I. Background:

A. Predictions of intentional communication for children w/ disability

• Children w/cognitive impairment use more behavior regulation and less joint attention than in typical development (McLean, Brady, McLean & Behrens, 1999). Only persons with distal gestures showed joint attention (McLean, McLean, Brady & Etter, 1991).

• Children w/severe cognitive impairments used fewer coordinated gestures + vocalizations, and used fewer consonants (Ogletree, Wetherby & Westling, 1992)

• Children w/Down syndrome produced more social interaction acts and were more respondent (less initiation) than children with typical development (Weitzner-Lin, 1997)

• Early communicators with severe cognitive disability produced communicative repairs using more repetition than modification (Brady, McLean & McLean, 1995).

• Children with Down syndrome produced a somewhat lower communicative rate for intentional communication than expected for typical development (Weitzner-Lin, 1997)

• Children w/SLI produced a higher rate, used more joint attention and coordinated gestures + vocalizations than children with DS (Wetherby, Yonclas & Bryan, 1989)

• Children who are late talkers tend to produce numbers of intentional gestures more like age-matched than language-matched peers (Thal & Tobias, 1992, 1994).

  B. Reasons to expect different intentional communication patterns from children with PI

• Much of early learning involves physically acting on the world, which is hard for kids w/PI.

• Many early communicative routines familiar to parents involve hand or vocal skills, both of which may be unavailable to children

• Children may not have a clear sense of their own body's movements (kinesthetically) which makes it difficult to relate their behaviors to play or interaction effects.

• Parents may not recognize children's unusual or subtle movements as intentional or communicative, and not respond as often.

• Motor delays in children's behaviors and response may limit early awareness of the relationship between their own behaviors and other events

• Many of children's early communicative attempts may be unsuccessful (e.g. using breathing as an attention signal), and children often grow passive without results

• Learning communication from a primarily receptive role limits children's access to trial-and-error exploration with communication

II. Method

A. Subjects: Nonspeaking children with physical impairments (1-3 years )

• 42 children are followed longitudinally for 18 months each (six visits, one every three months), 50 children have had at least one research session, 35 have finished all six.

• Children have primary diagnoses of physical impairments at risk for vocal expression: Cerebral Palsy=19, Inherited Condition or Syndrome=7, Oral/Motor Dysfunction =9, Postnatal Illness/Injury=11, Developmental Disabilities of unknown origins=4

• Children may have secondary diagnoses such as cognitive or sensory impairments24% of families are ethnically diverse. Mean HOH occupational status of 46.4 is comparable to norms of 42.7 (ISCO 88, updated in Ganzeboom & Treiman, 1996)

• Ages:  Begin at 12-24 months (corrected), End at 30-42 months

• Only 33 children demonstrated sufficient intentional communication to complete the CSBS for at least one session, mean age of this group at their first testable CSBS session: 20 mo. (range 12-28 mo.), last CSBS session: 32 mo. (range 18-47 mo.)

B. Measurement Scale for Intentional Communication: Communication and Symbolic Behavior Scales (CSBS) - Normed Edition (Wetherby & Prizant, 1993).

1. Standard administration: Natural structured play providing 9 "temptations" & other interactions to promote children's initiation of communicative acts without relying on adult verbal prompting. Some include breakdowns where the adult pretends to misunderstand.

2. Standard temptations are: wind-up toy, balloons, bubbles, peek-a-boo, walk mouse (tickle), blocks in box, Cheerios in jar, toys hidden in bag, and books. Each prompts for communicative functions of behavior regulation, joint attention, or social interaction.

3. Acts are considered communicative if gestures, vocalizations or words directed to adult.

4. Each communicative act is scored from videotape for multiple behavioral aspects including gesture, social and vocal parameters. Elements of language comprehension, constructive and symbolic play were scored but not analyzed in the present study.

5. CSBS was administered for every research session in which the child showed intentional communication, which may not include all 6 sessions: average #CSBS samples/child = 4.62.

6. For the present study, CSBS scores were compared between the first and last samples for each individual child, which covered a time period from 6-18 months/child.
   
