No more “More” : A Response to “In Defence of More”

No More “More:” A response to In Defense of “More”—10 Reasons I Still Teach the Sign More First 

By Tracy Vail, MS, CCC-SLP, Autism Consultant and Heather Forbes, MA, CCC-SLP, BCBA

 

There is currently a great deal of debate in the field of speech-language pathology about the kinds of words that should be taught first to nonverbal (or minimally verbal) individuals with communication impairments. This debate mainly surrounds whether interventionists should first teach a broad range of specific, concrete words or a small set of abstract words that can be used across items and environments. Clinical decisions like choosing first words should not be made randomly or based on practitioner preference. Important factors to consider include the values of the learner, his/her family, and community as well as and evidence from high quality research. A third critical factor to consider is the nature of the communication disorder itself. What are the baseline skills (and missing skills) of the individual we are trying to teach? No diagnosis highlights the importance of this third factor more than autism spectrum disorder (ASD). As a well-known saying jests: “If you’ve met one child with autism, you’ve met one child with autism.” ASD presents with high variability both across children and within children, as children with autism may not develop skill sets in the same sequences as peers (Sundberg, Galbraith, & Miklos, 2007). However, the paramount deficits across children diagnosed with ASD are in social communication and social interaction—what SLPs would typically call pragmatic language (American Psychiatric Association, 2013). For instance, a child with autism may learn to say many things, but those utterances may simply be scripted from a favorite TV show and have no communicative purpose at all. Or a child with autism might learn to label many things in his/her environment, but the child might not know how to ask for those same items when he/she wants them. Therefore, when analyzing factor three, we cannot simply look at the forms of the skills missing in a child’s repertoire—especially for children with ASD. We must also observe whether or not the child has all of the foundational skills necessary to use the target skill effectively across all relevant social contexts. Laura Mize, a pediatric speech-language pathologist, wrote a blog entitled In Defense of More—10 Reasons I Still Teach the Sign “More” First. The purpose of the blog was to support the continued teaching of the sign “more” as a first word to children receiving speech and language intervention. To that end, we will consider each point highlighted in Ms. Mize’s blog and specify why her rationale may not be validated by research or applicable to many children with communication impairments, especially those with ASD. This response is not meant as a personal attack against Ms. Mize, as we have read her blogs and feel that she has made important contributions to the field of speech-language pathology. Rather, this response is one way—in the age of “electronic conversations”—for offering a different viewpoint.

1. “The sign for ‘more’ is easy.” Ms. Mize claimed that the sign for “more” (i.e., signing “o” with both hands converging at midline) is a relatively easy motor movement and relatively easy for the clinician to physically prompt. While the sign “more” may be easy in comparison to more complex signs, research does not support “more” being the easiest sign to emit. In fact, there are earlier-developing motor movements than those required by the sign “more.” Bonvillian and Siedlecki (1998) noted that movements involving hands on either side of the body occur before converging hands together, bringing hands in contact with a broad surface (e.g., torso, leg) occurs before bringing hands in contact with a narrow surface (e.g., fingertips), and the hand movements involved in holding up five fingers, pointing with the index finger, and signing “b” or “a” all occur before the hand movements involved in signing “o.” In other words, there are many other signs available to clinicians that may both be easier to prompt and easier for children to physically produce than “more.” Furthermore, given that many early signs in typically-developing infants and toddlers are approximations (Bonvillian & Siedlecki, 1998), it seems feasible that clinicians can teach modified forms of even complex signs initially, and shape complexity as the child’s motor skills improve. All-in-all, the sign for “more” might be easy, but research does not support that it is by any means the easiest.

2. “The sign for ‘more’ is fast.” Here, Ms. Mize was referring to both speed of acquisition and speed of emission of the sign. Her argument for rate of acquisition was related to her first point—easily prompted and easily produced motor movements will be acquired faster. Because she relates those arguments, we encourage the reader to please see the response above negating the relative simplicity of “more” in comparison to other signs. Regarding the ability to emit “more” quickly, we would argue the relevance of this point. We could find no research to support that “more” is the speediest sign to emit. Nearly all signs can be emitted equally as quickly. Furthermore, let us consider what might be the advantages of emitting a sign quickly. Ms. Mize (correctly) pointed out that the quicker the sign is emitted, the quicker the child gets what he/she wants. This is exactly where a sign for “more” fails— particularly in the ASD population. When the average person says or signs “more,” it is only under the conditions in which he/she already had something and the listener knows what, in fact, he/she wants more of. The irony (and danger) of teaching the sign for “more” first is that the child has not been taught to request the original item he/she desires! Most typically- developing children who use “more” have other skills such as leading, pointing, and even speech—all of which they can use to communicate desired items to their listeners (Bates et al., 1994; Tardif, Fletcher, Liang, Zhang, & Kaciroti, 2008). But some studies show that early social communication skills such as “pointing” are lacking more often in the ASD population when compared to both typically-developing children (Osterling & Dawson, 1994) and children with developmental delays and language impairments (Stone, Ousley, Yoder, Hogan, & Hepburn, 1997). When these and other skills are lacking, teaching the sign “more” first can actually slow access to reinforcement, since signing “more” does not indicate to caregivers exactly what the child wants. Even when the child can lead and point, reinforcement is often more delayed than if the child said or signed the name for the specific item right away, since pointing alone is not always effective. (Consider if a desired item is in a high or well-stocked cabinet.) For these reasons, research demonstrates that training a child to ask for specific items actually reduces problem behavior better than generalized signs like “more” (Kahng, Hedrickson, & Vu, 2000).

