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Nancy Brady University of Kansas Presented to Illinois Speech Language Hearing.

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2 Nancy Brady University of Kansas Presented to Illinois Speech Language Hearing Association April 1, 2011

3 Part 1: Overview of Prelinguistic development Why focus on stages of prelinguistic development? Typical and atypical developments Part 2: Assessment Strategies Part 3: Interventions Specific considerations for Down syndrome and FXS Part 4: Working with communication partners

4 Gestures and vocalizations that precede speech in typically developing children Occur in a developmental order

5 Why focus on describing, assessing and teaching these types of behaviors?

6 There is great variability in the communication skills of prelinguistic children Prelinguistic = before children are speaking or signing or using another formal language system

7 Perlocutionary = children communicate by crying or acting on objects. Others assign meaning to these behaviors.

8 Next sections: Vocalizations Coordinated attention Gestures

9 Crying and experimental sounds

10 Crying and experimental sounds continued – Raspberries

11 Canonical babbling (reduplicated consonant vowel babbling)

12 Variegated babbling (jargon babble)

13 5yIiGF8WGk. 5yIiGF8WGk.

14 Crying Experimental Sounds (e.g., raspberries, noncanonical babbling) Canonical Babbling Variegated Babbling Speech

15 Do we hear similar vocalizations in older children and adults with disabilities? Should we continue to encourage vocal development in older children and adults with disabilities?

16 3 month old: 9 month old: How old?

17 Anatomical differences Vocal folds High palatal vault Larger than typical tongue in relation to the oral cavity Weak facial muscles General hypotonicity Is babbling delayed in DS? Not much!

18 Recent study by Thiemann-Bourque, Warren and Brady: How do children with Down syndrome differ from an age and SES matched sample of typically-developing children in regards to their home language environments (i.e., adult words, child vocalizations, and adult-child conversational turns)?





23 Differences in prelinguistic quality and quantity of vocalizations in children with Down syndrome

24 Discriminative vocal characteristics could be used to help identify children at risk for ASD Automated vocal analysis of naturalistic recordings from children with autism, language delay, and typical development Oller, Niyogic, Grayd, Richards, Gilkerson, Xud, Yapaneld, and Warren (2-10)

25 Lots of variability

26 Aka…joint visual attention, line of visual regard, What is it and why is it important?


28 Within routine, child is looking at object, then, intersect gaze

29 Verbally prompt for eye gaze Specifically acknowledge the eye gaze Provide the desired object contingent on the eye gaze

30 Bring toys up to face

31 Step 1. obtain the childs attention (e.g., move face in front or call their name) Step 2. Look in direction of a target even (e.g., remote control car or fan) Step 3. Activate the target event -repeat Steps 1-3 many times- Step 4. Gradually increase the time interval between the shift in the gaze and activation of the event. (This creates opportunities for the child to anticipate and look in direction that interventionist is looking) Activity: practice teaching eye gaze shift with a friend

32 Illocutionary or purposeful gestures What is the function? Behavior regulation = imperative Joint attention = declarative Social interaction

33 Crais et al. (2004) study Deictic vs. representaitonal Different functions Whats the developmental sequence?

34 Contact gestures = gives, leading by the hand, showing. Gestures that are in direct contact with an object or person.

35 Example of a contact gesture

36 Distal gestures = points. The index finger is extended and other fingers are pulled back. The gesturer is not in direct contact with the referent.


38 Example of a distal gesture

39 Head nod and shake, shoulder shrug, open palm request Depictive gestures such as pantomimes

40 Sometimes people combine gestures to convey complex meanings Gesture + vocal combinations Gesture + gesture combinations Gesture + word combinations

41 Examples of children combining 2 or more gestures

42 Prelinguistic Stages PerlocutionaryContact gesture+ Perlocutionary Distal gesture+ Contact gesture+ Perlocutionary Other conventional+ Distal gesture+ Contact gesture+ Perlocutionary

43 Work in pairs or groups One person act out the title of the song from the paper Partner guesses the title Discuss the types of gestures you used to convey the title What titles seemed easier and why?

