Thursday, October 28, 2010

Pumpkins to Jack-O-Lanterns: Autism, Language Development, Speech Therapy


It has been a busy week before Halloween.  Halloween can be a difficult holiday for children with Autism Spectrum Disorders, Developmental Disorders, Language Disabilities, etc.  Children who fail to understand the differences between what is real and make believe can find this an unsettling time with all of the spooky decorations.  Even the basic friendly jack-o-lantern face can make them nervous. 

We spent the two to three weeks before Halloween exploring related themes.  I began with a monster theme by reading Laura Numeroff's fun book about raising a pet monster, 10 Step Guide to Living With Your Monster.  It is a very cute book and is not scary at all.  The children then had an opportunity to draw and paint their own versions of a pet monster, name it, and tell or write a short story about it.  We played the Guess Who deluxe version that includes monsters and we used a "build-a-monster" toy to create our own monsters again.

Here is a link to more Childrens books about Monsters and Halloween themes.

This week we focused on the pumpkin.  Younger children engaged in painting a round orange pumpkin on a sheet of paper.  When dried, we used sticky-backed foam sheets to cut out jack-o-lantern faces.  The older children worked on carving their own jack-o-lanterns, with an appropriate amount of assistance as needed.  For some children, this was a first time experience.  This was no easy task for the therapists.  It required extra prep time, lots of hands on work, and clean-up time.  But it was well worth all of the effort.

Some parents may have questioned, silently, whether it was a productive use of therapy time.  The answer I would give is a resounding, "Yes".  Here are some of the lessons learned.

First of all, any experience broadens the child's knowledge of the world around him.  It builds a larger framework of prior knowledge on which to draw for learning and developing in all areas: language, concepts, processes, motor, sensory, social, and emotional skills.  "Activating prior knowledge" is a term one often sees in literature about helping children with learning difficulties. 

Language, vocabulary, concept development:  During the activity much vocabulary was explored from the physical descriptive words (round, sphere, smooth, ridges, slimy, gooey, slippery), the labeling of parts (stem, skin, rind, pulp, seeds), categorization of pumpkins (not as easy as you would think since pumpkins can be classified as either/both fruit and vegetable), and new vocabulary (carve/cut, pumpkin/jack-o-lantern, light/illuminate).  Speech tends to flow much more easily from a child whose attention is captivated by a task and whose imagination is engaged.  Also learning tends to "stick" when it occurs in a functional manner or with practical application.

Concepts and Processing:  Children learned to process the sequence of the tasks; this might be difficult for someone who has not experienced the need to cut off the top first so that they are able to scoop out the insides.  They had to listen to and follow directions to understand how to use the tools and what to do with each one.  They had to process the idea that the toothed edge of the saw needed to be pointing the direction in which one was cutting.   We also threw in some concept processing tasks during the carving time:  Which is larger a pumpkin or an orange?  Is a pumpkin harder or softer than a banana? ...

Motor and Sensory Processing:  It goes without much explanation that this activity involves motor skills:  holding, sawing, pushing, and manipulating tools.  The feel of the pumpkin addresses sensory processing.  Many children with or without Autism had difficulty touching the gooey insides and picking out seeds.  But all of them experienced it, if only briefly.  Some really conquered their difficulties and plunged into the task.

Emotional:  One child in particular is a new client with an Emotionally Disturbed label.  He has been standoffish and minimally engaged in the therapy process.  Having come into the office reluctantly, his eyes seemed to light up when asked if he wanted to carve a real pumpkin.  He was engaged during the entire process, he spoke more readily to the therapist, and he even smiled during the task.  I think the next time he comes to speech therapy, he will not be dragging his heels.  We made a real connection through the activity.

Additionally, many of the children had some fear of the strange jack-o-lantern faces.  This activity took a very innocent and non-threatening pumpkin through the transformation process.  Their hands made that process happen.  The end result was what they fashioned it to be.  Now they have full knowledge and understanding that the scary jack-o-lanterns are all just humble pumpkins decorated or carved by someone's hands.  This knowledge can only serve to reduce, if not eliminate, the old fears.

Social:  All of the above feeds into the social domain because to be social we need to develop our language skills.  Additionally, such a task engages even the least socially developed to child to at least look at you and what you are doing and to pay closer attention thus increasing communicative interest.  When two or more children are working at the same time, it fosters a desire to share the experience, to check out the other one's work, and to show off their own creations.

Expression:  Now that the children have this experience, they will be willing to talk about it, if not initiate the discussions.  They will engage in telling family members about the experience, explaining the process, and describing what it was like.  Only reading a story about carving pumpkins would not build that kind of excitement for them.  For the older children, they will be asked to write sentences or a short paragraph about the experience.  They now will have greater understanding and increased vocabulary for these tasks.

I would say that carving pumpkins is quite the opposite of  "wasted" therapy time.  It is an excellent use of therapy time.

Friday, October 1, 2010

PECS

I am always amazed that PECS (Picture Exchange Communication System) is not being more widely used among those in my profession to help children. PECS is a program based on ABA (applied behavioral analysis) that teaches a non-verbal child to communicate with others by using pictures. I learned it over 10 years ago and it is now my first choice in my tool arsenal for helping non-verbal or minimally verbal children to begin to communicate. It is almost the magic "bullet" so to speak for most of these children. So, I have decided to post the basic steps. If you want the full training you need to attend a workshop. But here are the basics that I use in my speech therapy practice.

