Behavior and Communication Strategies for Children with Autism Spectrum Disorders Amanda Oakes M.S. CCC-SLP Kerry Hankins M.A. CCC-SLP Vanderbilt Bill Wilkerson Center

Presenters • Amanda Oakes, M.S., CCC-SLP – [email protected]

• Kerry Hankins, M.A., CCC-SLP – [email protected]

We have no relevant financial relationships to disclose, but do want to disclose that we are on the executive board of Talk with Me Tennessee, a 501c3 nonprofit organization. We do not receive financial compensation for our roles in the organization

Learner Objectives 1) After this course, Learners will understand communication assessment methods. 2)After this course, Learners will be able to describe the characteristics of a variety of different available AAC systems and feature matching techniques for appropriate device selection.

3) After this course, Learners will be able to describe a variety of communication and behavioral treatment strategies to improve the functional communication of children with ASD.

What is Augmentative and Alternative Communication? According to the American Speech Language and Hearing Association…..

Augmentative and Alternative Communication can involve external aids (books, technology) or natural communication, such as facial expression, body posture, gesture, or sign language. The best form or forms of communication are determined by the needs of the individual with disabilities and their communication partners.

Who Benefits from AAC? • Anyone with who presents with unmet communication needs benefits from AAC. • There are NO prerequisite skills required to use AAC. • Instead of prerequisite skills we use a Continuum of Communication Competence: o Beginning/Emergent Communicators o Context-Dependent Communicators o Independent Communicators 5

Who Benefits from AAC?

• Continuum of Communication Competence: o Beginning/Emergent Communicators – • May use facial expressions, pointing, behaviors, eye gaze, reaching, guide caregivers o Context-Dependent Communicators • Understands pictures and visuals symbols for communication. • May combine symbols to produce “go+car” o Independent Communicators • May combine use of pictures, spelling, gestures to independently utilize the device TobiiDynavox, 2015 PrAACtical AAC

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Who Benefits from AAC? • What about AAC Intervention when a patient is partially intelligible? • YES! – AAC interventions are used whenever individuals are unable to rely on speech to meet all of their daily communication needs.

ASSESSMENT

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Assessments • The American Speech-Language-Hearing Association (ASHA) maintains the position that “there is no standardized battery of tests that comprise an AAC evaluation, but several principles are generally associated with current recommended practices in relation to AAC assessment.”

Assessments • Valid assessment: Use procedures that solicit valid, representative, and generalizable behaviors. • Capability assessment: Determine cognitive, sensory, perceptual, social, motor, reading/literacy, writing, and linguistic capabilities. • Feature matching: Identify relationships between an individual's strengths/capabilities and communication needs in relation to various features of a device. • Identifying barriers to participation: Can be related to policies, practices, attitudes, knowledge, and skills.

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Assessments • Feature-Matching-the systematic process by which a person’s strengths, abilities and needs are matched to available tools and strategies. • Language first, technology second! The iPad is not the language solution, but only the hardware that will provide access to the language software. • Situations where the hardware matters: when alternative access to the device is needed

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Feature Matching

• http://praacticalaac.org/praactical/aac-assessment-corner-by-vicki-clarke-is-aac-feature-matching-still-relevant • https://www.gadoe.org/Curriculum-Instruction-and-Assessment/Special-EducationServices/Documents/GPAT%20AAC_Evaluation_Protocol.pdf/

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AAC Assessment Tools • • • • • • •

Caregiver Interviews and Case History Communication Behaviors Inventory Augmentative and Alternative Communication Profile Functional Communication Profile-Revised Pragmatic Language Profile Comprehensive AAC Device Trials MyTobiiDynavox Resources- Assessment Goals Grid

Collaborative Assessments • • • • • • • •

Speech-language pathologist Special education and general education teachers Assistive technology teams Occupational therapist Physical therapist Behavior Therapists Vision specialist Parents/caregivers

Competencies • To become a successful communicator, individuals must have competencies in 4 difference areas. • Linguistic Skills • Operational Skills • Strategic Skills • Social Skills

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Linguistic Skills • Linguistic skills include receptive and expressive skills in the native language spoken by the family and broader social community. • This includes skills in the “linguistic” code of the AAC system. • Examples: – Vocabulary – Verb forms – Icon sequences (Light & Binger, 1989)

Operational Skills • Operational skills refer to the technical skills required to use the AAC system(s) accurately, efficiently, and appropriately. • Examples: – Finger point – Eye gaze – Switch scanning (Light & Binger, 1989)

Strategic Skills • Strategic skills refer to compensatory strategies that may be utilized by individuals who use AAC to overcome functional limitations that restrict their effectiveness as communicators. • Examples: – Providing new partners with information about how to communicate with them. – Repairing communication breakdowns.

