"Choose Your Words Wisely…"

Guest post written by Amy Prince

As a Speech Pathologist, words are my jam - my favorite thing - really my super power. 

But as I have done this job for a few years (and a few more and a few more) I have come to understand that some words are so much more valuable than others. 

 

The first time it hit me that I needed to be more conscious about the words I chose, it was an apple (or at least my first clear memory).  I was working with a sweet kiddo (all my kiddos are sweet...and cute...and I am not biased, I swear!!) who was minimally verbal and even more minimally motivated.  Between the lack of play skills and the fact that social connections were not reinforcing, my sessions we more struggle than celebration.  One consistent thing about me, a habit I have not outgrown, is the fact that I am a snacker, and I get hangry without my snacks.  And I love a perfectly ripe Fuji apple. 

On this day, I was working with this little guy during that witching 3pm hour (100% snack time).  I had placed my apple on the table in anticipation of my very own positive primary reinforcement at the close of his session.  So he sat in his chair...and I tried to play...put all my effort into being fun...and he signed “more” which was in his repertoire.  I provided more of the toy...NOPE, wrong...tried more of another toy and again, wrong.  So I moved away and instructed him to “Show me”...and he went straight for my apple.  He’d never had an apple in my room, so a request for recurrence was not appropriate, but he was definitely showing a clear preference - more clear than I had seen in the past.  So I asked (not expecting an answer), “Do you want to eat apple?”, and he responded, “eat”.  I quickly checked with mom, then allowed a bite.  Then another “eat” and another and another...so I pushed, modeling “eat apple”...and he imitated, “eat apple”.  By the end of the apple, his request to “eat apple” was independent - mediated only by me holding the apple as a visual prompt.

This doesn’t make apples magic (but they are for some kids).  And I have no desire to venture down the rabbit hole of core vocabulary versus fringe vocabulary with you.  But, what is does mean is SALIENT is IMPORTANT.  Salient...noticeable, remarkable, essential.  These are the words we need.  And these are the words that will facilitate real communication.

So today, roughly 9 years after the magic apple, my cause is your words.  I teach on topics like “Want for nothing” - which is an entire presentation about killing the word want. 

Well, not killing, but maybe really really reducing:  You don’t want cake...you want to EAT cake.  You don’t want new shoes....you want to WEAR new shoes.  You don’t want Hawaii...you want to GO to Hawaii. 

The path I hope to forge is one where even our most limited speakers can do more with the words they have.  And, there is a little known tool, a TTR (Type Token Ratio) used in speech pathology...a TTR, documents lexical richness, or variety in vocabulary. TTR is the total number of UNIQUE words (types) divided by the total number of words (tokens) in a given segment of language. The closer the TTR ratio is to 1, the greater the lexical richness of the segment.

Typically (anecdotally?) we advise starting with five really useful verbs.  For many kids, these five are excellent:

• Get
• See
• Have
• Hold
• Play

Now, these are not for everyone.  Sometimes we switch out and add:

• Eat
• Go

(Or whatever falls solidly within the interest area of the child!!)

We find that those lend themselves so well to building phrases.  And they can build a variety phrases - and they don;t all sound the same because they are using a variety of words!

• Go up
• Go outside
• Go get
• Go play

~ or ~

• Get car
• Get toy
• Get marker
• Get Thomas

~ or ~

• Hold Slinky
• Hold ball
• Hold iPad
• Hold popper

You see the pattern?  For some children you may choose 5 verbs, for others the number is endless. 

Goals?  Yup…

Here is the school version…

In one year’s time, little Timmy will independently request using two or more words (verb and noun) within structured settings, showing use of 5 or more unique verbs within a 10 minute language sample.

Or something like that!

So, my request to anyone who has stuck around to read all of this is NO MORE WANT...be creative, respect kids by gifting them a rich vocabulary...and remember that that does not necessarily mean a huge vocabulary - just add variety! 

