Learning to Understand Language

To begin to teach a child to discriminate verbal and auditory sensory signals, we begin by using contagion. We repeat the child’s vocalizations back to him/her. In repeating the child’s vocalizations, we are calling attention to the vocalizations. A nice added benefit of starting with contagion is that you are demonstrating empathetic understanding to the child as you demonstrate that you can recognize and repeat their soothing vocalizations. Contagion should not be done with distress alerting vocalizations. Contagion exercises should be done in a face to face position while playing a physical interaction game that the child likes. I don’t believe that the child will benefit much from contagion that is done as you follow the child around and are not face to face or if a child is engaged in something other than the person doing the contagion exercise. As we repeat their vocalizations, we call attention to the vocalizations, demonstrating empathy and helping the child to distinguish between the vocalizations. The child has the opportunity to hear their vocalization and compare it to our echo. Here we are teaching the child that some things are the same and some things are different. As we do this, the focus is on creating a playful, engaged interaction. What begins as an echo of the child’s vocalizations turns into a give and take vocal exchange similar to a playful conversation. This conversation is lacking meaning in the verbal sense but can be full of meaning from an emotional or affective sense.

As contagion becomes an affective interaction conveying emotional tone, the therapist can experiment and match the tones to facial expressions to give the child an understanding of coordination between vocal tones and facial expressions. The goal here is to eventually have an affective conversation with the child as you play and interact. The more this can become a game for the child, the more the child will be comfortable with experimenting with vocal tone and facial expressions to convey meaning. In essence, we are giving the child the ability to communicate vocally before verbal ability has emerged. During this time, the therapist should focus on conveying meaning to the child with voice tones and inflections, as well as facial expressions. This should be a continuous focus throughout therapy and throughout the child’s life.

At the same time that we are focusing on contagion, we focus on labeling the child’s environment. As you follow the child’s lead and play with the child you should label objects, actions, and emotions in simple terms. As the child smiles at you say, “I’m happy”; as he throws down a toy say, “I’m mad”; as he reaches for a cookie, say “cookie.” Labeling the child’s world, actions, and emotions will give the child the experience of equivalence between the words and the objects, actions, and emotions that they are paired with. It is also important to match, mirror back, and label the child’s affect. This creates the experience of equivalence between the child’s affects and yours, and between their affects and the labels you provide.

We can also expose the child to animal sounds and begin to echo and repeat the animal sounds as we pair the sound of the animal with their name or picture. This can also be done with preschool songs. General environmental exposure, along with labeling will also help the child experience the connection between sounds in the world and your vocal labels. The overall goal with these programs is to help the child discriminate between auditory sounds. Discrimination basically means that the child is learning what is and is not the same. They are learning that some sounds are the same and some are distinctly different. The ability to recognize that some sounds are the same and some are different will lead to the ability to respond to different sounds in different ways. Children will also gain the ability to generalize some sounds and respond more flexibly to sounds that have not been directly taught.

Motor Imitation/Discriminations

As we work with children to increase their ability to discriminate auditory/verbal information, we simultaneously work to increase motor imitation. This is often referred to as non-verbal imitation. This is one of the most important basic skills that a child needs to learn. Built-in and inseparable from non-verbal imitation is attention to another human being. Imitation is thought to be a core human ability that leads to sharing emotional states and instrumental learning (Travarthen, Kokkinaki, & Fiamenghi, 1999). Imitation of body movements provides a child with the shared experience of interpersonal connection which leads to imitation of facial expression leading to emotional expressions (Gopnik and Meltzoff, 1994). Earlier work on building emotional engagement and purposeful signaling sets the stage for a child’s ability to mimic the behavior of others. Successful non-verbal imitation sets the child up for improved observational learning skills. One of the things that sets children with autism apart from their peers and significantly interferes with their ability to learn is a lack of observational learning. Most typically developing children learn almost everything important to them through observational learning. Children with autism often lack these skills. A focus on non-verbal imitation helps to build emotional engagement, purposeful signaling and leads to improved observational learning.