(Light & Binger, 1989)

Social Skills • Social skills refer to knowledge, judgment, and skills in the social rules of interaction. Included are skills to initiate, maintain, develop, and terminate interactions; skills to develop positive relationships and interactions with others; and skills to express a full range of communicative functions. • Examples: – Greeting – Asking partner focused questions – Using humor

(Light & Binger, 1989)

AUGMENTATIVE AND ALTERNATIVE COMMUNICATION SYSTEMS

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NO TECH COMMUNICATION SYSTEMS

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Pragmatically Organized Displays: PODD Pragmatic Organization Dynamic Display Created by Gayle Porter in 2007 PrAACtical AAC Post Linda Burkhart Also available as a pageset on Tobii-Dynavox Compass • Video Example: • • • • • • •

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http://praacticalaac.org/video/video-of-the-week-reading-withpodd/ https://www.youtube.com/watch?v=4Jz9yzBn4dY

Pragmatically Organized Displays Communication Books (PODD): A Promising Practice to Individuals with Autism Spectrum Disorders (Porter & Caifero, 2009) SIG 12 Perspectives on Augmentative and Alternative Communication, December 2009, Vol. 18, 121-129. http://praacticalaac.org/praactical/how-i-do-it-using-podd-books-and-aided-languagedisplays-with-young-learners-with-autism-spectrum-disorder/

Picture Exchange Communication System -

Picture Exchange Communication System Created by Frost & Bondy in 1985 Utilizes printed pictures for communication Six Phases of Instruction PECS Phases

LOW TECH COMMUNICATION SYSTEMS

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HIGH TECH COMMUNICATION SYSTEMS

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Snap Scene • Visual Scene Based language program • Great for Emerging Communicators who benefit from photos. • Quick and efficient programming for “in the moment” communication • This program can be easily implemented into play based activities. • Program can be purchased as an app or on the TobiiDynavox device.

TobiiDynavox Devices • Compass App- Phrase based language system that offers both visual scenes and grid layout options. • Visual Schedules • Video Modeling • Behavior Supports • Core First App • Word Power App

Word Power

Compass App

Core First

Language Acquisition Through Motor Planning • • • • •

Similar to the Prentke Romich UNITY Programs Developed using principles of motor planning. Language system with a Core Words focus Language system+therapeutic approach Key Components of LAMP: • Readiness to Learn- Addressing the child’s sensory needs • Joint Engagement- Choosing communication activities that will result in shared enjoyment with another individual

• Unique and Consistent Motor Planning – Vocabulary will always stay in the same position

• Auditory Signal – Multisensory feedback • Natural Consequence – Give an immediate response to a communication attempt. Keep it fun!

LAMP example in a preschool setting

“He [student] was especially motivated by music, so I used “Five Little Monkeys Swinging From the Tree” to work on core words such as “want,” “play,” “eat” and “go.” – ASHA Leader.

LAMP • Video Example.....Stay Tuned!!! • AAC and Autism

TREATMENT PLANNING

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“What should I work on?” “What kinds of AAC goals should we write?” Our answers generally have one consistent themewrite goals that matter! PrAACtical AAC Post: October 11, 2012 • Goals That Matter:

• Goals That Matter DO address skills that make the communicator happier or more independent. • Goals That Matter DO teach things that enable the communicator to be a more efficient learner.

• Goals That Matter DO provide a strong foundation for further language development. • Goals That Matter DO positively influence how other people treat the communicator. (Zangari, 2012)

Goals That Matter, continued • Goals That Matter DON’T address a skill just because the communicator missed it on a test/ evaluation instrument. • Goals That Matter DON’T teach something just because it is part of a goal sequence that someone developed for a generic program. • Goals That Matter DON’T assume that because someone hasn’t mastered ‘early skills’ that ‘later skills’ are out of the question.

(Zangari, 2012)

Goals • Don’t Forget about all of your communication competencies! • linguistic, operational, strategic, and social skills

• Communication and language is more than requesting! Don’t forget to expand beyond simply requesting objects.

Goal Examples –

Student will use picture symbols to request highly motivating fringe vocabulary during play based activities in 4/5 opportunities over 3 consecutive data days.

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Student will direct activities core vocabulary terms on SGD (e.g. "go", "make", "get", "give", "stop", "help", etc.) during interactive play based activities in 8/10 opportunities.

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Student will seek attention using a total communication system (e.g. words, signs, gestures, and/or a speech generating device 2x per session.

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Student will generate 2-word utterances using core vocabulary ….

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Student will use a sequencing to engage a peer/adult in social conversation using a social script in ¾ opportunities.

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Student will use a total communication system (e.g. words, gestures, picture symbols, and/or SGD) to request a turn during play 5x per session.