3. “The sign for more is popular.” While many listeners might know the sign for “more,” as indicated above, knowing that a child wants something does not specify to that listener exactly what the child wants. Furthermore, this point is only relevant if it is conversely difficult to teach listeners other signs at the rate in which the child is learning them. This is almost never the case. It typically takes little more effort than telling listeners what to do one time before they learn how to appropriately respond to specific signs of early communicators. Certainly, competent adults should be able to learn a sign just as quickly if not quicker than the learners we are trying to teach. Even siblings and peers can learn signs fairly quickly and easily. In fact, typically-developing infants as young as 8.5 months have learned to sign and respond to sign without explicit teaching (Bonvillian, Orlansky, & Novack, 1983). If clinicians cannot speak to family members and members of the community in-person, it is also quite easy nowadays to snap a picture or video of a child’s sign and send it via an e-mail/text, or print it out to hang on a ring. Given the downfalls explained above of teaching the sign for “more” first, clinicians are cautioned about making decisions about best practice based mainly on what is easiest for the clinician. Program decisions should by and large be based on what is best for the child.

4. “The sign for ‘more’ is functional” Ms. Mize defined the term “functional” as “[enabling] you to ‘function’ better and more consistently in everyday life.” Given this definition, in our 43 years of combined practice, we have not encountered a less functional word to teach first than “more”—particularly for a child with ASD. Yes, many toddlers say “more juice” or “more cookie.” Some might even just say “more.” However, as indicated above, typically-developing and even some language delayed children have existing communication skills that allow them to discriminate that they only use “more” when they have already had some of something (and their listeners know exactly what they want). Tardif et al. (2008) analyzed the first 20 words to develop in a sample of 865 children in the United States (n=264), Bejing (n=367), and Hong Kong (n=336). “More” did not show up on any of the lists for any of the languages studied. Bates et al. (1994) analyzed language development in 1,803 infants. They found that “closed-class words” (including quantifiers like “more”) did not appear in the children’s vocabularies until they developed at least a 50-word vocabulary of specific nouns and verbs. It appears to be conceptually, developmentally, and functionally problematic to teach a child to ask for “more” of something before he/she can ask for the thing itself. Let’s consider an example in which an interventionist taught a child to sign “more” in a therapy session in order to be bounced on the therapist’s knee, to receive a snack of crackers, to get a drink of water, to be rolled on a scooter, and to get the therapist to blow bubbles. Let’s say that interventionist even communicated to the child’s parent what the child was taught that day (as a good interventionist should). What happens when the child goes home and spontaneously signs “more” to his/her parent without any other clues? Will the parent immediately know what the child wants? Is the sign really enabling the child to “’function’ better and more consistently in everyday life?” For communication to be functional, it has to be clear to both the speaker and the listener. This is often not the case with “more.”

5. “The sign for ‘more’ is multi-purpose.” In her blog, Ms. Mize encouraged that the sign for “more” be introduced “for lots of things the child might want—snacks, toys, activities.” She indicated that introducing “more” in this way makes the sign “multi-purpose.” However, when the sign for “more” is taught to access everything a child might want, we would argue that it only has one purpose: to inform adults that the child wants something. Teaching “more” as a single-purpose request like this can be a problem—and not just because it can lead to problem behavior as indicated above (Kahng et al., 2000). Ms. Mize encouraged parents to begin fading in new signs only after the child has learned to use the sign “more” “in many contexts, for many reasons throughout the child’s day.” Unfortunately, research shows that behaviors become more resistant to change if they are strongly practiced initially, followed by variable practice later (Cooper, Heron, & Heward, 2007). In other words, evidence shows it may be more difficult to introduce specific signs if a single- purpose sign like “more” is taught first than if specific signs were taught from the beginning. Ms. Mize acknowledged that children sometimes “get stuck” if they are taught the sign for “more,” but she implied the reason for “getting stuck” was the failure of adults to “move the child along to other signs after learning the sign for ‘more.’” We would argue that a child “getting stuck” has less to do with the failure of adults to move on and more to do with the nature of teaching a single-purpose sign like “more” first. Children “get stuck” because the laws of behavior take effect, whether or not adults are aware of them. A second problem with teaching a single-purpose sign like “more” first is the child does not receive the benefits that research shows come with teaching specific signs. In fact, evidence shows that teaching specific signs to request specific things can actually support the development of other skills, including using those signs in other appropriate social- communicative contexts (Arntzen & Almaz, 2002; Drash, High, & Tudor, 1999).

6. “The word ‘more’ is easy to say.” We agree with Ms. Mize that a spoken approximation of “more” is easy for early communicators to say. However, for that matter, any combination of early developing sounds (e.g., “bah” for ball) is going to be just as easy for a child to say as “more.” The problem is, if the clinician or parent is just teaching one sound combination, he/she has missed out on the opportunity to teach many other sound and syllable combinations. Research shows that sign training combined with speech training can increase vocalizations better than speech training alone (Barrera, Lobato-Barrera, & Sulzer-Azaroff, 1980; Barrera & Sulzer-Azaroff, 1983; Carbone et al., 2006; Carbone & Sweeny-Kerwin, 2010). Sundberg and Partington (1998) offered an explanation for this advantage of sign-plus-speech training: “Once the motor movements are learned, specific vocalizations can be matched with [specific] signs. This sign-vocalization prompt can help…a child to prompt his own vocalizations (p. 77).” In other words, when the specific motor movements of signs are matched with the specific motor movements of speech, the sign acts as a “built-in” prompt for speech. This unique process can only occur if the clinician is teaching more than one sign at a time.

7. “The word ‘more’ is evidence based.” Ms. Mize referenced a 2011 study at Bryn Mawr College that listed 25 words that 2-year-olds should know—one of which was “more.” While a list of words known by most typically- developing 2-year-olds may be interesting, this kind of list in no way supports teaching the sign for “more” first. Typically-developing 2-year-olds have many, many more communication skills than simply saying or signing the word “more,” including a minimum of a 50-word vocabulary (Bates et al., 1994). It does not seem to be sound clinical judgement to imply that a child with communication skills of a nonverbal infant should immediately start working on skills at the level of a typically-developing 2-year-old, especially when research shows that words like “more” are likely not among the first to develop in the general population (Bates et al., 1994; Tardif et al., 2008).