When teaching non-verbal imitation, our focus is on increasing the child’s abilities related to attending to, discriminating between, and imitating the behavior of others. We start by increasing the child’s ability to attend as we did earlier when building initiation. As the child looks at the therapist, the therapist becomes active and engages the child in the soothing and enjoyable experiences they developed together during the environmental acceptance exercises and play. Again, we are going to look at the chains of events that we have established. The child comes to you and demands a body slam, cookie, or swing. The chain continues with you providing the wanted behavior. Within this chain of established activities, you insert a request for a behavior before the fun activity. Where the chain used to be request-response, now we have request-demand-behavior-response/reward. Here the request is “body slam;” the contingency cue is, “do this” as you touch your nose. Because of earlier work teaching the child about contingencies, the child has experience with contingencies and behavioral strategies to solve the contingency begin. The child then needs to touch their nose (we will often prompt the child at this point by taking their hand and touching their nose). When the child touches their nose, the therapist provides an enjoyable activity such as a “body slam.” We then fade the prompt of helping them to touch their nose. The end result is the child watching the therapist intently. The child attends to the therapist for verbal and visual cues and responds based on the cues to the therapist’s actions. Here we have everything we need for observational learning. Through teaching multiple single behaviors, the child learns that it is enjoyable and functionally productive to attend to and mimic the actions of the therapist.

We usually start with object cued non-verbal imitation, such as putting a block in a bucket. We have a bucket with two blocks. When we have the child’s attention and motivation, we take one block and place it in the bucket as we say, “Do this.” After we say “Do this,” we very quickly place a second block in the child’s hand. If the child does not immediately place the block in the bucket, we overhand prompt the child to place the block in the bucket. We overhand prompt quickly to keep the child successful, which avoids distress and confusion. We slowly fade our overhand prompt so the child is imitating our actions without prompts.

After object cued non-verbal imitation, we move on to non-object cued non-verbal imitation such as imitation of clapping, touching the table, patting the head, and waving. From here we move on to chaining non-verbal imitations together, doing facial non-verbal imitations and games like follow the leader. Eventually we change the cue of “do this” to “do this to me” as we move into reciprocal actions. The child is doing a non-verbal imitation in a mirrored fashion dealing with another person. Here the child is learning the beginnings of concepts such as self and other.

We use simple one or two word requests as cues at first to keep the language as simple as possible. In doing so, the child learns one cue: “do this,” which applies to many behaviors. The child need only focus on the behavior he/she needs to imitate and is not distracted by varied or confusing language. Remember, at this stage the child is still preverbal. After teaching 20-30 non-verbal imitations this program moves nicely into a verbal responsiveness program (receptive instructions) by going back over all of the learned non-verbal imitations and changing the cue (do this) to the request (touch your nose). This program also moves nicely into vocal, and then verbal imitation.

Visual/Spatial Discrimination

We need to teach a child that objects in the world are discrete separate items distinct from other objects, and the objects can be related to each other and the self in certain ways. The most basic way to teach this is by teaching the concept of sameness and difference. We usually start with wooden peg puzzles. The child inserts the puzzle piece into an indentation on the puzzle board that matches the shape of the piece. What we are teaching here is the concept of sameness in the form of visual/spatial objects. We usually start to teach puzzles with the process of backward chaining. First we remove one piece and only have the child place one piece. We then remove two pieces and so on until the child is doing the whole puzzle. We will use hand over hand prompting to help the child be successful if the child does not put the puzzle piece in independently.

At the same time, we work on nesting (matching) 3-D items. We will use items from the child’s environment that can be matched and nested. A small plastic bowl is given to the child with an identical plastic bowl on the table and the child is told to match and is prompted to nest the bowl within the bowl on the table. This will be done with as many objects as the child needs to move on to 3-D object matching. Usually four to five nested objects is sufficient.