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Student will use a total communication system (words, gestures, SGD) to comment ("look", "funny", "Wow!", "Yuck!", "Then end!" appropriately during literacy activities in ¾ opportunities.

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Student will use a total communication system (words, gestures, lite tech device, SGD) to engage in simple conversations using topic specific phrases (Hi, how are you?", "what's your name?", "high five!") with peers and adults 5x per session.

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Student will carry his/her own device between classes independently across 3 data days.

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Student will use a total communication system (words, signs, pictures, SGD) to protest (or reject) undesired objects/actions/activities in 4/5 opportunities.

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Student will utilize navigational keys (e.g. “Go Back!”, “Clear”, "Next Page") independently in 8/10 opportunities.

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Student will Provide partner instructions (e.g., “It’s going to take me a minute. Please hang with me.” “Say each word as I point to it. If you’re wrong, I’ll shake my head and show you the right one.” “Ask me yes/no questions.”

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Student will use visual supports such as a first/then board, visual schedule, and time timer to increase participation in functional activities.

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Student will adjust volume to adapt to the setting in 4/5 opportunities.

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Student will utilize grammatical morphemes (e.g. present progressive –ing, past tense verbs, plurals, etc.) during structured literacy/academic tasks in 8/10 trials.

IMPLEMENTATION STRATEGIES

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Prompting • Use a least to most prompting sequence. • Avoid the use of physical prompting unless absolutely necessary. • Fade physical prompts as soon as possible

Wait

Gesture

Verbal

Physical

Video Example 39

Engineering Environment • Easy access to multiple communication supports. • Arrange opportunities that promote communication in everyday routines.

Engineering the Environment

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Aided Language Stimulation • Partner Augmented Input • Evidence Based Practice • “…a communication strategy, where a communication partner teaches symbol meaning and models language by combining his or her own verbal input with selection of vocabulary on the Augmentative and Alternative Communication (AAC) system” (AAC Institute 2011)

Aided Language Stimulation • Model language through use of your child’s AAC system • Concept: Input = Output

Aided Language Stimulation • Resources – PrAACtical AAC Post: April 9, 2015 • “S’Morres” – Articles: • Binger, C., Maguire-Marshall, M., & Kent-Walsh, J. (2011). Using aided AAC models, recasts, and contrastive targets to teach grammatical morphemes to children who use AAC. Journal of Speech, Language, and Hearing Research, 54, 160-176) • Dada, S. & Alant, E. (2009). The effect of aided language stimulation on vocabulary acquisition in children with little or no functional speech. American Journal of Speech-Language Pathology, 18, 50-64. • Kent-Walsh, J. & McNaughton, D. (2005). Communication partner instruction in AAC: Present practices and future directions. Augmentative and Alternative Communication, 21 (3), 195-204. • Video Examples

Core Vocabulary • Core language is the basic set of words we all use to get through our daily lives. • Everyone uses Core Vocabulary in their daily lives. • Majority of verbal output includes Core Vocabulary Words

Core Words •

Fringe Words

http://praacticalaac.org/praactical/praactical-teaching-in-an-asd-classroom-bigger-isbetter-with-core-vocabulary/

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Core Word Strategies 1. Introduce the new word(s) using focused aided language stimulation; 2. Teach the new word(s) with explicit instruction activities; 3. Elaborate on the new word meanings with engaging practice activities; 4. Provide repeated exposure to the new word(s) on an ongoing basis; and, 5. Check for understanding and reteaching, as necessary. (from praacticalaac.org, April 6th, 2013 | by Carole Zangari)

• Video Examples

Total Communication Approach - Respond to and encourage all communication attempts from your child. - Gestures - Talking - AAC Device - Sign Language and Body Language - Vocalizations

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Total Communication Approach

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Social Scripts • Developed by Deanna Wagner, Caroline Musselwhite, and Linda Burkhart • “A script is pre-stored message/set of messages, or prewritten phrases or sentences that provide the language that goes into a specific conversation. Scripts can involve conversation starters, the content of a topic, responses to conversations and/or ideas that connect conversations. Scripts can even help speakers appropriately change topics, ask questions, be the leader, be the speaker, or finish/terminate conversations.” – PrAActical AAC (2/9/13)

Social Scripts • “Social scripts are a prompting strategy which has

been used to successfully teach students with autism to use a variety of language during social interactions. In many studies these prompts are systematically faded out and the students with autism many times continue to spontaneously communicate with peers using scripted and unscripted phrases. The use of visual prompts (or verbal prompt provided via a speech output device) have potential to be more effective than verbal prompts given by an adult because they are much easier to fade out.” -www.autism-community.com

• PrAACtical AAC Post • Video Example: McKenzie

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Natural Learning Opportunities • "Incidental Teaching" or "Naturalistic Learning" • Teaching opportunities that build on functional activities with natural learning opportunities built through planting sabotages in the environment; relies on natural and functional reinforcers • Activities are motivating, fun, and FUNCTIONAL! 51

Natural Learning Opportunities vs. Other Methods • "in all eight studies with language criterion responses, normalized language training was more effective than discrete-trial training. Furthermore, in both studies that assessed parental affect, normalized treatment yielded more positive affect than discrete-trial training." – Delprato, D.J. (2001). Comparisons of discrete-trial and normalized behavioral language intervention for young children with autism. Journal of Autism and Developmental Disorders, 31 (3). 315325.

