Abstract: Standard strategies for play and communication assessment/intervention often require vocal and physical skills unavailable to children at risk for being nonspeaking. This session will present systematic differences in early play development introduced by physical disabilities, and demonstrate strategies for integrating AAC, early communication and play intervention, including videotaped case examples.

I. Background and Terminology
A. What skills does a child need before you start addressing AAC & literacy?

*Communication starts with interaction and the earliest behaviors of children - there are no prerequisites. Augmentative and Alternative Communication (AAC): Anything that helps children or adults to communicate when traditional strategies are not sufficient to accomplish a communication goal (Cress, working definition) Previous research that attempted to assign prerequisites to AAC were only considering symbolic forms of communication

* Basic AAC intervention includes behaviors, gestures, cooperative actions, and sounds, and does not depend upon controlling complex systems or devices. These early skills do facilitate the gradual development of more complex skills.

* Behaviors are the earliest forms of AAC expression, including spontaneous and intentional behaviors, posture & body shifts, vocal behaviors, & partner responses There is a continuum of AAC from behaviors to symbolic behaviors. Behaviors & gestures support later AAC development. Even symbolic AAC users will continue to use gestural strategies for some purposes.

* Intervention with gestural strategies still counts as AAC even if the intervention doesn't include other aids, boards, or devices.

* Children may have specific impairments that additionally impair their ability to process their experience in the word (e.g., sensory, cognitive, attention).

* One of the hardest transitions to understand is between spontaneous behaviors and intentional behaviors, since typically developing children make this transition quickly without much help. Skills that help this earliest transition include imitation, attention, causality, and parent responses. The key to all of these is making them salient and meaningful within the child's experience.

* Research suggests that parent responsivity is a powerful tool to help children transition from intentional behaviors to intentional communication.

* 42 children are followed longitudinally for 18 months each (six visits, one every three months), 50 children have had at least one research visit, 34 have finished all six. Children have primary diagnoses of physical impairments and demonstrate characteristics of risk for vocal expression: Cerebral Palsy=19, Inherited Condition or Syndrome=7 (8), Oral/Motor Dysfunction=9, Postnatal Illness/Injury=11, Developmental Disabilities of unknown origins=4

* Children may have secondary diagnoses such as cognitive or sensory impairments (with some useable hearing/vision)

* The first "tool" that a child learns to control is their own body, and operation of any other types of "tools" relies on controlling some type of behavior (including eyegaze, sound, or movement). These "tools" are not necessarily physical items, but separate aspects of interaction that we use to accomplish communicative goals. "Other people" tends to be the second "tool" a child uses. If a communication task is too difficult for a child, try reducing or scaffolding the number of the above tools that are necessary to accomplish particular communicative goals.

* For example, using a single switch that says "more tickle" for requesting uses: Child's behavior + Other person's behavior + Message Content + Language + Symbolic representation + Device

III. Intervention Strategies for Promoting Spontaneous into Intentional Behaviors

A. Imitation

1. Imitation and Children with Physical Disabilities

• Children with physical impairments tend to be less likely to imitate behaviors and gestures than other children at similar developmental ages. (Cress, Reynolds, & Andrews, 1998). Why isn't this just a physical problem? Children who are nonspeaking would be expected to have poorer verbal imitation skills, isn't gesture the same situation? No, because: - Gestures modeled for children were taken from their signal inventories of behaviors that they produced spontaneously in play and interaction Children were credited for imitation if they attempted to produce a target behavior, even if they were unsuccessful (e.g. posturing)
• Children imitated behaviors with toys that they didn't imitate "just because"

2. Should we teach imitation skills directly? Probably not if...

• Children already have a wide range of behaviors that they are not using communicatively (e.g. autism). The risk in teaching imitation skills directly is that we promote splinter skills that do not carry over to effective interactive communication. This is a particular concern for children with autism, for whom the transition from trained behaviors to social skills is difficult.
• Children already learn new communicative behaviors quickly through other means (e.g. children with symbolic communication).