8. “AAC experts include ‘more’ as a first option for pictures systems and speech-generating devices too.” A child learning to push a button that says “more” for everything he/she wants can have the same detrimental effects as saying or signing “more.” In addition, if the practitioner is not careful to teach the child with an AAC device to approach a listener, the end result may be a child sitting in the corner by himself/herself pushing many buttons, including “more.” We have seen such situations in action, and instead of analyzing problems with teaching procedures, the “AAC experts” claimed these children were not “ready” for an AAC device. Being titled an “expert” does not inherently make a professional correct in his/her clinical decisions. An argument from authority tends to be an empty argument if that “expert” cannot back his/her claims with sound evidence and analysis.

9. “Asking for ‘more’ is an early form of requesting and requesting is one of the earliest pragmatic functions to develop.” Here we wholeheartedly agree with Ms. Mize that requesting is one of the earliest (and most important) functions of communication to develop. Early language training should be filled with teaching the child to request! We also wholeheartedly agree with Ms. Mize’s statement that “signing is more complex and more purposeful than other less-mature forms of requesting such as when a younger baby uses crying or reaching.” But where we strongly disagree with Ms. Mize is in her decision to teach “more” as a first signed request—particularly in the ASD population. In fact, we do not believe that “more” should be taught at any point in the single word stage until the child can request many specific things (through sign and/or speech). Research does not only link the practices we recommend with fewer problem behaviors, but these practices also more closely follow the developmental sequences of typically-developing children. Some of the evidence supporting our clinical decision-making has already been elaborated above (e.g., Arntzen & Almaz, 2002; Barrera et al., 1980; Barrera & Sulzer-Azaroff, 1983; Bates et al., 1994; Carbone et al., 2006; Carbone & Sweeny-Kerwin, 2010; Drash et al., 1999; Kahng et al., 2000; Sundberg & Partington; 1998; Tardif et al., 2008).

10. “I’ve seen success with the sign.” We have no doubt that this is true. If one were to work only in early intervention, we are sure it would be easy to assume that the teaching of abstract vocabulary is working because the child using it. The problem is that we often see these same children when they are 5, 6, 7, 8 years old and beyond—when they are banging their heads against the wall, pounding their knees to their heads, and falling on the floor because they have no functional way of getting their specific needs met. Their parents often report to us that they “tried signs” and that signs “don’t work” for their child. When probed, we have come to find that the signs they “tried” were single- purpose signs like “more, please, and want.” The literature shows these signs were likely ineffective because they never resulted in the child immediately getting the specific things he/she wanted. On the topic of overgeneralization: We do not feel that it is fair or accurate to equate teaching a child “more” in the way that Ms. Mize described with overgeneralization seen in the typically-developing population. First, when we traditionally talk about overgeneralization, we are typically referring to a process that occurs when a child erroneously emits a previously-learned (specific) word in the context of an item that shares a similar physical property/use. Hence, as Ms. Mize noted, “many babies call every man they see ‘Daddy,’ every round object ‘ball,’ and all four-legged animals ‘doggie.’” But, past the crying and reaching stage, we have never heard of any typically-developing child call everything he/she wanted by the same name—solely based on the property of “wanting.” This likely does not happen because science shows “wanting” does not affect our communication and other behaviors in the same ways as physical properties (Cooperet al., 2007). Second, when typical children erroneously overgeneralize, they are often immediately corrected by an adult. If a toddler sees a cow and shouts “Doggie!,” his/her parent is likely to say something like, “I see! It’s a cow!” You cannot compare this process to an instructor deliberately choosing to teach a child only one name for a countless number items he/she might want. In the latter case, the clinician has purposely instructed a child to use “more” erroneously under a context in which typically-developing children do not error, and then (rather than gently correcting the child) the clinician reinforces the error. Teaching the sign “more” is not an accidental mishap; it is calculated. The lack of clarity from the adults in the environment, the ensuing maladaptive behaviors, the difficulties of teaching new signs after teaching “more,” and the total breakdown in communication can all be avoided by teaching clear, concrete requests for a child’s favorite things right away. Abstract language such as “more, please, yes/no, want” makes it difficult for a child to communicate independently and a challenge for those in the environment to reinforce. Teaching effective communication is the least we can do for these children who already have so many struggles to overcome.

 

References:

