Expanding the Abiltity to Communicate
At this point there is a dual focus in therapy. Expressive language is built upon through maintaining a close relationship with desires and behavioral outcome. Expressive language can be taught through sentence completion by teaching a child to finish a common phrase where some part of the phrase is missing and expressive labels but after acquiring multiple statements, comments, and information in this format the information has to be made meaningful to the child through requesting. As we are working on expanding the complexity and structure of requesting we can also work on receptive language by expanding and integrating our requests (SD) of the child.
Extended Requesting
At this point the child can request in a short sentence such as “give me a cookie please.” When the short sentence request is strong and occurs often the therapist then attempts to expand the request by offering options. The options should integrate previously learned labels. When the child requests, “give me a cookie please,” the therapist has a variety of options. The therapist could not respond, leading the child to request again and possibly alter the request. The therapist could offer options such as “should I get it or should you get it?” or the therapist could ask a question such as “where are they?” Who, what, when, where, why, and how questions can lead to more complex and lengthy requesting. The therapist can offer obstacle statements such as no, not right now, or maybe later to expand the child’s requesting. The child could also be asked questions about past events like “didn’t you just have one?” or about the future such as “won’t that spoil your dinner?” The point here is to have the child come up with better arguments for their desired items.
The focus should be on making functional all of the statements the child has learned through phrase completion and expressive labels. Much of the expressive labels were taught in a format that is not functional to the child. Often the child is taught multiple labels and given access to some desired item or action after the say the label. To consolidate the expressive labels the child has learned, the labels must become functional. There must be a reason to remember the labels. Using all of the labels to expand requesting will tie the previously learned labels to the child’s desires and make them functional.
Therapist’s at this point have to be very careful to decrease prompting. Up until this point prompting has been used extensively and parents and therapists tend to prompt way too often. After the child has been prompted 20-30 times, the prompt should be faded and eventually the child has to be left to figure out the solution on his or her own. At this point we are not looking for one correct response. We are aware of the child’s developmental level and typical requesting ability. What we are looking for is anything that is more complex than the child’s typical request.
B. T. is a four-and-a-half year old. He has been in the program for a year and a half. He has made great progress moving through typical Lovaas programs at the table. He has the ability to request items but doesn’t self initiate a lot of requests. His parents and therapist are often prompted by his simple requests like “truck” to prompt him back by saying “I want truck”. After this prompt he easily says back to the therapist “I want truck”. The problem is, he is prompting the therapist to prompt him before he says the request in a more complex form. He is starting to get more and more restless and inattentive at the table. A decision was made after a consultation between Senior Therapist, Supervisor, Clinic Director and Supervising Doctor that he was getting board at the table and was starting to learn more like a typically developing child. We decided to move programs away from the table and teach his programs in a more natural fashion integrated into games. We also had his mother and father remove most of the toys from ground level and place them on shelves around the room.
Therapists and parents were taught not to continue prompting higher level verbal requests but instead to wait patiently until the more advanced request was made without prompting. The environment was set up to elicit many opportunities for requests of games and toys. The changes energized the therapy experience for B.T. He began to request more objects and interact with therapists and his parents more often. His ability to self-initiate and direct others increased. He started to move much more quickly through his programs and integrate the language and skills he learned in his programs more naturally in conversation.
Making these changes requires a shift in how programs are done. The same documenting and data keeping procedures have to continue with changes to accommodate the changed structure. Changes like these in programming also involve much more overlap by the Senior Therapist to ensure quality control in programming. When you move to a more natural learning style away from the table there is always the risk that programming will deteriorate. It takes careful micromanagement of the therapist’s interaction with the child and high levels of supervision, at first, to ensure quality of treatment doesn’t suffer.
In the case of B.T. he began to make significant gains away from the table. Eventually some programs will be moved back to the table to work on school readiness, listening to instructions from a distance and independence skills. Flexibly adjusting programs to accommodate the changing needs of each child has to be a continual process throughout the child’s therapy. The Lovaas based program allowed B.T. to get to the point where he could understand and interact with the world much more like a typically developing child. We see the integration of programs away from the table and generalization of programs learned at the table as just the logical extension of a quality Lovaas based approach. A functional analysis of the environmental conditions that are leading to slowed progress will lead therapists in the direction of changing programs on a regular basis to maximize the child’s gains from therapy.