• What does ASHA have to say? – http://www.asha.org/NJC/Applied-Behavior-Analysis-andCommunication-Services/ 52

EVIDENCED BASED PRACTICE

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Kasari et. al, 2014 • Population: Children with Autism Spectrum Disorder between the ages of 5-8 years. • All children were considered limited verbal communicators (- less than 20 spoken words). • At least 2 years of previous intervention • Treatment: – Combined Joint Attention Symbolic Play Engagement and Regulation (JASPER) - joint attention in play contexts –

Enchanced Mileu Teaching (EMT) - responsive interactions to increase joint attention with modeling and prompting

– Speech Generating Device- incorporation of a SGD – Participants were seen 2x a week for 60 minutes each for 24 weeks – Parents were present and trained for half of the sessions.

Kasari et. al, 2014 • Results: • Significant gains in spoken with use of an SGD in play-based responsive interventions • Improvements in spontaneous verbal communication beyond requesting • Progress was maintained after a 3 month follow up. Kasari, C., Kaiser, A., Good, K., Nietfeld, J., Mathy, P., Landa, R., Murphy, S., & Almirall, D. (2014). Communication Interventions for Minimally Verbal Children With Autism: A Sequential Multiple Assignment Randomized Trial. Journal of American Academy of Child & Adolescent Psychiatry, 53 (6), 612-613.

CASE STUDY

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Patient Information • • • • •

Atticus 10 years old diagnosis of autism and developmental delay Home-schooled Used PECS and Proloquo2Go in the past

Assessment process-how was the device/language system chosen: • When patient lived in Alabama, private speech – language therapist wanted a more robust language system so had Atticus participate in LAMP training. • AAC System: the iPad mini with LAMP on it. • A GoTalk Pocket was recommended by Vanderbilt therapist as part of a total communication system when he started therapy (November 2015). • Visual Supports were also more systematically implemented after starting therapy at Vanderbilt.

Description of the device/language system • Hardware: iPad mini with carry strap-mom wears it out and about because Atticus won’t • Language system: LAMP (Language Acquisition through Motor Planning) by Prentke Romich Company-describe • GoTalk Pocket by Attainment Company (www.attainmentcompany.com)-use for topic-specific scripts

How goals were determined

Parent Identified Needs

Treatment Goals • AAC Short Term Goals: 1. Use the LAMP AAC application to express a variety of communicative functions during prioritized functional home and community activities as reported by his mother: -eating out at a restaurant -dressing -play activities -school work

Goals, cont. 2. Use the LAMP AAC application to communicate a variety of communicative functions using the following vocabulary: -foods -clothing -personal needs -family words -Wh-questions -describing words (e.g., temperature) -feelings -opinion words/phrases (e.g., I like/don't like, good/bad)

Goals, cont. 3. Use the GoTalk Pocket device to communicate scripts/pre-programmed messages for topicspecific communication needs: -greeting, telling people his name -asking questions and commenting during car rides -requesting and commenting during cooking/meal preparation -requesting, asking questions, and commenting at church

Goals, cont. 4. Use visual supports as comprehension supports and expressive communication aides for the following activities: -pet care (service dog) -home school schedule -visual schedule-places he is going -pain/illness (e.g., tell where it hurts, what he needs) -bathroom (e.g., request wet wipe, hand towel)

Therapy techniques & resources used to teach the language system http://www.aacandautism.com/educators • Know the vocabulary available on the child's device: print it out and keep it on your desk. Know the locations of words on the device so that you can teach them. • Give the AAC communicator a chance to communicate for a variety of reasons, not just labeling and requesting (greeting, rejection, commenting, directing, describing, etc.)

Resources used in therapy • Language Lab: https://aaclanguagelab.com/ • Core Language books from Tobii Dynavox website: http://www.tobiidynavox.com/mytobii-dynavox-overview/ • Visual supports-Where are we going?, What are we doing?, First-Then, Token Boards

Video Example

RESOURCES

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RESOURCES • • • • • • •

Technology Access Center Talk with Me Tennessee Device Representatives PrAACtical AAC Center for AAC and Autism News2you MyTobiiDynavox.Com – Free App! • Assessment Goals Grid 72

QUESTIONS?

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