44 Other child behaviors correlate with these stages Intervention strategies may differ for children at various stages Stages are like milestones that indicate to parents and teachers that children are progressing

45 Form and function Individuals with intellectual disabilities who only communicate with contact gestures rarely communicate joint attention (comments).

46 Lack of joint attention- example of boy with autism

47 Persons who communicate with contact gestures and distal points frequently communicate joint attention Significant differences between contact and distal gesture users reported in: Brady, Marquis, Fleming & McLean, 2005; Brady, McLean, McLean & Johnston, 1995; McLean, Brady, McLean and Behrens, 1999; McLean, McLean, Brady & Etter, 1991)

48 Example of person pointing in a joint attention task.


50 Individuals who communicate with only contact gestures communicate significantly less often than children who communicate with more advanced gestures Findings reported in Brady et al.,2008; Brady et al., 2001; 2004; McLean et al., 1999)

51 Example of low rate communicator

52 Example of high rate communicator

53 Children who use only contact gestures try to repair communication breakdown less often than children who use more advanced gestures

54 Input How do children respond to gestures? Respond to joint attention Disambiguate messages

55 Brooks and Meltzoff, 2008 JCL Gaze following, as measured by length of looking at object adult looked at, significantly predicted vocabulary 11 month olds who pointed had an additional 1.16 words/month…or 167 word advantage by age 2

56 Differences in gesture type associated with differences in: Communication functions (requests, comments) Frequency of communication Repairs of communication breakdowns

57 Are different intervention strategies better for children at different stages of prelinguistic development? Examples Teaching children to use natural gestures Outcomes from teaching words or other symbols to individuals at different stages of communication development

58 Individuals progress in communication even if they have not yet begun using words or symbols Progress in: Frequency of prelinguistic communication Use of points and other advanced gestures Diversity of communication functions Repairs of communication breakdowns

59 Assessment strategies for prelinguistic individuals Intervention strategies for prelinguistic individuals Increasing parent and peer responsivity Teaching joint attention

60 Standardized assessments are not very helpful Need to determine how a child is communicating across environments

61 Early identification of a language problem Early identification of a developmental disorder Predictive value for later language Provides information for identifying intervention goals, monitoring progress Responsiveness to prelinguistic behaviors provides linguistic input

62 Parent/Caregiver Questionnaires Direct Observation Assessment Protocols

63 Characteristics of a good parent questionnaire Questions about here and now Use recognition memory (vs recall) What does your child do when he or she needs help (e.g., opening a container or getting a toy to work)? How to use information from parent questionnaire

64 Examples of Questionnaires What do you use?

65 Good contexts to observe in Contexts indicated by the questionnaire as showing high probability of communication Meal or snack time Contexts for vocalizations?


67 1. list student characteristics-age, setting, likes, dislikes, sensory abilities 2. list two or three good activities/contexts to observe and why 3. Describe what communication behaviors to record and how. How could you summarize your observation?

68 Tests designed to see if the individual will communicate with whatever means available in order to request, comment, etc. If no communication noted in Direct Observation, need to see if they will do it when provided a specific opportunity to do so

69 Adaptations for older participants

70 Assessment protocols have been used in research by Dr. Brady and colleagues to study Initiations Requests and Comments Responses to Communication Breakdowns

71 Example of child initiation

72 Example of repair protocol item

73 Case 1, boy with fragile X syndrome Assess two things-rejecting (or protesting) and repair Case 2, girl with Down syndrome Assess indicating preference of different items Case 3, boy with autism: Assess use of PECS and gestures to indicate joint attention (commenting) functions) Case 4, individual your group previously created

74 The Communication Complexity Scale = CCS Example from current research by Brady & Thiemann-Bourque

75 I. Behavior Regulation Task 1:2 wind-up toys (1 broken) Task 2:Food items placed in a container (with tight lid) Task 3:2 battery-operated hammer toys (1 toy switched off) Task 4: Train tracks and toy trains (child has only one track) Task 5: Sealed bubbles (2 bottles, one sealed) Task 6: Bumble ball (examiner switches off) II. Joint Attention Task 1: Ball chute toy (one ball is too big to fit) Task 2: Spider mixed in with blocks in a container Task 3:Musical instruments Task 4:Pretend hot dog placed in a marker box Task 5: Book with altered pages (e.g., upside down, marked, ripped) Task 6:Foot controlled switch toy (in childs line of vision)