   Coding: Research assistants scored CSBS training tapes until > 80% reliability, then scored pilot CSBS samples for children w/PI until all categories > 80% reliability
   Reliability coding on a random 20% of CSBS samples was 88% (range 75-100%)

2. Modifications of CSBS for children with PI on Child positioning and support

• Toy manipulation & assistance (e.g. no grasp & release)

• Adapted play materials, routines, and books

• AAC strategies available & recognized (e.g. signs, symbols, behaviors)

• Unconventional types of gestures and sounds (e.g. lip smacks, head lean)

• Adult cueing/response associated w/ AAC (e.g. scanning, attention cues)

• Separate reliability for individual children (e.g. eye pointing)

• Scoring responsivity when the child began act or posturing w/in 3 seconds

• Allowing gestures, vocalizations, and looks to be slightly sequential.

• Additional or substitute temptations: Cheerios in jar: Feeding and swallowing problems

Balloons & some pretend play toys: Latex sensitivity, Bubbles, windup toy, toys in bag: Visual processing difficulty, Blocks & various small toys: Grasping & manipulation difficulty
Peekaboo, Walk Mouse: Older children too familiar with these routines

• Alternative behavior regulation, joint attention, or social routines

• Variable order & timing of temptations (e.g. fatigue, distractions)

• Trial AAC strategies as needed preceding CSBS trials ("mean old lady")

• Possible "weighting" of scores if less than 5 temptations possible

III. Results & Discussion:

A. Planned comparisons to CSBS published norms

1. Hypothesis confirmed:

Children w/PI show fewer joint attention acts and more sociability.

• Children w/PI produced as many behavior regulation acts as expected by last sample.

• Children w/PI produced fewer joint attention acts at the first sample, and consistently more sociability at both samples than expected. Both sociability and joint attention increased.

• Children w/PI produced consistently fewer gaze shifts at both samples.
  
  Within-Group Trends:
  
  Behavior Regulation: Transitional (one-word) communicators increased their behavior regulation production to the highest category of scaled scores by last sample.
  
  Joint Attention: Only skilled communicators (multiword) showed relative increase in JA
  
  Sociability: All language stages showed increase in sociability over time, with the greatest increase for skilled (multiword) communicators.
  
  Gaze Shifts: The more skilled communicators did not show a relative increase in gaze shifts over time; only poor communicators increased their use of gaze shifts.

2. Hypothesis confirmed:
Children w/PI showed less gestures & vocalizations together.

• Children w/PI in the first sample produce less G+V Coordination than TD children, particularly evident among prelinguistic groups. Multiword children at the last sample produced comparable amounts of G + V coordination as TD children.

•  Children at both samples produced fewer conventional gestures than TD.

•  Children at last sample relied more on distal gestures than TD children, primarily evident in a relative emphasis on distal gestures for multiword children over norms.
  

3. Hypothesis not confirmed:
Some children with PI showed more frequent vocalizations, although more restricted productive repertoires.

• Children w/PI who were prelinguistic or early one-word produced more vocalizations that expected from CSBS norms at either first or last sample.

• While children w/PI in the last sample produced amounts of consonants, syllables & multisyllables approaching TD norms, these numbers were highly variable across individual children and not compared statistically as group data.
  

4. Hypothesis confirmed:
Children with PI were more likely to be respondent.

• Children w/PI at last sample produced more respondent acts than TD norms.

• Children who were less skilled communicators (prelinguistic and one-word) tended to be the children that increased their responsivity.
  

5. Hypothesis not confirmed:
Children with PI tended to show more modifications than repeats when repairing communication breakdowns.

• Children w/PI produced fewer total repairs than expected for TD children, but produced more modify than repeat actions when repairing breakdowns.

• Anecdotal observation: Skilled communicators often showed very long lags between communicative acts and repairs ? since they clearly anticipated the desired action, there may be less cost/benefit of producing a repair even when feasible.
  

6. Hypothesis partly confirmed:
Children with PI showed a slower overall rate but only some patterns expected for children of similar language stages.

• Children w/PI showed slower communication rate than TD, which increased with language stage. However, children w/PI showed internally consistent patterns where more skilled communicators were faster. Rate may still indicate relative communicative skill.

IV. Discussion:

A. Developmental patterns for nonspeaking children with PI

• Children who remain at the prelinguistic stage from 1st to last sessions tend to show: Slower rate of change in behavior development over time, Less gesture + vocalization coordination, but plenty of vocalizations.  Possible "passive" communication patterns: increase gaze shifts, increase respondent acts (depend on adult cues), decrease reliance on communicative repairs over time, best communication in social routines w/ adults.