Step One: Identify things that are motivating for the child. These things need to be controllable by the communication partner. I like to start out with a snack like goldfish crackers or small consumable items, but some children respond better to a toy or other item. Some toy ideas are small wind-up toys that must be wound again or other such activated toys, marble to be rolled down a marble works maze and quickly retrievable by you (before the child), toy car rolled down a ramp, disney toy, etc. It often depends on the likes of the particular child. It is key that you are able to regain control of the toy or that the item requires a request for more, again, or continuation.

Step Two: Make a picture of the item. You can get almost any pictures by printing them off of Google Images, or take a real photo, or you may be lucky enough to have a picture program such as Boardmaker. Real pictures are great but representational graphics (drawings or clip art) usually work well too. If the picture will be used frequently, consider laminating it or covering it in clear contact paper or packaging tape to increase durability.

Step Three: At first you will need a helper. Place the picture in front of the child. The communication partner holds the desired item in view of the child. When he reaches for the item the communication facilitator (you sitting behind the child) directs his hand to the picture, assists him in picking it up, and then handing it to the communication partner (person with the goodies). The partner immediately gives the child a treat and then places the picture back in front of him. This process is repeated until the child figures out that handing over the picture gets him what he wants. Most children figure this out quickly if the item is sufficiently motivating. Note about assistance: At first you may need to assist the whole process hand over hand style. Then you may simply need to assist parts such as directing the hand onto the picture or picking it up or giving it to the partner. Only assist what needs assistance. The partner can assist by holding out their hand to receive the picture as a cue to the child.

Step Four: As soon as he starts retrieving the picture and handing it over himself, you fade (only assist steps needed) or stop assisting him altogether (or else he will never become independent with the task). It is also important to fade the cue of an open hand waiting for the picture. We do not want the child only to request when prompted (prompt dependent). We want him to become a self-initiating communicator.

See a demo of this phase: PECSvideo

This process needs to be practiced until the child is consistently initiating and requesting the desired items, one at a time, over several sessions.
Step Five: Change the communication partner so that the child learns to do this with several people. *Can also introduce Distance and Persistance training at this point.

Step Six: Introduce two items for choices. Present choices of two items and give him the one he hands you. Now the child is learning he has the power to make a choice! ChoicesVideo

Step Seven: To teach him to discriminate between the pictures more closely, you can present a liked choice and a disliked choice (ex: cheetohs vs. pickle). When he wants a cheetoh and gets a pickle (or vice versa), he may get mad but will soon learn to pay attention.

Other Steps: PECS presents some other factors to be learned in the process but I tend to teach in this order presented, and it has worked for my clients. Once we achieve these basics, I add the other parameters.

*Distance: Move away from the child so that the child has to get up and come to you to deliver the picture.

*Persistance: Move the picture away from the child so that the child has to seek out the picture to request the item. You can also turn away from the child, so that he has to get your attention.
Demo
Advanced Applications: Because it is a picture based system, it can later go on to be used to develop the child's abilities to generate phrases, sentences, and to answer and use questions. The use of pictures is invaluable to the teaching process for vocabulary and concept development. PECS can also be used to establish schedules for basic routines or daily tasks and ease the children through transitions in their day and help them understand what is happening and what will happen throughout the hour or day. If they have a schedule to refer to, they understand that they will eventually get to a desired activity if they first complete other tasks. This can eliminate lots of frustrations for everyone.

The real beauty of this system is multi-fold. It teaches the child several very critical elements of communication:

1. Communicative Intent: Learning the power of communication: If I communicate, I can get something I want rather than being at the mercy of others to anticipate my needs & I have to interact with another person in order to achieve an end goal or get a desired item.

2. Reciprocal Communication: Communication is a two-way street. Communication requires an exchange with another person (give and take).

3. Referencing Skills: Looking at or noticing others in the environment is often a missing skill in those with autism. Some believe it is one of the major reasons why some with autism often seem clueless to the environment or have such dramatic reactions to changes or transitions. They fail to notice the cues around them. Having to deliver a picture to a partner requires them to notice the partner. I often hold the item up by my face so they will have to look up at me to retrieve the item. Or, I will hold my hand to receive the picture a bit higher than needed, to direct the eyes to me. Later in the process after the child has consistently learned the basic requesting, I require at least a quick glance at me before giving the desired item.

4. Improved Behavior: Once the child understands he has an effective method for communication, many of his problematic behaviors like throwing tantrums tend to disappear. It is very frustrating to be unable to communicate and get things you want or need when you want or need them. Some children who may appear autistic due to the behavioral issues sometimes turn out to be simply speech/language impaired.

5. Verbal Skills: I always pair verbal models with the pics: When the child gives me the goldfish pic, I may say, "goldfish" or "I want a goldfish" or "You want a goldfish." Most of the time the child will begin imitating the verbalizations. This does not mean you need to stop using PECS. But if the child uses the verbal request, you do not need to insist on picking up the picture before rewarding. After all, being verbal is the ultimate goal.

As an SLP (speech language pathologist), I always start here rather than with a voice output device. Devices are great but do not teach the other critical communication pieces as well as picture exchange. Of course, if the child has those skills already and just cannot verbalize effectively (such as a child with apraxia of speech) then a device would be the best choice. I like the Dynavox devices, but that will be material for another blog...

For more info or to find workshops: PECSwebsite