77 1 - single orientation only– toward an object, event or person 2 - single orientation only + 1 other PCB 3 - single orientation only + more than 1 PCB 4 - Scanning- eye gaze shift between objects 5 - dual focus– shift in focus between person and an object

78 6a- triadic eye gaze 6b- dual focus + 1 PCB 7- triadic eye gaze + 1 PCB 8- triadic plus more than 1 PCB

79 9- one-word verbalization, sign or AAC symbol 10- two word verbalization, sign or AAC symbol 11- three-word verbalization, sign or AAC symbol 12- four-word or more verbalization, sign or AAC symbol

80 How would you score the following example: Example for a boy that uses lots of different forms!!

81 Average of the three highest forms observed Can average within each function (joint attention; behavior regulation)

82 Assessments are designed to determine how and why a prelinguistic child communicates Gather information from interviews, direct observation, and assessment protocols Assessment protocols can be constructed to provide opportunities for particular behaviors of interest Repairs, communication with peers, use of AAC

83 Summarize information regarding: Communication forms Functions Frequency/rate of communication Stage of prelinguistic development Initiations/responses/repairs Contexts Motivation

84 Increasing prelinguistic communication Gestures Vocalizations Eye gaze Increasing communication across multiple contexts and with multiple people Facilitating transition into symbolic communication Speech, sign language, pictures

85 Create contexts where children communicate naturally Follow the childs lead but address specific communicative targets Use the least intrusive prompts necessary to promote communication targets

86 Increase the frequency and complexity of requests and comments For both of these goals the first step is to build routines

87 Theoretical reasons Occur developmentally before symbolic communication Thought to pave the way for symbolic communication Provide opportunities for linguistic input

88 Practical reasons May be easier to teach than some forms of symbolic communication No extra equipment needed Gestures are readily understood by members of community Can be used across many different contexts

89 Gestures as one part of communication intervention Early phase of expressive communication As augmentative forms when other forms of communication are not available or are not working e.g., SGD not available e.g., communication partner doesnt know sign

90 Principles described in Prelinguistic Milieu Teaching (PMT), see Warren et al., (2006) Warren, S., Bredin-Oja, S., Fairchild Escalante, M., Finestack, L., Fey, M., & Brady, N. (2006). Responsivity education/ Prelinguistic milieu teaching. In R. McCauley & M. Fey (Eds.), Treatment of language disorders in children (pp ). Baltimore, MD: Brookes Publishing Co.

91 Step 1: Find objects/activities/people that participant will be motivated to communicate about Different for every individual Preference assessments or questionnaires Examples of activities: toy box, snack activities, motor activities like swinging, Range to match development and interests

92 Step 2. Develop turn taking routine(s) involving activities identified in step 1 Examples: Rolling a ball Putting colored discs on a light box Pretend cutting food Turning on and playing with any battery operated toy More elaborate routines can be used with children who have advanced play skills

93 Meal times Getting ready to go outside Play with a certain toy or object Songs with repetitive lines and actions The type of routines will vary with the childs play skills

94 Step 3 (for teaching requests) Interrupt the routine in order to provide an opportunity for the child to request For example: hold on to the ball, or pause the swing, or turn off the battery operated toy…. May add an expectant look

95 Step 4: wait Step 5: if necessary prompt the targeted response Physical, hand over hand prompts Model prompts Verbal prompts Fade prompts as quickly as possible Clip from Super Nanny

96 Step 6: continue the routine/activity. This reinforces the childs behavior. General pointers Shorter routines provide more opportunities for communication Change activities when child just begins to lose interest

97 One of you is teacher, other is student Using the steps we just discussed….Teach student to do one of the following: Point to blinking fan Open palm request for yummy treat Give to request more bubbles Vocalize to continue a social routine Reverse roles