Guest post author:

Amy Prince, along with Amber Ladd, is the owner of The TALK Team, a speech pathology clinic with locations in Fresno, CA and Visalia, CA.  
They also co-own TALK ABA, Inc, an ABA clinic in Fresno, CA, focused on ABA service with an emphasis on communication and social skills.  Amy and Amber are both dually certified Speech Pathologists and Board Certified Behavior Analysts.  
Find out more at www.thetalkteam.com or email Amy at amy.prince@thetalkteam.com

     

    

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Tameika Meadows, BCBA, Blog Author

Today's QOTD isn't quite a direct inspirational quote, it's more of a helpful -and important- resource.

From Dr. Mary Barbera, here is a short and sweet vlog on teaching non-vocal individuals to communicate distress due to pain:

For parents and professionals alike, this hits home. I have worked with many kids who had recurrent medical issues or problems, such as frequent colds (which can bring an unpleasant head fog and nose irritation), bowel/indigestion issues, acid reflux, ear infections with painful blockage, etc.

Can you imagine for a sec, experiencing some kind of painful event and not having the means to communicate that to anyone? Especially if you are a child, and cannot just run to CVS and pick up some medication to make yourself feel better. And we wonder why some of our clients get so frustrated or angry??

Taking this beyond physical pain for just a sec, in my own life when I am in a funk/sad, furious, or anxious about something, it can manifest in my body as physical symptoms. Ever heard of "butterflies in your stomach"? Or "a stress -anger headache"? WOO, I've definitely had more than a few of those.
But unlike many of my clients, I have the ability to communicate I feel like being left alone. Or, I can obtain and then ingest medicine. Or, I can choose to postpone tasks until I feel better (i.e. "Guess I'll be finishing up that report tomorrow...").


The ability to communicate not just thoughts & wants, but private events (feelings, moods, sensations, etc.) is SO critical, regardless of age or ability. I consider it a life skill.

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Tameika Meadows, BCBA, Blog Author

Photo source: www.pinterest.com, http://blog.kevineikenberry.com

*Recommended Post: 3 Step Prompting

This post is really about 2 issues, but I almost always see them done at the same time: stating instructions over and over, and delivering utterly non-concise instructions.

There is almost a quizzical cause and effect thing going on, where the more times the parent delivers the instruction to the child the more and more unclear the instruction becomes. I’ll give you an example:

(parent is trying to get child to touch a flashcard)“Okay Nicholas, touch the frog…..Come on, touch the frog….Hey—are you looking? Nicholas……Nicholas?....Nicholas!.....Nicholas, touch the frog…..Look, the green FROG right here……Just touch it…..” etc., etc.

I promise I am not exaggerating, I saw an exchange very similar to this just this week. These 2 issues that I will really boil down to 1 issue (stating non-concise instructions over and over), are extremely non- helpful whether your child has Autism or not.

An individual with communication delays (receptive or expressive) is not likely to respond well when instructions come at them too quickly, in a jumble of other words, or without any prompting to help them understand what they are supposed to do. Children with communication delays or impairments can struggle to comprehend language spoken to them, understand abstract words/terms, make inferences, read facial expressions, and respond appropriately to spoken language.

Since most of my client base consists of children with pervasive communication deficits, one of the first things I work on teaching parents is how to deliver a concise instruction. This seems like something that should be common knowledge, right? I disagree. I think most of what ABA professionals do is not common knowledge to the average parent, so it’s important to take the time to explain these concepts and strategies that we love to implement.

There are a few common objections that I almost always hear from a parent when we start working on this issue:

Objection #1- “But what if s/he didn’t hear me the first time?”

Objection #2-“But I KNOW s/he can do this, so I just keep asking”

Objection #3- “S/he doesn’t respond unless I yell/get “firm”.

My lovely rebuttals to these objections:

Rebuttal #1- Many of the families I work with tell me during our first meeting that they actually had their child’s hearing evaluated, because it truly seemed that the child had hearing loss. Definitely, make sure your child’s hearing is working normally. But lots of my clients can ignore people so well that it seems like something must be wrong with their ears (their ears are fine).