• Children w/PI who are transitional communicators tend to show: More behavior regulation, Poor gesture + vocalization, Communicative rates considerably poorer than TD children.

• Children who become the most skilled communicators tend to show: Increased joint attention, but not necessarily in gaze shifts, Continued reliance on vocalizations and distal gestures more than typically developing children, possibly to compensate for difficulty expressing words. Some possible passive strategies: anecdotal lag in repair initiation, responsive communication.

ACKNOWLEDGMENTS:  Supported in part by research grant #1 K08 DC00102-01A1 from the National Institute on Deafness and Other Communication Disorders (NIDCD), National Institutes of Health. The authors also appreciate the critical contributions of research assistants Kelli Bartels, Erica Aaron, Teresa Andrews, Collin Reynolds, Holli Imig, and Jennifer Clark, as well as all of the families and children that participated in these research activities. B. Summary:  Differences & Clinical Implications for Children with PI:

1. Communicative Function:

• If children produced joint attention behaviors, they tended to be more skilled communicators. This may provide an alternative perspective of communicative skill separate from rate or vocal production that is influenced by physical ability. Poorer communicators may have insufficient social benefit to offset motoric cost of these acts.

• While children w/PI tend to produce some gaze shifts that support joint attention development, 3-point shifts may be limited by difficulty in head/eye control. Behavior regulation & social interaction are hypothetically less dependent on 3-point shifts. Skilled communicators seem to be able to develop joint attention acts without more gaze shifts.

• Children w/PI tend to rely on social interaction and routines at all stages more than would be expected for typically developing children. Children are more likely to show their "best" communication in the context of a familiar routine, which may be unconventional, and AAC should emphasize social routines to introduce new strategies.

• We need to teach joint attention skills as event-based communication, particularly using independently active toys or in the context of social interaction. It's difficult to demonstrate many types of joint attention acts without symbolic communication, so we need to provide AAC support for joint attention early (e.g. "what's that").

2. Gesture/Vocalizations:

• Skilled PI communicators gradually increase their amount of coordinated gestures & vocalizations to approximate that of typically developing children, while prelinguistic communicators are significantly poorer than norms. This may be related to both physical control and cognitive processing skills, and coordinated acts are particularly important for skilled nonspeakers who rely less on complete verbal expression alone.

• Skilled nonspeaking communicators continue to rely on distal gestures more & longer than TD children, and use of distal gestures may be a sign of communicative skill rather than immaturity. Since conventional gestures are relatively complex movements, it is not surprising that children with PI rely on different types of gestures than TD children. This suggests that early AAC intervention emphasize idiosyncratic or unconventional communicative gestures as effective communication strategies through early childhood.

• Poor communicators do not consistently use distal gestures and may rely on vocalizations, which may be hard to interpret. Skilled as well as poor communicators using AAC continue to vocalize as much as TD, which supports that AAC does not interfere with  vocal development.

Initiations: Respondent Acts, Repairs, and Rate:
All three factors are consistent with patterns in older children relying on AAC who show passive communication styles.

• TD children may produce an appropriate balance between initiation and response, but children w/PI may rely too much on respondent acts (esp. poorer communicators). Some AAC strategies like partner-assisted scanning or y/n questions require responsive strategies as appropriate communication. However, children relying on AAC are at risk for passive interaction styles and need support to independently initiate communication.

• When children produce communicative repairs, they tend to use relatively complex strategies of modifying their actions. Even though children w/PI produce fewer repairs than expected for TD children, this may occur when they recognize that an initiated act should be effective and a second act has too high cost/benefit to produce without need.

• Slower rates with increasing communicative skill may result from children's effort to be explicit in their communicative messages. However, slower communication increases the risk that listeners will shift attention or reduce their response to the child. Rate vs. explicitness is a dilemma for augmented communicators of all ages.

• What might help to overcome a tendency for passive communication styles? Further research is addressing mastery motivation and partner/environmental factors that promote persistence and creativity in communication for children with PI.

Contact Information:
Cynthia J. Cress, Ph.D., CCC-SLP
202G Barkley Memorial Center
University of Nebraska-Lincoln, Lincoln, NE 68583-0732
Phone: (402) 472-4431
fax 472-7697
Email: ccress1@unl.edu