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5 th ed.). Arlington, VA: American Psychiatric Publishing. Arntzen, E., & Almas, I. K. (2002). Effects of mand-tact versus tact-only training in the acquisition of tacts. Journal of Applied Behavior Analysis, 35, 419-422. Barrera, L. D., Lobato-Barrera, D, & Sulzer-Azaroff, B. (1980). A simultaneous treatment comparison of three expressive language training programs with a mute autistic child. Journal of Autism and Developmental Disorders, 10, 21-37. Barrera, L. D., & Sulzer-Azaroff, B. (1983). An alternating treatment comparison of oral and total communication training programs with echolalic autistic children. Journal of Applied Behavior Analysis, 16, 379-394 Bates, E., Marchman, V., Thal, D., Fenson, L., Dale, P., Reznick, J. S., Reilly, J., & Harting, J. (1994). Developmental and stylistic variation in the composition of early vocabulary. Journal of Child Language, 21, 85-123. Bonvillian, J. D., & Siedlecki, T. (1998). Young children’s acquisition of the movement aspects in American Sign Language. JSLHR, 41, 588-602. Bonvillian, J. D., Orlansky, M. D., & Novak, L. L. (1983). Developmental milestones: Sign acquisition and motor development. Child Development, 54, 1435-1445. Carbone, V. J., Lewis, L., Sweeny-Kerwin, E. J., Dixon, J., Louden, R., & Quinn, S. (2006). A comparison of two approaches for teaching VB functions: Total communication vs. vocal-alone. SLP-ABA, 1, 181-192. Carbone, V. J., & Sweeny-Kerwin, E. J. (2010). Increasing the vocal responses of children with autism and developmental disabilities using manual sign mand training and prompt delay. Journal of Applied Behavior Analysis, 43, 705-709. Cooper, J. O., Heron, T. E., & Heward, W. L. (2007). Applied behavior analysis (2 nd ed.). Upper Saddle River, NJ: Pearson Education, Inc. Drash, P. W., High, R. L., & Tudor, R. M. (1999). Using mand training to establish an echoic repertoire in young children with autism. The Analysis of Verbal Behavior, 16, 29-44. Kahng, S. W., Hendrickson, D. J., & Vu, C. P. (2000). Comparison of single and multiple functional communication training responses for the treatment of problem behavior. Journal of Applied Behavior Analysis, 33, 321-324. Mize, L. (2014, September 2). In defense of “more”—10 reasons I still teach the sign more first. Retrieved from http://teachmetotalk.com/2014/09/02/defense-10-reasons-still-teach-sign- first/. Osterling, J., & Dawson, G. (1994). Early recognition of children with autism: A study of first birthday home videotapes. Journal of Autism and Developmental Disorders, 24, 247-257. Stone, W. L., Ousley, O. Y., Yoder, P. J., Hogan, K. L., & Hepburn, S. L. (1997). Nonverbal communication in two- and three-year-old children with autism. Journal of Autism and Developmental Disorders, 27, 677-696. Sundberg, M. L., Galbraith, W. A, & Miklos, M. (2007). The Verbal Behavior Milestones Assessment and Placement Programm (VB-MAPP) [PowerPoint slides]. Sundberg, M. L., & Partington, J. W. (1998). Teaching language to children with autism or other developmental disabilities. Pleasant Hills, CA: Behavior Analysts, Inc. Tardif, T., Fletcher, P., Liang, W., Zhang, Z., & Kaciroti, N. (2008). Baby’s first 10 words. Developmental Psychology, 44, 929-938

What is Parent Training?

Parent training refers to involving the parents or caregivers in their child’s learning of new skills. At Aspire parent training is a cornerstone of our intervention programs. Not only in our early intensive programs but also our consultancy programs once children go to school

Some parents think that the cost of parent training would be better spent on more intensive therapy or providing more hours for your child. The evidence actually shows the opposite. As you will be your child’s parents forever it is crucial for you to know;

  • What we do
  • How we do it
  • And most importantly why we do things

As you receive services from us or other providers for a few years, it is important for me as a behaviour analyst that I teach you the skills to not only teach your child new skills but for many children with ASD to prevent problem behaviours occurring in the first place and if they do start occurring for you to figure out as soon as possible why they occur so we can nip them in the bud before those problematic behaviours become habitual.

Parent training doesn’t have to be difficult or time consuming. As a parent you can ask your behaviour technician at the end of each session to go through some data and behavioural concerns with you. If you’re a program manager, BCaBA or BCBA you could schedule weekly meetings or telephone consultations with the families to discuss their child’s programs. When it comes to ABA, parental involvement is key.

Research has consistently shown that when parents are involved in the ABA therapy process, and understand what, how and why a skill is taught and are shown how to do this yourself, the outcomes are more positive. ABA just isn’t as effective without a team approach. If the new skills that behaviour technicians teach your child are not reinforced, maintained and generalized by the family, then one of two things will happen; your child may lose the skill, OR your child will only display the skill for the therapist. For example, a child who uses PECS or vocal requests with a behaviour technician, but leads their dad by the arm and grunts. Or a child who is toilet trained at school, but wets their underwear when they are at home or at their grandparents. Partial success only when the therapist is around isn’t real success at all.

Parents and primary caregivers need to know and understand the therapy goals, behaviour reduction plans, and strategies so well that in the absence of therapeutic intervention you could independently work on and generalise these skills and manage problem behaviours. That is the degree of involvement we are shooting for.

Empirical support for parent training

A recent study by the Chicago Children’s Clinic found that providing parents with training in established treatments is a necessary component and essential component for children with autism to make and maintain skills. Parents in the Chicago study received 25 hours of training and in one case only 6 hours learning key skills to help their children with autism made significant improvement.

With permission I share a video of one of our little boys (6 years) who at intake presented with no functional communication though had some echoic skills. He had poor attending and concentration skills, he was unable to sit down and complete simple tasks (puzzle or other simple close ended activities) unless presented with highly preferred items such as food or ipad.

The parent (who you see in the video) received a total of 9 hours training in basic behavioural principles. Aside from attending a classroom for children with special needs (10:2) he did not receive any other form of intervention or therapy. This video was taped about 10 weeks after the 8 hours of parent training were delivered.

Processing a diagnosis

Starting a program for your child can feel like a daunting and intimidating process, on top of coming to terms with the fact your child has been given a diagnosis. Every parent as part of a natural process will experience the stages of grief – shock, denial, anger, depression, bargaining and at some point, in an ideal world acceptance. Every family we meet is at a different stage in their journey of processing their response to their child’s diagnosis. We aim to walk alongside parents, meet them where they are at but equip and empower them to feel strong enough to support their child in meeting their goals, and working towards their success.

Ultimately if our parents are showing signs of stress, not coping, or burn out we aim to provide more intensive support as if our parents burns out, then everything breaks down!

Signs you might need further support

  • Feeling consistently low over a prolonged period of time
  • Feeling consistently irritable and liable to snap
  • Uncontrolled crying
  • Changes in appetite and sleeping pattern
  • Anger towards your child or others for no particular reason
  • Feeling helpless or hopeless

If a parent identifies with 2 or more of these indicators, it might be time to seek some additional support. Having a space for yourself to be able to talk about how you feel, process your emotions and develop your own coping strategies can go a long way in improving life.