Rebuttal #2- How do I know what you know? By what you show me. If you show me inconsistent behavior, then I cannot say with certainty what you know. In the absence of consistency, I have to treat the behavior like an unlearned skill.

Rebuttal #3- I usually respond to this by reminding the parent that I don’t have to yell, get aggressive, or anything else like that to get their child to comply (and if I did, they should fire me immediately!). Do you think the child’s teacher has to yell? What about their nanny? What about their speech therapist? I hope not, because that’s a lot of yelling. What this objection is actually saying, is that the child has been conditioned over time to know that mom/dad are not serious, and do not mean business unless they get angry and threatening. The goal is for the child to know you mean business wayyy before that point.

Now that you thoroughly understand how NOT to give instructions, let’s jump into what I mean by Show & Not Tell.

A little trick I like to teach to parents is that when they give an instruction, start a mental countdown clock. Example: “Tameika, go brush your teeth (1….2….3)”. Once the clock in your head has counted to 3, this means it’s time to move from Telling to Showing. Does that sound radical, impatient, or worse? How long do you think teachers give your child to respond? Or a friend on the playground? You don’t want to unrealistically teach your child that its ok to respond to a question the 4^th or 5^th time the person asks it.

Let me back up just a bit, and repeat the original instruction: “Tameika, go brush your teeth”. This is a concise instruction. It tells the child what to do using simple and clear words. Now that a full concise instruction has been given, there is no need to repeat it. That’s right, once you have given the concise instruction you want to only use less language. Why? You want to make it clear to the child that you do not have to repeat yourself, you know they heard you, and that ignoring instructions does not gain more of your attention. I know parents don’t intend to do this, but amping up your reaction after your child starts ignoring you is actually giving them WAY more attention for ignoring you, than for listening to you.

The next (and shorter) instruction should be combined with some type of prompt. Remember, inconsistently correct behavior is still inconsistent behavior. Show the child what they need to do, and don’t assume they already know.

You may have noticed something else about the Show & Not Tell: it’s faster. Have you ever used a timer or stopwatch to see how much of your day you spend telling your child to do something over and over? Well, I have. I do it at work all the time.

Most parents don’t realize how much time is wasted when each instruction is given 5 or 6 times before the child responds. Buckets and buckets of time. Do you have buckets and buckets of time to waste? I doubt it.

Want a handy -dandy example of all of this in motion? Here you go:

“Tameika, clean up these blocks”	Clear, simple language. Use the fewest words necessary for the child to understand. Gain their attention before you give the instruction. Once you say the instruction, start your mental clock.
(Approach the child and use some level of prompting to SHOW them what to do) “Clean up”	Remain cool and calm. Use less words than you did the first time. Move in quickly to provide assistance/a prompt. Assistance does not equal completely allowing the child to get out of following the instruction.
(Move quickly through the prompting to get the task completed. Make a brief and neutral statement at the end) “You cleaned up/This is cleaning up/All done with blocks”	Continue to remain cool and calm. Avoid lectures or reprimands about how the child does not listen. Use short, simple words. IF the child had complied right away they would have received praise and/or reinforcement, so at this point provide neither.

*Resources:

Kennedy Krieger Institute article about teaching ASD children

Research article “Verbal Expression and Comprehension Deficits in Young Children with Autism”

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Tameika Meadows, BCBA, Blog Author

Photo source: www.quotesgram.com, www.toptenz.net

Yes, I admit it: I am a huge meanie who spends lots of time forcing small people to communicate. Yup, guilty.

When I am starting a new early intervention case, something I like to do is give my staff an “Early Learner Protocol”. Over the years I realized there are  so many important skills to teach and not enough hours in the day, so I wanted my staff to have a tangible understanding of the focus of intervention for the little ones. To summarize: reducing problem behavior and increasing imitation skills, attending, turntaking, waiting, play/socialization skills, and COMMUNICATION are usually the main things we are intensively targeting with young clients.