98 Vocal play Imitation

99 use sounds within childs repertoire

100 Verbally prompt for vocalizations Specifically acknowledge vocalizations

101 Vocalization + eye gaze + gesture = a clear, recognizable communication act!

102 Time Delay If the child produces one or two components of a communication act, wait expectantly (i.e., use time delay) to prompt the second (or third) component. Ask, what do you want? or another general prompt and wait again

103 Immediately after the child produces the targeted component (eye gaze, vocalization or gesture), provide the appropriate consequence and verbal feedback

104 Children with Down syndrome Children with autism Children with fragile X syndrome Children with multiple disabilities Children learning AAC

105 Characteristics to consider when planning assessments and interventions Intelligibility Learning style (may not respond well to Do/say ___.) Persistence Exciting new treatments in development!





110 Fragile X syndrome (FXS) is the leading inherited cause of mental retardation Delayed language typical in boys Profiles: relatively weak in Short term memory Processing sequential information Directing and sustaining attention Co-occurrence of ASD in about 10-40% boys

111 Characteristics to consider when planning assessments and interventions Wide range of variability of communication Many autistic-like characteristics Mothers may be shy or reticent in their interactions Oral needs Exciting new developments Drug trials Newborn screening

112 Input includes sign and touch cues Directionality of communication act, indicated through whole body orientation (not just eye gaze) Routines emphasize tactile and vestibular stimuli Prompts are physical rather than verbal

113 Research isnt available yet to guide this decision We start working on words when children are communicating prelinguistically at a rate of more than one communication per minute Start sooner with children who have severe physical impairments

114 How can AAC complement prelinguistic interventions? How can prelinguistic interventions complement AAC?

115 AAC does not slow down acquisition of speech communication Blishak (2000); DiCarlo et al. (2001); Kouri (1988); Shepis et al. (1982); Yoder & Layton (1988) Acquisition of prelinguistic behaviors may follow a different course for some children with severe disabilities Parents are eager for children to communicate symbolically

116 child who is slow to acquire natural gestures and vocalizations

117 Child who meets/exceeds goals of PMT but is slow to develop speech. Use typical naturalistic teaching strategies such as incidental teaching, mand model and delayed prompts to teach AAC and spoken verbal utterances

118 Incorporate AAC within prelinguistic interventions In beginning AAC instruction, focus on communicative foundations such as directing behaviors toward partners and use of gestures Research is needed to identify optimum strategies for combining prelinguistic intervention and AAC PECS and spontaneity example

119 Evidence that children increase their use of communicative gestures Yoder, Warren and colleagues studies: Effective for children in low-responsive environment Fey, Waren, Brady, Finestack, Bredin-Oja and Fairchild (2006) Significant increases after 6 months of intervention Warren, Fey, Finestack, Brady, Bredin-Oja (2008) Effects did not maintain over time Possible differences in effects for children with Down Syndrome

120 Brady and Bashinski (2009) research with deafblind children Results from 9 children who had relatively good motor skills 2 children with severe motor limitations




124 Summary: All 9 kids with adequate motor skills increased their initiated communication Mostly requests Effects did not generalize to different contexts Less effective for children with severely limited motor skills


126 Working with partners to increase responsiveness and decrease directiveness Goal is to promote a context where children have a need and desire to communicate

127 Increase communication Play Social interactions

128 Video demonstrating need

129 Warren, S., Brady, N., Sterling, A., Fleming, K., & Marquis, J. (2010). Maternal resposivity predicts language development in young children with fragile X syndrome. American Journal on Intellectual and Developmental Disabilities, 115(1), Brady, N., Herynk, J., & Fleming, K. (2010). Communication Input Matters: Lessons From Prelinguistic Children Learning to Use AAC in Preschool Environments. Early childhood Services, 4,

130 It is very hard to change a persons behavior. It is usually easier to learn a new behavior than to change an old one. People must be highly motivated in order to change behavior and maintain that change.