Sentence Completion:
At the same time that we are focusing on expanding the child’s requesting ability we continue with programs to teach language by way of cued responses such as sentence and phrase completion, conversation questions, statement-response, statement-statement, question-statement-question, statement-statement-question, statement multiple questions and W/H questions. We will briefly describe each of these cued response programs.
Statement-Response starts with the therapist asking a question such as what is your name or what is your mother’s name? The child then responds with the correct response. At the beginning of these programs we will often ask the child the question followed immediately with the correct response as a prompt. For example we may say “what is your name” and then without hesitation say “Billy” to prompt the correct response. Prompting would then be delayed and stopped all together as the child was able to answer. Statement –Response will also involve the therapist saying common general statements and prompting the child to respond such as, the therapist may sneeze and prompt the child to say “Bless you” or the therapist my say ouch and pretend to get hurt as they prompt the child to say “Are you ok?”
In the Statement-Statement program the therapist makes any simple statement and prompts the child to respond to the statement. For example the therapist may say, “My shirt is red” and prompt the child to say “my shirt is yellow” assuming the child’s shirt is yellow. Or the therapist may say “my mom’s name is Dee Dee” and prompt the child to say “My mom’s name is Beth.”
In Question-Statement-Question the child is asked any simple question. The child then answers the question and repeats the question back to the therapist. For example, the therapist may ask “what is your name?” The child would respond by saying “Billy, what is your name?” Or the therapist might ask “Do you like pizza?” and the child would respond with “Yes, do you like hot dogs?’
Statement-Statement-Question would involve the therapist making a statement such as “I like pizza.” The child would say the statement back changing one aspect of the statement and ask a question back to the therapist. The child would respond to the statement of I like pizza with, “I like cake, do you like cake?”
In statement multiple questions the therapist makes a statement and the child responds asking multiple questions about the statement. The therapist says “I went out to eat last night.’ The child responds with “where did you go?” and “what did you have to eat?”
WH questions involve the therapist asking who, what, when, where, why and how questions to the child. After the child has learned colors, familiar people, actions etc. the therapist could touch the child’s mom on the shoulder and say “who is this,” or “what color is mom’s shirt?” When mom goes into the kitchen the therapist could say, “where did mom go?’
Stock phrases and conversations can be taught to provide the raw material for more flexible and creative conversations and comments when the child is capable of more advance language ability. Just as typically developing children often use echolalia and movie talk as the raw material for future flexible language, developmentally delayed children benefit from a wide range of statements that can slowly be used more naturally as the child’s language ability grows.
All of these programs focus on teaching the child certain stock responses and statements that are cued by the verbal behavior of others. We also start to work on open ended responding with programs like tell me about/describe, what happened, comprehension questions (what is a), predicting outcomes and problem solving. These programs start to address generative language cued by the language of others.
In the describe program the therapist could make many different requests based on what is being targeted. Some examples are, “tell me about a chair (object), tell me about a picture (photograph or drawing), tell me what he is doing (action), tell me about the zoo (place), tell me about math (topic), tell me about sadness (emotion or feeling) or tell me about honesty (idea). If the child is doing an object we will want the child to make three descriptive statements about the object including the category the object belongs to, describe what parts make up the object and describe the function of the object. For example the therapist says “Tell me about a car.” The child may be prompted to say, “A car is a vehicle, it has four wheels, and you can ride in it.” We usually begin with an object the child can see and naturally interacts with on a daily basis and eventually move to objects out of sight and not experienced on a daily basis.
In tell me about a picture we will show the child a picture and say “tell me about the picture”. The child then describes what is happening in the picture. We would want the child to comment on the participants, actions, colors, emotions and possible consequences. For example we may show the child a picture of and elephant with a monkey riding on its back and ask “tell be about the picture.” The child would then be expected or prompted to say there is a big grey elephant with a monkey riding on his back. We may ask questions at this point to help prompt the child to describe more about the picture. We could ask “Where do you think they are?”
For topics we would ask “tell me about the beach, “We would want the child to be able to describe about 5 things about the beach including its category, actions that occur there, and salient features of the beach. For example the child could say, “a beach is land, it is near the water, it is made up of sand, people lay out to get a tan, and it is often very hot.”
For actions we would give a child a picture of some action and say “tell me what is happening.” For example we could show a picture of a man throwing a ball and ask “tell me what is happening.” The child would then be expected to say “this is a man throwing a ball.”