I try to get staff and parents to understand that everything involved with working with early learners is all about Pushing. If you can grasp the concept of pushing, then you will do just fine as an ABA therapist for any young child.

Pushing could look like, “He manded for a sip of juice, lets try having him mand for a bite of cookie”, “She labeled 2 toys in the bath last night, lets push for 3 tonight”, “He waited 10 seconds before I opened up the pretzels, now I’ll push for 12 seconds”. See, push.

I remember the mother of the first client I ever worked with telling me that her son was perfectly content to allow me to do everything for him, if that is what I chose to do. I didn’t really believe her at the time, and thought to myself she was just too hard on him (she was just being a meanie). So what if he needed help putting his shoes on…every day. My job was to help him, right? Then there was the day I observed him with another ABA therapist and it went a bit like this:

Therapist- “Put your shoes on”

 Child- (promptly put his shoes on)

Imagine my shock.

 After the shock faded then I just felt like a chump. I had been putting this child’s shoes on for weeks, and the entire time he was fully capable of doing it himself. Lesson learned!

To parents and new ABA staff, I know it feels like helping but it can actually be harmful if you neglect to push the child to learn new skills, dress themselves, talk, display manners, etc. It’s kind of like saying “Since this child has a disability, I’ll just lower my expectations”. You would never say that out of your mouth, right? Well then don’t say it with your actions.

When it comes to teaching/expanding on language, motivation is KEY. What motivates you and I to communicate with others may not at all be motivating for your child/client with Autism. Or let me put it like this, have you ever considered why the child should communicate? What do they get out of it? If they don’t communicate, is anything different? Does communicating make their life better somehow?

Here are some practical ways you can start to push more, to increase language, build independence, and teach skills. Many of these are things I do on a weekly basis across my clients.

• When the child wants something (a toy, to watch a TV show, etc.) place a demand on getting it. Connect some form of communication to accessing the most preferred items, instead of giving them away for free.
• Embed language trials into daily activities, such as eating breakfast, walking to the park, or getting dressed. As your child is getting dressed say , “Pick up the SHIRT/Give me your SHOES/Pull your shorts UP”. Repetition and prompting are how you get the child to respond to your language. I embed language into almost everything I do with an early learner.
• Mimic and imitate the child’s sounds. This is also a great way to get spontaneous eye contact (my clients usually stare at me like I’m crazy), and this can become a fun social interaction. Sit or lay down near the child and make the same sounds they are making, including pitch, intonations, etc.
• Look and sound like someone worth talking to. With my early learners, I smile big and keep animation in my facial expressions. Everything is a bit exaggerated. Talk a bit louder than usual, and lay the praise on super thick. If interacting with you is fun and exciting, the child will approach you more which just gives you more opportunities to push.
• Don’t give up too fast on manding trials. This is a mistake I see all the time. The child wants something, so you withhold it and try to get a mand. Then the child cries, walks off, or stares blankly at you. This is totally normal, and doesn’t mean the child is confused. It could mean they don’t want to mand, or they just don’t want the item anymore. What it definitely should not mean, is you give up on the manding trial and just give them the item.
• Sing songs to the child, or with the child. Music can work wonders for teaching or expanding on language. I’ve had many clients who would sing or hum far before they ever said words. Don’t just play music though, remember this is about pushing. Sit down with the child and sing songs that have movements, such as Itsy Bitsy Spider. Remember to be fun and animated, with lots of praise. Or, dance/hop around while singing together and then stop and look intently at the child. They might keep singing (we call this “fill ins”), or tug/pull at you as a way to request more singing. I also like to do songs that include suspense or surprise, such as “….we all fall (pause and freeze dramatically) DOWN! (lightly pull child to the floor and tickle them)”. After you do this a few times, the child may start requesting more of this game such as tugging or pulling at you to do it again. That is when you add a demand, such as the child saying or signing “more”.
• Receptive language is language too! “Receptive” just means an action is required and not a vocal response. I rarely see parents think to work on receptive language with their children, but it’s a very important part of language development. Get some flashcards or pictures and have the child match them as you label the item (“Tree”), or line up cards and then point to each one and label it. Lots of my clients like to line things up, so pushing would mean embedding language into that activity. If the child likes to sit and look at cards or photos (many of my clients do) then sit with them and say the names of the items on the cards. A way to expand this further, would be to require the child imitate your label before they pull out another card. This means if you say “car” they also have to say “car” before you let them pull out another picture.