Factors that help parents to thrive in a time of challenge

  • Having a strong support network
  • Using self care strategies, eg, consistent exercise and sleep routine
  • A ‘can do’ attitude – parents who are able to in the face of a challenge grit their teeth, and say, let’s do this are those who can jump on board with us and collaborate with their child’s therapist which leads to better outcomes for our children
  • Sense of mastery in their own life – As integral as having children is in the life of parents, having additional interests and commitment that help to foster fulfillment and mastery in a parents life can help to provide balance and purpose in a world that can often feel unbalanced.
  • Asking for help – parents who are able to ask for help and accept it are those who go on to thrive. None of us were created to be islands, and it is our parents who can access the supports that they need in times of challenge who go on to survive and thrive in the future.

Behavioural Skills Training

What is Behavioural Skills Training (BST)?

Behavioural skills training is a 4 step approach we use in almost every session we have with our parents and therapists. It is a simple sequential tool that can teach skills in bitesize pieces and as immediate feedback is provided it can help to teach and shape behaviour very quickly and practically through modeling and rehearsal.

Dr. Miltenberger defines BST as “a procedure consisting of instruction, modeling, behavioral rehearsal, and feedback that is used to teach new behaviors or skills” (2004, p. 558). And that’s exactly what it is, a 4-step teaching strategy that works!

BST teaches a person what to do in a given situation via a series of simple steps.

1.Trainer provides instruction:

The trainer provides initial instruction on how to do something. In the case of parent training, this might be explaining to parents what a skill is, why we teach it how to teach it. We would verbally describe this as well as providing a written guideline as a back up tool for parents to refer back to.

Example: Describe what a mand is, when a child would mand, and how you would teach a mand.

2. Trainer Models:

Following instruction a trainer would then model for a parent how to teach the skill.

Example: In the case of training a parent to teach their child to mand, the therapist would contrive or capture a situation where the child has to mand for something that they want.

3.Parent Rehearses:

The trainer would then hand over to the parent to practice the skill that the trained has instructed and modelled for them. This stage often requires lots of practice to get used to teaching the skill and feeling confident in applying it in everyday life. The trainer will record data on correct and incorrect responding during this step.

4.Trainer provides Feedback and models again if necessary

The trainer should provide positive praise for correct responding and some form of corrective feedback for incorrect responses.

Example: Provide any feedback to parent on method of teaching the mand. Try to use mainly positive reinforcement and constructive feedback. The trainer will return to earlier steps if a parent continues to struggle.

In summary, parents are the ultimate teachers for their children and it is incredibly important that they are involved and understand how to implement procedures to give their child the best outcome possible. The advantage of also having behaviour technicians come to your home is twofold, parents receive respite and they see how others implement the same procedures and behaviour replacement procedures.

Our Aspire team are here to support you in feeling confident in teaching your child the skills they need to flourish.

A big thank you to Melissa for giving us permission to share this video. Well done on making this amazing progress in a short space of time!

Download Video from Dropbox

References

Brereton, A., V. & J. Tonge., B. J., (2005). Pre-Schoolers with Autism. An Education and Skills training Programme for Parents. Jessica Kingsley Publishers, London, UK.

Dempsey, I. & Dunst, C.J. (2004). Help giving styles and parent empowerment in families with a young child with a disability. Journal of Intellectual & Developmental Disability, 29 (1), 40-51.
Feldman, M. A., & Werner, S. E. (2002). Collateral effects of behavioural parent training on families of children with developmental disabilities and behavior disorders. Behavioral Interventions, 17, 75-83 Parents Play Key Role in Autism Treatment

Johnson, C.R., et al. (2007). Development of a Parent Training Program for Children with Pervasive Developmental Disorders. Behavioral Interventions, 22(3):201-221.

Johnson, B.M., Miltenberger, R.G., Egemo-Helm, K., Jostad, C. J., Flessner, C., & Gatheridge, B. (2005). Evaluation of behavioural skills training for teaching abduction-prevention skills to young children. Journal of Applied Behavior Analysis, 38, 67-78.

Hastings, R.P. (2002). Parental stress and behavior problems of children with developmental disability. Journal of Intellectual & Developmental Disability, 27(3), 149-160.

Miles, N.I., & Wilder, D.A. (2009). The effects of behavioral skills training on caregiver implementation of guided compliance. Journal of Applied Behavior Analysis, 42(2), 405-410.

Miltenberger, R. (2004). Behaviour Modification: principals and procedure (3rded.) Belmont, CA. Wadsworth Publishing.

Miltenberger, R.G., Flessner, C., Batheridge, B., Johnson, B., Satterlund, M., & Egemo, K. (2004). Evaluation of behavioural skills training procedures to prevent gun play in children. Journal of Applied Behavior Analysis, 37, 513-516.

Perry, A. (2004). A model of stress in families of children with developmental disabilities: Clinical and research implications. Journal on Developmental Disabilities, 11(1), 1-16.

Summers, J. & Hall, E., (2008). Impact of an Instructional Manual on the Implementation of ABA Teaching Procedures by Parents of Children with Angelman Sundrome. Journal on Developmental Disabilities, Vol. 14(2).

Steward, K.K., Carr, J.E., & LeBlanc, L.A. (2007). Evaluation of family-implemented behavioural skills training for teaching social skills to a child with asperger’s disorder. Clinical Case Studies, 6, 252-262.

 

9News visited Aspire! ” ‘Unbelievable’: The therapy parents claim is transforming the lives of children with autism!”

I recall vividly meeting Mia and her twin girls 12 months ago. The girls had very limited play skills and Dearne in particular had difficulty focusing on tasks/activities/toys for more than 10-15 seconds. They lacked the skills to occupy their own free time. Mia described life at home as difficult and said that it was impossible to leave them on their own in a room for any length of time.The twins did not make eye contact in response to their name. They communicated by constantly dragging or hand leading their parents.