• Children produce few spontaneous behaviors that parents can respond to Children don't react to parent behaviors or feedback as meaningful
• We need simple turn taking routines with mutually recognized roles

• Successful language learners acquire very early skills at checking for the directing adult attention (Baldwin, 1995). Joint attention also affects imitation. Coordinated Joint Attention: Shifting attention back and forth between the targeted object and person interacting, in order to monitor or attempt to direct partner attention or behavior.
• Children learn new vocabulary more effectively when the labeling follow their line of attention than when we try to redirect their attention (Tomasello & Farrar, 1992)

• In classroom environments, attention to teacher activity is tacitly expected, but rarely taught Many children, particularly children with pervasive developmental disabilities, have difficulty maintaining or effectively responding to joint attention. Joint attention may be actively avoided.
• When introducing new language, particularly new picture symbols, we tend to redirect the child's attention to that symbol rather than waiting for them to discover it and what it might mean.

• Encourage the child to give or transfer objects of interest to prompt joint attention. During joint activities, plan novelty and change to provide opportunities for child to comment and request needed information by waiting and looking expectantly (Wetherby, 1996) Promoting joint attention with objects that do something independently can both promote simple attention and provide enough novelty to prompt children to comment on the activity.
• As with other kinds of behavioral requests, children may indicate an early version of "joint" attention to the person they are interacting with in social play, before joint attention to objects.

• Several authors have demonstrated that improving parent recognition and response to children's intentional behaviors significantly improves children's development of intentional communication (e.g. Wilcox, Bacon, & Shannon, 1995; Yoder & Warren, 1998) for children with a variety of disabilities, including some that rely on AAC.
• Researchers have been less successful with effective parent responsivity intervention for children who aren't yet showing intentional communication (Yoder & Warren, 1999).

• Failure to respond meaningfully to parent feedback for spontaneous behavior communicators may reflect children's difficulty in associating the child's own behavior with the response received. We need better methods of helping the child recognize this connection. Touching or providing other concrete reinforcement of the relevant child behavior that a partner is responding to helps the child be aware of their own behavior and consequently its association with the response received.
• Since many behavior signals by children with physical impairment are difficult to interpret, it is very helpful to keep a gesture dictionary or "Communication Signal Inventory" to highlight behaviors that parents perceive as meaningful, and how all partners respond systematically.

• Typically developing children tend to learn cause/effect skills without much adult coaching, through simple interaction with available toys.
• The application of toy-related cause-effect skills to communication does depend on environmental prompting and response to children's initiations. For children with autism, this transfer of skills is a difficult transition.

• Some uses of cause/effect and means/end activities can actually foster a passive communication style, if they are primarily adult-directed rather than child-directed.
• Much of the cause/effect skills that children with physical impairments are particularly good at controlling involve affecting other people's behavior more than toys or events themselves.

• Cause/effect and means/end behaviors need not be separated from social activities. In fact, the most important thing to learn control over is how to manage and understand the behavior of people. All communication is also a cause/effect activity in controlling one's environment. Even simple switch toys and messages can have a complex role in games with a little creativity. Examples of ways to intervene with passive communication strategies include providing children independent strategies for controlling activities that they are involved in.
• Parents often create unique interactive routines with nonspeaking children that take advantage of actions/sounds that their children can control.

• Typically developing children spend a year or more using single words to represent a wide variety of messages for a wide variety of communicative functions across different contexts. We tend to use single switches with nonspeaking children for a very limited number of functions, such as operating toys, routines (saying ABCs, singing songs), or making single requests
• Children using AAC need to have experience in using the same messages for different functions (e.g. saying "bye-bye" as a greeting or to stop an activity), as well as different messages with the same strategy.