*Recommended Post: Teaching Communication to Non-Verbal Children

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Tameika Meadows, BCBA, Blog Author

Photo source: www.autismsparks.com, www.pbs.org

**Recommended Post: Teaching Communication to Non Verbal Children

When teaching or providing intervention to young children with Autism, communication impairments are often pretty high on the list of priorities. This can include issues such as echolalia, poor articulation, syntax difficulties, or the child may be nonverbal (remember, nonverbal does not mean “no talking”. That would be “non vocal”. Nonverbal would indicate a lack of a consistent means to communicate).

A highly effective method for teaching a child with communication deficits to communicate is: Mand Training. If you read my Verbal Behavior post then you know that “mand” just means request.

Notice I said Mand Training is about teaching an individual to communicate, not “talk”. Communication is far more than being able to speak. I have clients who can talk, but aren’t communicators. I also have clients who communicate all the time, but do not talk. Some of my previous clients never reached a point of producing vocalizations (talking), and that does not mean treatment failed. They made amazing gains, and developed other means of communicating.

Since Mand Training is far more than just talking, this means that communicating can be taught via sign language, picture communication (photos or iPad), use of an assistive device, etc. While many parents often want to target vocalizations, manding does not have to be vocal.

So WHY teach manding? What is so important about being able to communicate with others?

-A child who cannot request wants and needs, is (very often) a child who will use problem behavior to communicate: aggression, tantrums, property destruction, etc.

-A child who cannot request wants and needs has no way to communicate a problem to caregivers: “Are you sick? Do you hurt? Are you tired?”. I work with many parents who often have to guess if their child is hungry, guess what their child wants to eat, guess when their child is full, etc. It’s a very difficult and challenging way to live. Not just for the parent of course, but for the child.

-A child who cannot request wants and needs is a child who may struggle with social interaction. How will the child let other children know they want to play? How will the child let other children know they are tired of playing? For a nonverbal child this can often happen through exhibiting problem behavior (such as pushing a peer down who stands too close, or snatching an interesting looking toy from a peer).

Before learning more about Mand Training my biggest tip would be NOT to read this post and then try to implement a mand training procedure on your own. It’s important to work with a BCBA to accurately design and implement a manding intervention. This is one of those skill areas where you definitely want the assistance of a qualified professional.

Okay, so here is a basic outline of how Mand Training occurs. At the end of the post I will include a clip of some actual mand training (taken from an episode of Supernanny) because I think seeing how the procedures are implemented could really be helpful.

• Mand Training kicks off with a good amount of highly preferred items/reinforcers. You need to know what the learner is MOST interested in, because those are the mands you will want to teach first. You teach reinforcers first -- before general nouns (“school”), before generalized mands (“more”), and before manners (“please”) --- because motivation is key. If I love my talking Elmo doll more than anything in the world, I will be ridiculously motivated to mand for my talking Elmo doll.
• Next, you will start requiring a mand in order to access the highly preferred items. No mand= No access. From the perspective of the learner, they are used to getting what they want, when they want it, without having to mand. So once you start to require communication, you can receive some pushback.
• Be knowledgeable about vocal shaping, if you are targeting vocalizations. When the learner begins to vocally communicate the speech may be unclear, garbled, or otherwise fractured. It is important to work with a professional who understands shaping procedures and how to accept closer and closer approximations to clear speech. This means that initially, “BUH” may be acceptable to request “Bubbles”.
• Consistency will lead to success. Mand training can take literally hundreds of trials per target, or per item. In a typical therapy session, I can incorporate mand training into nearly every few minutes of work.  Be prepared to work on manding consistently. 
• Mand training gets increasingly more complex. I may start out with a client by having them mand for a reinforcer that is present, and accept any vocalization as a correct response. From there, the item may be hidden from view, the learner may have to accurately state the name of the item, the learner may have to request using a full sentence, etc. Building and building until the individual has many words, many ways, and complex motivation to let other people know what they want and need.