Next, we will move to identical matching of 3-D objects. It is important to use objects that the child will be exposed to every day so that the objects are personally meaningful to the child. Objects such as familiar toys, utensils, dishes, foods, and clothing are appropriate. We want the objects to be available and meaningful to the child. Here we are focusing on teaching the child to pick the distinguishing characteristics in the objects that determine sameness and difference. Initially we use objects that are as exact as possible. This leads into using objects that are not exact but very similar. For example, two cars that are exactly the same but different in some way, such as color, may be taught next.

In teaching sameness, we want the child to be able to abstract sameness from the main features of the object. We are rewarding the response of responding to the salient features that make the item a car. At the same time, the child has to disregard the unimportant variation (color). Through multiple trials (multiple exemplar training), the child learns to focus on the socially important aspects of the objects to be successful. I say social because the child has to respond in a way that has been determined by the therapist. In essence, the child is trying to figure out what characteristics the therapist has determined are important. The child is learning to abstract meaning based on a socially derived consequence, to problem solve, and to respond in a prescribed way.

From 3-D matching we move to 3-D to 2-D matching, to 2-D to 2-D matching and finally picture to word matching. Again, we start with pictures of objects that are as identical as possible. We then move to non-identical matching. When we move to non-identical matching, the child again has to solve a problem. We make this problem easy at first by having the objects very similar. Eventually the child has to respond to items that are very different. For example, it would be fairly easy to match one picture of a bear with another. It would be more difficult to match a snake with an elephant. Both are animals. The child is again abstracting from the contingencies socially prescribed meaning. The child learns to attend to the features that the therapist has decided are important. In doing so, the child is learning to perceive the world based on others perceptions and what others think is socially relevant.

In teaching visual/spatial discrimination we also teach block design, which takes the concepts of same and different a bit further. Now the child imitates block patterns that the therapist sets up. First we will start with just one block. We next move to the child copying our block design one at a time as we place blocks, and eventually the child can copy a block structure that has been built before the child begins their structure. The final step is to have a child copy a block pattern from a 2-D picture.

Here the child has to recognize sameness and distinction in picking the proper blocks and arranging them to match a pattern. The child is also learning about visual/spatial organization and that larger patterns are made up of smaller patterns. Block design, sorting, patterning, and order by size give the child their first systematic exposure to comparison, spatial, and hierarchical relations among objects. The child is learning to compare the preformed block design with the one they are making. The child is learning to coordinate the blocks spatially, and they are learning that each block makes up a larger pattern.

Within each of these programs, the child has to figure out what the salient characteristics in the objects or group of objects are in order to make a response. What the child is figuring out is what the therapist cares about today. We are teaching general ways of perceiving and organizing objects in the world based on social ideas. A car is not a car because it is black. Why is a car a car? The child learns tires are important. Windows may be important. The child is forming an understanding of cars based on social contingencies. A car to the child will then (since the child’s understanding is based on social contingencies) be approximately the same thing a car is to other people. These programs, at a very basic level, are teaching a child how other people perceive and categorize the world. This is all being done before a child can even respond to a request such as “give car.” If a child has no understanding of what a car is, the child will not be able to behave in relation to the car. This first step is to understand and incorporate society’s perception of discrete objects. Once the child learns what a car is, the child can do something with the car.

Summary

At this point I have outlined the initial programs. Beginning programs are used with pre-verbal children and children who need extra help distinguishing and manipulating objects in their environment. These basic programs build the relationship between therapist and child and set the tone for all of the following programs. We want to make sure that our focus through these programs is to build a quality relationship with the child. You will know that you have been successful building a quality relationship with the child if the child is happy and smiling throughout most of the session, the child looks to you for fun, the child’s eyes are bright with anticipation of what you might be able to do for them next, the child is pushing you to interact, and the child is trying new strategies when old strategies aren’t working to activate you. Next we will be moving on to programs that focus on increasing response to words (verbal responsiveness), vocal and verbal imitation, and receptively responding to labels. The next programs up the expectation for levels in interaction, and that will only be stable if the child is solid with beginning programs.