• Cause/effect and means/end behaviors need not be separated from social activities. In fact, the most important thing to learn control over is how to manage and understand the behavior of people. All communication is also a cause/effect activity in controlling one's environment. The best way to introduce new strategies for causing effects in other people is to add the new tool onto a child's existing communication strategies, rather than expecting the new skill alone. Even simple switch toys and messages can have a complex role in games with a little creativity. Some uses of cause/effect and means/end activities can actually foster a passive communication style, if they are primarily adult-directed rather than child-directed.
• Examples of ways to intervene with passive communication strategies include providing children independent strategies for controlling activities that they are involved in.

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 author also appreciates the critical contributions of research assistants Mandy Linke, Cindy Dietrich, Sara Havelka, Jody Elliott, Kelli Bartels, Erica Aaron, Teresa Andrews, Collin Reynolds, Holli Imig, and directed research students Jennifer Torraca, Jennifer Clark, Ann Benal, and Lisa Moskal, as well as all of the families and children that participated in these research activities.

Cynthia J. Cress, Ph.D., CCC-SLP
University of Nebraska-Lincoln
202G Barkley Memorial Center
Lincoln, NE 68583-0732, USA
email: ccress1@unl.edu
 
 
Additional References:

Baldwin, D.A. (1995) Understanding the link between joint attention and language. In C. Moore & P.J. Dunham (eds.), Joint Attention: Its Origins and Role in Development. Hillsdale, NJ: Lawrence Erlbaum Associates.

Cress, C.J. (invited). Expanding children's early augmented behaviors to support symbolic development. In J. Reichle, D. Beukelman, & J. Light (eds): Implementing an Augmentative Communication System: Exemplary Strategies for Beginning Communicators.

Cress, C.J. (submitted). The "tools" of early communication: A conceptual model for children relying on technology for communication. Topics in Early Childhood Special Education.

Cress, CJ, Andrews, T, & Reynolds, CD (1998) Gestural imitation and contingent parent responses in nonspeaking children with physical impairments. Paper at the International Conference on Infant Studies, Atlanta, GA.

Kangas, K.A. & Lloyd, L. (1988). Early cognitive skills as prerequisites to augmentative and alternative communication use: What are we waiting for? Augmentative and Alternative Communication, 4 (4), 211-221.

Romski, M.A. & Sevcik, R.A. (1989). An analysis of visual-graphic symbol meanings for two nonspeaking adults with severe mental retardation. Augmentative and Alternative Communication, 5, 109-114.

Romski, M. A. & Sevcik, R. A. (1996). Breaking the speech barrier: Language development through augmented means. Baltimore: Paul H. Brookes

Warren S. F., & Yoder, P. J. (1998). Facilitating the transition from preintentional to intentional communication. In AM Wetherby, SF Warren, & J. Reichle (Eds.) Transitions in prelinguistic communication, Baltimore: Brookes.

Wetherby, A. M. (1996). Communication assessment with infants and toddlers for early identification and intervention planning. Paper at the AAHEI Regional Conference, Omaha, NE.

Wetherby, AM & Prizant, B. (1995) Communicative and Symbolic Behavior Scales. Applied Symbolix

Wilcox, M. J., Bacon, C. K., & Shannon M. S. (1995). Prelinguistic intervention: Procedures for young children with disabilities. Paper presented at the American Speech-Language and Hearing Association, Orlando, FL.

Yoder, PJ & Warren, SF (1998). Maternal responsitivity predicts the prelinguistic communication intervention that facilitates generalized intentional communication. Journal of Speech, and Hearing Research, 41 (5), 1207-1219.

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 author also appreciates the critical contributions of research assistants Mandy Linke, Cindy Dietrich, Sara Havelka, Jody Elliott, Kelli Bartels, Erica Aaron, Teresa Andrews, Collin Reynolds, Holli Imig, and directed research students Jennifer Torraca, Jennifer Clark, Ann Benal, and Lisa Moskal, as well as all of the families and children that participated in these research activities.