needs, impacted his ability to understand how to communicate and to use speech effectively to communicate his wants and needs. It’s important to recognize that having complex communication needs does not imply that one cannot learn language.
Unfortunately, there are many people that believe this misconception, and many therapists find themselves up against other professionals who I like to call “naysayers.” These “naysayers” are people who think that “because children with complex communication needs learn language differently, the focus of therapy should be nouns or pre-stored phrases”. Yikes!! That’s a scary thought. As a speech-language pathologist, my training tells me that language is comprised of many different types of words (verbs, pronouns, prepositions, demonstratives, etc.), and it’s my job to work on all parts of language.
Sean is a great example of an individual who deserves access to a communication system which can help teach him these parts of language! He needs access to core vocabulary words, the words that account for 80% of what we say in natural conversation. Sean has complex communication needs, but this doesn’t limit his right to learn language just like any other child. It means that Sean may learn differently and may need an augmentative means to help him communicate.
After meeting Sean, I started my therapy using the same methods that his other therapists were using, sign language. Sign language is a great no-tech AAC method which facilitates communication for many individuals; however, for some children who lack imitation skills or who are prompt dependent, sign language may not be the most efficient tool for spontaneous communication. Because of their motor complexity, signs are not readily taught. While manual prompts can be used to teach a few initial signs, a lack of imitative ability will preclude the acquisition of an extensive repertoire (Schuler and Baldwin 1981). For Sean, signs like “more” and “all done” had been modeled for months by multiple communication partners, but no progress had been made. To initiate a sign, full physical prompting was needed to teach the motor plan for his fingers and body movements, and Sean did not initiate any communicative interactions with sign. Additionally, it was evident that Sean didn’t understand how to communicate. He didn’t demonstrate receptive or expressive joint attention, and didn’t orient (turn his body) to a communication partner to express a message. His communication consisted primarily of vocalizations to indicate displeasure, smiling and laughing, and physical means of communication (hand dragging or hitting an object/container). At times, Sean demonstrated some “lost words,” where he would repeat a word like “off” or “yellow,” but these words were usually used once and weren’t directed at a person.
Overall, Sean couldn’t express his wants, needs, preferences or ideas. I decided to introduce CVES™ to target skills such as how to communicate, reciprocal interactions, increasing understanding of spoken language, and communicating spontaneously at the single word level. I also focused on incorporating his favorite things into therapy (Be sure to check back for a future post about nouns and personal core!). My five areas of focus became:
- Take advantage of naturally occurring/routine opportunities throughout Sean’s day/daily routines
- Set-up/engineer Sean’s environment with opportunities
- Provide a communication system which allows for teaching of functional communication skills: CVES™
- Teach Core Words while teaching single meaning noun items
- Use Motivators and Reinforcers to drive learning
I began by working with Sean’s mom and talking a lot about activities that were motivating for Sean. Motivating activities, or “reinforcers,” can often be a starting place in therapy. These words should be added to a child’s CVES™ communication binder. What items did Sean always love no matter what? What items did Sean like sometimes? These were important noun words which should be added to his system (cheetos, barbecue chips, teddy grahams, ipad, bubbles, puzzle pieces). I also looked at which core words would be reinforcing for Sean in activities and throughout his day? We started with: open eat, drink, up, help, more, all done, go, out.
When looking at choosing a core vocabulary foldout for Sean, I primarily looked at his access and fine motor skills.
What size icon can Sean pick up?
I compared the icon sizes in each series, the Emergent (large icons), Intermediate (medium icons), and advanced (small icons). Sean was able to pick up icons in the Intermediate series, which contains medium icons. Based upon input from Sean’s developmental therapist and Sean’s mom, we selected the Intermediate (Medium) Gate Fold, which contains 65 total icons. We then added his favorite noun words to inserts in his communication binder so that he would have access to both core words and noun words (fringe vocabulary).
By giving Sean access to 65 different core vocabulary words, we were able to target a lot of language! One area we worked on was replacing physical hand over hand prompting for sign language with a core word. During highly preferred activities, we modeled the word “open.”
We also set Sean up for success by engineering his environment for opportunities for communication. For example, Sean’s mom began to designate locations and containers for favorite items. This has now become an opportunity for Sean to work on how to communicate (exchanging a core vocabulary icon as a message to a communication partner), as well as an opportunity for generalization of the core word “open” across multiple activities.
Other opportunities for Sean were routine activities which happened every day or several times throughout the day. For example, all of Sean’s favorite snacks are kept in the kitchen cabinet. Sean’s mom can now model the word “open” when opening the cabinet to get out his favorite foods.
Goals for Sean are both receptive and expressive language goals. We are targeting his understanding of language as well as his use of language. For example, we may target receptive joint attention and increased understanding when we are modeling words. “When communication partner uses aided language input to model a core word (i.e. open), Sean will respond by turning his body or head, looking at the communication icon, touching or grabbing the icon, or eyegaze shifting between the icon and the communication partner.” Alternatively, we have expressive goals for Sean. “Sean will request action by removing the icon “open” or “help” from the core vocabulary foldout, reach to a communication partner, and release it into their hand given most to least prompting as needed.” Depending upon the needs of the child, goals and prompting can be adjusted depending upon amount of support needed, a child’s motoric access, and current communication abilities.
Where is Sean now? Sean continues to work on functional communication skills, and is working on removing icons directly from the core vocabulary foldout (insert link). Taking single icons off of the foldout is the most efficient means for Sean right now as he learns how to communicate with pictures. During times when he becomes frustrated, a single core word can be pulled off and handed to a communication partner to indicate “help” or “finished.”. As we move forward in therapy, we will continue to generalize the words he is learning across environments and contexts, and will begin to use the core communication card to expand his utterances.
Check back for future blog posts about functional communication and communicative intent, personal core, reinforcers, and MORE!