I saw a Mum who was very stressed out and I knew what I needed to do. Immediately when I met the girls, I identified a number of skills that the girls needed to work on. The first two skills that we targeted explicitly were imitation (copying actions) and play skills. I prioritized these skills first as I know that by learning these skills, we could then begin targeting a whole range of skills across a variety of developmental domains. In less than two months, we taught the girls to imitate the actions of others, this opened up all sorts of new possibilities for them. They learned to copy our actions and dance to their favorite songs, they learned to manipulate their favorite toys and play with them functionally, they learned to follow their peers at daycare and sit with them at group time, for the first time they became aware of others around them.

During the first 12 months of the girl’s programs I have noticed a significant amount of change. The dedication of the twins’ family and team of therapists has been inspirational. They are now interacting with each-other (this is something we targeted in therapy sessions, initially starting with side by side parallel play and then progressing to turn taking and co-operative play), they are now communicating (Dearne is using one word vocal mands, Marissa uses some words and also communicates through Picture Exchange Communication System- PECS), they are attending weekly mainstream dance lessons and taking part fully in those lessons. The biggest success of all is seeing Dearne and Marissa smiling, they are happy! They enjoy their therapy sessions. There are many misconceptions out there about ABA and there are many people who argue that ABA tries to “normalise” individuals with autism and make them fit in with society. This is the opinion of people who truly do not understand what the science of Applied Behaviour Analysis is. Before ABA, the twins were unable to express themselves or have their needs met. We are now starting to see their individual personalities emerging. Previously, we did not know their individual desires or preferences. Thanks to ABA they now have some degree of choice and control over their own lives.

For anyone who says that ABA tries to “normalise” individuals on the spectrum, here is a great link to a blog post dispelling this myth:
http://profhastings.blogspot.com.au/2013/03/autism-and-evidence-5-15-criticisms-of.html?m=1

Jac Murphy – Aspire Behaviour Therapist and Program Manager

Here’s the article from 9News!

‘Unbelievable’: The therapy parents claim is transforming the lives of children with autism!

In a playroom in Sydney’s inner west, two women are leading a frenetic, high-energy, carefully choreographed lesson blending song, dance, drawing and storytelling.

These women are therapists who work for Aspire early intervention clinic, and their pupils – three-year-old twins Dearne and Marissa, diagnosed with Autism Spectrum Disorder (ASD) – are responding with equal enthusiasm, breaking out in pirouettes when one of the therapists play their favourite song.

It’s a stark change from just a couple of years earlier, when the girls were largely unresponsive to their environment.

Mother Mia Cazilieris, 34, said it was the girl’s grandfather who first twigged to the fact they were different.

“At about 18 months, dad expressed concerns that the twins weren’t saying any words and that I would leave and they wouldn’t show any normal reaction,” she told 9news.com.au.

“They wouldn’t cry – they weren’t too bothered about it.”

Ms Cazilieris said the girls would also “hardly” respond to their name, didn’t play with each other or other children, and showed no interest in toys.

In April 2014, a paediatrician advised her the girls were exhibiting signs that suggested they might be on the autism spectrum.

Ms Cazilieris said she went into “absolute hysterics”.

“You go through this sort of numbness, where it’s like a bad dream,” she said.

“Like any parent, you hope that they have a normal sort of typical life and then I was told this, [and suddenly] didn’t know where we stood.”

Read more at http://www.9news.com.au/national/2016/02/21/16/38/the-therapy-parents-claim-is-transforming-the-lives-of-children-with-autism#ohuZtpTxhlw7I0j1.99

 

 

Top 10 considerations for a successful transition to adulthood.

The period of transition from being a child to an adult can be one of the most difficult periods of life for us all, let alone for a young person with special needs. School ends, paediatricians hand over to adult doctors, hormones are raging, more and more support services are becoming involved, guardianship issues arise, social media issues arise, privacy, and their world starts to get larger and more difficult to control.

For those supporting someone at this stage in life, it can be a difficult and confusing time, sometimes even overwhelming. Like most situations though, with a bit of preparation, some good ideas, and a bit of support, it doesn’t have to be such a bad experience. Here are my top 10 considerations to help give you the best shot at a successful transition.

1.Early intervention: The younger you start, the better prepared your child will be. It is always easier to prepare and develop skills when a child is young, rather than repair and overcome difficulties as a child moves through adolescence and into adulthood. For every year of therapy you put in early, you can expect to save 2-5 years of therapy later in life.

 

2. Be prepared: If you get to know all of the available options well in advance, you can make a plan to achieve the best future for your child. It takes time to do well, and there are usually quite a few moving parts to attend to at once. In making a future plan for a child, consider making plans that are short term (this year’s goals and supports), medium term(to see you through the transition period) and long term (setting up for adult life).

3. Post-school options: The main post-school options available to people with special needs are

    1. day programs (social skills, recreation, community access, life skills),
    2. transition to work (developing the skills needed to enter the workforce),
    3. supported employment (supervised work, often in packing, warehousing, gardening, etc),
    4. Mainstream work through a support agency (working in the mainstream with occasional help to maintain the job),
    5. and further study (TAFE, Uni, etc).

Developing a goal and plan with your child early can help you to better prepare them for the option that suits them best.

4. Social life: Positive social interactions are one of the best activities you can involve your adolescent in to prepare for adult life. What matters most here is the development of real connections, achieving a place of value and worth in a group, and being exposed to positive social role models. Look for mainstream groups, rather than just special needs specific groups, and be prepared for a fair bit of hard work in the beginning to help them to successfully integrate and participate. It will all pay off in the end though when your adolescent develops positive connections and lasting friendships.

5. Meaningful activities: Try to find ways to engage your adolescent in more meaningful activities around the house, in the community and in your social groups. The value here comes from developing a valued status and achieving something that is important to the others present. It is the difference from being present and truly contributing. This helps to feed their growing desire to have a valued role and clear responsibilities, helping to bring out maturity and responsibility.