For emotions we would show a picture of a person with obvious emotions and ask “what do you think this person is feeling.” We could then go on to ask questions such as “why do you think he feels that way?’
The main point with all of these programs is that we are expanding the child’s expressive language abilities and giving them opportunities to use the information they have learned in the labels programs. The child combines their labels of objects, actions, colors, shapes, places, occupations, emotions, prepositions while describing. As a child gets good at describing we want them to use their ability to describe to describe themselves and others. We also want the child to be able to describe patterns of behavior in themselves and others and to describe their emotions and how their emotions affect their behavior. We also want the child to be able to describe physical sensations in their body.
We continue to teach common useful statements to the child through sentence completion. The statements should be based on the child’s environment and geared toward providing the information and statements needed while requesting. Statements can be taught that provide information about the world such as; “A window is made of _________”, the child is prompted to say glass. Information about the world and statements the child may use can be taught in a very low demand fashion with this approach. Conversation statements can be taught in the same manner. Giving the child the beginning statement; “How are you doing this morning _______,” as the therapist hold up a picture of the child’s mother and prompts, “Mom”.
Lead in statements, popular language, telephone statements, topical information and statements, self statements, and other statements can also be taught in the sentence completion format. For example, for lead in statements the child could be cued with the statement “would you like to play on the______.” The child could be prompted to say swings. We could then use backward chaining to get the child saying the whole sentence. For popular language the child could be prompted to make statements that other children would be saying using the terms that are popular at the time with same aged peers.
These programs focus on providing information and statements to the child that can be used in requesting to consolidate the usefulness of the information learned. While making item lists for these programs the therapist should be focused on the child’s environment and the communication style of the family. Statements can be taught about everything the child comes in contact with on a daily basis.
Once the child has multiple statements that can be made to verbal and environmental cues, the child can also be given sentences on note cards mixed up and the therapist can read them to the child saying, “Dad doing are morning this you how” and then saying “that doesn’t make any sense can you fix it” and have the child rearrange the cards to say, “How are you doing this morning dad.” You will often find that a child who naturally says sentences in unusual order or omits words can learn to order sentences and will learn to correctly order their statements through ongoing use of these programs. Providing information, comments and statements in the sentence completion and mixed up word order format makes learning this information fun and easy for most children.
Extended and Integrated Expressive Label’s:
One main focus while extending expressive labels is on expanding the receptive language or ability to understand language in the child. The therapist should focus on moving from a two term SD (give ball or throw ball) to a nine term SD (bring the big, shinny, red truck to the kitchen and put it on the table). The therapist can also integrate all previously learned labels in the natural environment by commenting on and asking the child to respond to questions and requests.
The second major focus related to expressive labels is to build relational networks between the expressive labels. How do all the labels relate to one another? A child may know the label for a ball and be able to say ball when one is presented. When is a ball not a ball? Is the sun a ball? Is a watermelon a ball? The child needs to learn what is and is not a ball and why. What is bigger and smaller than a ball. What category does a ball fit into. How is a ball similar and distinct from other object labels. So the focus here is to use the labels the child has learned and focus on labels that will be meaningful to the child and then build up an understanding of how the labels all relate to one-and-other.
This can be done through many programs that focus on how everything relates to one another. Relations are largely based on the society’s ideas of how things relate to one another. Similarity based programs which ask the child to determine how two things are alike can be implemented. In what way are a dog and a frog alike? There are multiple correct answers and multiple incorrect answers. Answers such as they are animals, they have legs, they move, are all correct. Society may value, “they are animals” as a higher level response. Answers such as they are both green, they are plants, they are bigger than a horse are all incorrect. The child should be taught multiple relations among labels, correct and incorrect and also how society values each response.
At this point a child has many labels and we want to give the child experience using the labels and comparing and contrasting the labels. Each of the labels they have learned should be compared to the others and similarities and differences should be addressed. Programs such as these can be very fun as you explore how the labels are the same and different.
Games that encourage generic extension of the labels to similar but inaccurate objects will also increase the flexibility of language. Laying on the grass and looking up to the clouds and pointing out perceived objects will increase the flexibility of the object labels and encourage generic extension. Other games can also be played that encourage metaphorical extensions of labels. That goat looks like an old man with a beard. Walking through the zoo (or any where else) and practicing metaphorical extensions is a good way to consolidate previously learned labels and expand their use beyond the concrete use.