*More information about Mand Training:

 ABA Therapy Mand Training

Increasing Mand Repertoire of Children with Autism

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Tameika Meadows, BCBA, Blog Author

I have mentioned before on my blog that the skill of making choices is something I like to teach my clients pretty quickly once I start working with them. It is a sad truth that many disabled children (and adults!) can go through an entire day where other people have made all choices for them, not with them.

What to wear, what to eat, where to sit, what activities to complete, what rewards are available, etc.

The day is a series of following other peoples instructions and demands. Does that sound fun to you? Sure doesn’t sound fun to me.

When creating a Behavior Plan, teaching the skill of choice making is often an antecedent intervention I recommend. I find that many problem behaviors are maintained or strengthened by the individual having a lack of control over their environment, or a lack of a communication system to let others know what they want or need. Hopefully all my readers know this, but just because a child doesn’t speak does not mean they have nothing to say or don’t desire anything. 

·         So why teach choice making? Making a choice is really making a decision. What you are really doing is teaching the individual how to evaluate (Which one do I want), decide (Hmm, I want that one), and accept (If I pick red that means I can’t have blue). Beyond teaching decision making, allowing for choice making during teaching or therapy involves the kiddo in what is going on. You are now a team working together to complete something both of you are interested in. It’s just human nature that if I help decide or somehow invest in something, I am going to care more about the outcome. Lastly, teaching an individual to make a choice is a communication skill. If a nonverbal 3 year old can lead me to her toy cabinet and point to a teddy bear, she is now communicating with even though she can’t say “I want to see that teddy bear”.

·         How can choice making skills be taught? There are lots of ways to create a choice making program. What is most important is to focus on this key criteria:

1)   Begin with tangible and visual choices over abstract choices. Hold out a doll and a train to the child and tell them to “Pick one”, before you try to have them choose before eating dinner at 5:00 or 7:00. Also, start with just 2 choices to keep it simple.

2) If the child doesn’t choose anything, then you choose. They need to understand that “I can pick, or you can pick”.

3)   If the child tries to reach for both items, don’t allow them to. Move the items away and explain they need to pick one. Then try again.

4)   Once the child has made a choice, that’s it. Do not allow them to keep bouncing between two choices, or to say “But I wanted that one”. Once a choice has been made, remove the other choice. This is very important especially when initially teaching the skill.

5)   Accept the form of communication the individual is capable of. This could be telling you their choice, gesturing, sign language, pointing, etc. Be sure to reinforce appropriate choice making so the skill will increase in the future.

There are a few ways teaching choice making can go wrong. It’s important to consider how to program for and prevent issues such as: When should the choice options begin to increase? When should choice making move from tangible objects to more abstract concepts? Does the child understand that choosing something means saying “yes” to that thing, and “no” to the other things? What if the child wants to choose both items, or make more than one choice? What happens if the individual makes a choice but meant to pick something else (didn’t understand what they were picking)? When is offering a choice not appropriate?
                 

*Tip – This isn’t just a skill useful for early learners. For older clients, I embed TONS of choice making into their therapy. They not only choose where we work (in your room or in the backyard?), which programs to complete and in what order, but their individual preferences are included in the materials they use and telling me what they want to work for. I also teach them about great choices vs. not great choices (I call them Green & Red Choices). Green choices add things: reinforcement, fun, and my attention/interaction. Red choices remove things, or cause fun things not to happen. When the individual is having difficulty listening, completing work, or keeping their hands to themselves, I may give them a reminder such as “Are you making a green or a red choice right now?”, and then together we discuss how to get back to making green choices.



Resource: “Solving Behavior Problems in Autism” by Linda Hodgdon

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Tameika Meadows, BCBA, Blog Author