6. Clear and consistent supports: As your adolescent’s world starts to grow, and there are an increasing number of supports, services and organisations involved in their care, it becomes increasingly important to have a clear and shared understanding of how best to work with them. This doesn’t need to be a 150 page multi-elemental therapeutic support plan, but could be a tip-sheet, a list of the most important things to remember when supporting your child, a positive support plan or just whatever works for your situation. Inconsistencies can be the source of many behaviours of concern and issues with supports, so having a clear and documented plan can really help to smooth things out.

7. Care and support services: Who will be involved in your adolescent’s life as they mature? Respite, tutors, case managers, community carers, program staff, educators and more. Getting to know the available services and supports to assist your adolescent’s changing needs, and getting them on-board at the right time is key. Seek advice early and make it part of your plan. You don’t want to get past an important milestone only to then learn of a service that would have been of great benefit 18months ago.

8. Therapeutic supports: As an adolescent transitions to adulthood, there is often a greater need for coordination and collaboration of therapeutic services, and you might start to see more plans and programs that combine the input of a range of specialists in either a ‘multidisciplinary’ or ‘transdisciplinary’ model. This can lead to really well designed supports which meet your needs in a highly personalised manner. These styles of intervention also lead to clearer plans to aid in consistency across settings. While it can take a bit of additional coordination to make it work well, it can be a highly effective approach.

9. Medical and healthcare: You will be leaving children’s services behind and moving into the world of adult services. This usually means quite a bit of searching for the professionals who are ‘right’ for you. When looking for a new professional, it can help to write a list of key questions to see if they understand your needs, and are prepared to help. For example “What experience do you have with Autism?”, “Do you have ways to make appointments easier for people with special needs?”, “How do you feel about ______?”, etc. See your initial appointment or phone calls with them as an interview, where you are trying to find out if they are going to be the right care provider for your needs.

10. Accommodation: Where will your adolescent be living in their adult life? Will they stay with you, live in a supported situation, receive drop-in support, live in a mainstream share-house, or live independently. Having a clear and realistic goal will help you to know what skills to help them develop as they prepare for their longer-term life as an adult.

Everyone’s situation and needs are different so seek out the best advice and support you can so that you are as prepared as possible for the transition to adulthood. For each of the considerations above, there are a range of services and professionals who might be able to assist you.

As we start the journey towards a more individualised world of support services with NDIS it will be those who know what they need, and when they need it who will be able to make it work best for them.

If you ever get to a point where you are unsure of the next step, don’t know your available options, or wish to find out more, there are plenty of available professionals to assist. From case managers to social workers, behaviour consultants to service coordinators.

While the transition to adulthood can be a difficult one, with the right support it can be made a much smoother process. I wish you all the best as you support those you care for through to their adult years.

 

Alan Conradi (Alan’s Behaviour & Consulting) provides a wide range of behaviour supports, skill development and personal growth services, specialising in the needs of adolescents and adults.

With over 10 years of experience in disability support and therapies Alan offers a practical, realistic and understanding service.

Alan can help with planning and assessments (behaviour plans, positive support plans, person centred plans and more), coaching, training and implementation (walking the talk), therapeutic and skill development programs, planning and goal-setting, and much much more.

Call or email to discuss options to suit your needs on 0410487626 or alansconsulting@outlook.com 

What words do I teach my child with a language delay?

What words do I teach my child with a language delay?Speech

Your child may have a diagnosis of Autism, Down Syndrome, global developmental delay and she has just found her voice and has started talking. Yay! So how do we choose what words and language skills to teach? This blog will show you what kind of words you may want to choose to teach and what words to avoid.

Firstly, we will talk about some other important skills you would want to continue to work on that are not necessarily “speaking” skills but are incredibly important in language communication.

  • Indirect language stimulation or using declarative language (simple words)

  • Attending to salient stimuli

  • Pairing (having fun)

  • Simple turn taking activities

Any good program provider, speech pathologist or communication expert would consider these pre-vocal skills at the same time as well as actually communicative skills. Communication can be done through vocal speech, non-vocal communication (using PECS, sign, or other augmented form of communication) and in addition, we can also teach communicative gestures such as pointing, nodding and shaking for yes and no. Communication doesn’t occur in a vacuum but is part of a repertoire of skills.

What words don’t we teach?

When we first teach language we need to figure out what a child wants as it is far easier to set up successful interactions if you are fun and your child wants to be with you. If you child chooses to be with you, you can provide boundless opportunities and create opportunities for motivating your child. This is hard work! Once your child has motivation, we can start teaching her to request. Motivation sometimes may look like that she is grabbing your hand, or she may look at you and grunt, for other children this behaviour may be screaming, crying, or yelling. Some children have approximations of words but are not quite clear. Motivation is the cornerstone for teaching your child to request.

Requesting is one of the most important features of learning language, especially for children with a language delay. Remember that early on in development babies cry to get what they want, as babies get older they learn to communicate, initially by gestures (pointing, nodding), eye contact or social referencing and later by adding words vocally.

Often children engage in problem behaviour to get what they want, to avoid or escape situations or to receive attention. It often doesn’t matter to them how they are going about to get what they want, as long as they get it by any means possible. So for some children problem behaviour may consist of screaming, yelling, hitting, spitting and so forth. The possible problem behaviours are endless and you may have seen your fair share!

To change children’s problem behaviour and more specifically to teach them new words if they don’t have any as a way to communicate effectively we need to figure out what their desire is. What do they want? What motivates your child? When is their motivation strong? If they have just had a biscuit, their motivation will drop to request for that biscuit. If jumping on a trampoline outside is something your child likes, it will probably become more reinforcing if she has been inside for a few hours. Her desire to jump on the trampoline will increase. The more you understand and can determine what your child’s motivation is the easier it will be to teach requesting for specific items. The next question is, how can we use this motivation to then teach requesting. If a child likes to play with bubbles, and it is valuable for the child and they are interest in it, we can capture that and use that motivation to practice requesting.