131 Work with partner to increase: following the childs lead waiting for the child to respond listening to the child Play with the child face to face, placing few demands or constraints on the childs actions. Imitate the childs actions and sounds. commenting about childs actions, etc.

132 Discussion of topics covered in reading; direct instruction General sensitivity to parent issues of all kinds Parent observation of intervention sessions

133 Working with families that have a child with FXS Pilot study: 4 families Ten sessions were held approximately 1 week apart. Each session followed the Hanen curriculum but lessons were individualized. Key components of the intervention included teaching parents to wait for their children to initiate interactions recognizing communication attempts following the childs lead providing simplified input

134 Results: Three mothers showed increases in facilitative interaction style behaviors Three mothers decreased their number of utterances per turn Two children increased the number of different words produced





139 Top 3 suggestions….

140 Observation and discussion of video-taped parent-child interactions Coaching regarding use of techniques Brainstorming about the use of responsivity techniques in typical situations

141 Mothers helped select the goals for themselves and their child for the intervention. Mothers changed their behavior when the interventionist was present and coached them, but did not seem to maintain their skills.

142 Mothers Checklist of Skills When a skill is introduced, write the date in the Targeted space. When the skill is used at least part of the time, write the date in the Emerging space. When the skill is used during 80% of the opportunities provided, note the date under Mastered. Mothers Name_____________________ Childs Name ______________________ Should be Skill is Skill is Targeted Emerging Mastered How would you rate your skills in responding to your childs communication in the areas of Responding to Gestures Responding to Vocal Initiations Responding to Verbal Initiations (Words, Signs) Following Your Childs Focus Within Activity

143 Need to work with partners and children Should parents learn intervention strategies, or to be facilitative? Need to measure changes in partners and children

144 Blishak, D. (2000). Increases in natural speech production following experience with synthetic speech. Journal of Special Education Technology, 14, Brady, N., Marquis, J., Fleming, K., & McLean, L. (2004). Prelinguistic predictors of language growth in children with developmental disabilities. Journal of Speech, Language and Hearing Research, 47(3), Brady, N., Steeples, T., & Fleming, K. (2005). Effects of prelinguistic communication levels on initiation and repair of communication in children with disabilities. Journal of Speech, Language and Hearing Research, 48(5), Capone, N., & McGregor, K. (2004). Gesture development: A review for clinical and research practices. Journal of Speech, Language and Hearing Research, 47(1),

145 Crais, E., Day Douglas, D., & Cox Campbell, c. (2004). The intersection of the development of gestures and intentionality. Journal of Speech, Language and Hearing Research, 47, Cumley, G. & Swanson, S. (1999). Augmentative and alternative communication options for children with developmental apraxia of speech: Three case studies. AAC, 15, Fey, M., Warren, S., Brady, N., Finestack, L., Bredin-Oja, S., & Fairchild, M. (2006). Early effects of prelinguistic milieu teaching and responsivity education for children with developmental delays and their parents. Journal of Speech, Language and Hearing Research, 49(3), Hunt-Berg, M. (2001). Gestures in development: Implications for early intervention in AAC. ASHA Division 12 Newsletter, June 2001.

146 Warren, S., Bredin-Oja, S., Fairchild Escalante, M., Finestack, L., Fey, M., & Brady, N. (2006). Responsivity education/ Prelinguistic milieu teaching. In R. McCauley & M. Fey (Eds.), Treatment of language disorders in children (pp ). Baltimore, MD: Brookes Publishing Co. Warren, S., Fey, M., Finestack, L., Brady, N., Bredin-Oja, S., & Fleming, K. (in press). Longitudinal effects of low intensity responsivity education/prelinguistic milieu teaching for young children with developmental delays. Journal of Speech, Language and Hearing Research. Warren, S. F. (1992). Facilitating basic vocabulary acquisition with milieu teaching procedures. Journal of Early Intervention, 16(3), Yoder, P., & Warren, S. (1999). Facilitating self-initiated proto-declaratives and proto-imperatives in prelinguistic children with developmental disabilities. Journal of Early Intervention, 22(4),

147 The national Fragile x foundation: Down syndrome research:

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