First we should make a list what those potential motivators might be, your senior therapist or program manager can help you figuring out and choosing what words we can teach. Early on when teaching new words, we would like that motivation to be as powerful as possible. Sometimes this means that we need to withhold items. We can use a variety of items but for children who are 2, 3 or 4 already and who have little or no functional communication we can also use food. Food for most people is the most powerful item and situations are relatively easy to set up. So we may choose to start with having your child request for food items that are highly desirable. Those foods may not always be the most nutritious but as your child learns to request for one item, the second item will become easier, and then the third, and so forth. As your child learns more language, generally the easier it will become and then it will also be easier to teach your child to request for other items beside food. The list of motivators that we talked about are the words that we would introduce first.

Let’s have a look though at words in detail that we DON’T want to teach.

Choosing the wrong words could potentially hinder your child in learning functional communication.

  1. Words that are related to a variety of motivators. Words like “more”, “please”, “mine”, “yes”, “this”. These words tend to be to general. Your child will not learn to specifically request for individual items and she may become more frustrated at her attempts to communicate if she signs more for example and she would like a biscuit. Even though no biscuit is in her vicinity. Many children will start to sign for “more” or “please” to request for an individual item even though they have not had it yet. What “more” really means is give me an increased quantity of that item. This response will start to mean “give me something good”. It will make you guess as a parent what they would like. It will also be very difficult to then teach more specific requests as your child has now learnt to use a “general” request to get what they want and this may be effective in the short term.

  1. Words that are related to motivators from a general category. Words like “toy”, “eat”, “play”, “drink”. Similarly to words that relate to a variety of reinforcers, using these words is not specific enough and is generally too vague. Rather than teaching the word “toy” to request, it is far preferable to teach specific words such as car, book, play-doh etc.

  1. Words that for removing something undesirable. Words like “all done”, “break”,

“mine”, “no”, “go play”. The problem is that the first requests should not be a request to get away from you. You want to have a positive relationship with your child. We don’t want to create a situation that the most powerful desire or motivator is to leave you. You would want to be one of the most powerful desires the child has. See our section on pairing. This doesn’t mean that we don’t teach your child to use these words, but not for the first requests.

  1. Words that are related to items that are difficult to give or deliver to your child. Words like “swimming”, “bike ride”. If we can only give the item once or it takes a long time to complete the activity reduces the opportunity for your child to practice saying this and making this request. Especially when we first start teaching requests we would like to get a lot of practice in and present your child with a lot of opportunities to practice saying these words.

  1. Words that are related to politeness. Words like “please”, “thank you”. These words don’t benefit your child to get what they want but rather is a form of social convention that benefits the listener or the person who hears the words. Remember that many typically developing children only will start using these politeness phrases when they are 3 or 4 years old, when they already have a well established repertoire of functional communication. Children often will also only use these politeness phrases when prompted by an adult. So these words are also words we don’t want to teach as one of the first few requests and typically we wait until children start talking in 3-4 words sentences fluently before introducing this skill.

In short, word selection is critical but it is equally important to understand which words to avoid to teach initially.

So which words do we teach for a child that has a language delay?

  1. Words that are closely related to a strong desire for that item. The more desirable an item or activity is, the greater the chance that your child would want to request for it.

  1. Words that have long durations of desire. We would like to choose an item that children are less likely to become satiated or get over quickly. So if we were to use food for example, we would like smaller pieces of food, a mini m’n’m, or a popcorn piece, a small piece of chip, rather than a whole bag of chips. When we want to teach new words we want to make sure that we can give your child many opportunities to practice that same word.

  1. Words that are related to a specific item. This will help us to prompt your child if the item is specific. This will also assist in generalisation which means that your child is more likely to use that specific request or word in different settings such as school, outside and also with different people.

  1. Words that are related to specific items that are consumed or dissipate quickly. We would like the reinforcer to disappear quickly, and we don’t have to take the item from the child. Bubbles pop, and your child needs you to blow them again. A small piece of chocolate melts in the child’s mouth. When you are tickling your child, you can cease this and the child needs to you to continue this highly reinforcing activity. We don’t want to take items from the child. A book for example, you may need to take off the child and the child may not like that and results in a temper tantrum, which then would stop you from presenting more opportunities to practice.

  1. Words that are related to items hat are easy to deliver immediately and quickly. If we choose items that may take some time to deliver, for example, a doll house, if it is large and it takes some time to get there is a chance that the child may not make the immediate connection between making the vocal request and the delivery of the item. So when teaching new words, the item needs to be delivered as quickly as we can.

  1. Words that are related to items that are easy to remove when necessary. If an item is small or your child is happy to give that item back for short periods of time that would make teaching easier.

  1. Words that are already in your child’s repertoire. This could be a word that your child is already able to echo back to you when you prompt her to say this. Or if a child is already able to imitate a sign, we could have her imitate the sign “book” and use that for her to request a preferred item. So choose a word that she can already say or where she is able to sign for it or is able to imitate the sign. Rather than teaching words children cannot say, let’s use your child’s strengths and use words that’s already in her skill set.

  1. Words that do not rhyme or sounds similar to other words. We don’t want to teach words that are similar as it will be difficult for your child to produce the different words. This is also the case for using signs that look similar. (eat and drink for example in sign language look too similar). Looks for a selection of words that are easy to discriminate.

  1. Words that are used in the child’s natural environment. It is better to choose words that your child hears, sees and are functional for her. Choosing these words will promote generalisation and it is more likely that the child will use these words in her environment. There will also be many more opportunities if the word is more easily “set up” in her environment.

Some Sample Words that you may consider;

Remember this all depends on your child’s motivation!

  • Food (bikky / biscuit, cracker, apple, chip, ‘nana, m’m, popcorn, chocky-chocolate)

  • Drink (juice, milk, water)

  • Toys (ball, car, bubbles, doll, book)

  • Actions (up, spin, tickle, hug, kiss, crash, squeeze, down)

  • Individualised reinforcers (hat, music, ipad)

  • Electronic type toys Ipad (play, press, back, open)

  • People, pets, characters (Mum, Dora, Bob, Elmo)