Intervention Strategies for Caregivers & Young
Children Who Have Multiple Disabilities and
Cochlear Implants: Research to Practice to
Training
Kat Stremel Thomas, The Teaching Research Institute, Western
Oregon University
Objectives:
Participants will increase their
knowledge of:
1. …the demographics and outcomes for children with
2.
3.
4.
deaf-blindness and other disabilities,
…the critical aspects of cognition, social and
communication development as they relate to receptive
and expressive language development for children with
cochlear implants and multiple disabilities,
… effective procedures to teach these children in natural
environments, and
… effective adult learning strategies to teach caregivers
to effectively teach their child.
Practice: What To Teach & How To
Teach It
Considerations for Planning Intervention
for Children Who Are Deaf-Blind
(Multiple Disabilities)
• The tremendous differences between the
children – the need for individualization.
• The need for multiple disciplines planning
and intervening – collaborative teaming.
• The need to teach caregivers specialized
procedures for teaching the “What” and the
“How” of intervention.
Influencing Factors
for Individualized Instruction
• Age of onset of vision and hearing loss
• Severity of the disabilities/loss (vision,
hearing, physical, motor, medical)
• Impact of concomitant disabilities
• Age of diagnosis and intervention
• Use of vision and auditory devices &AT
• Cognitive and social development
• Support and training of the family
How Are Children With Multiple Disabilities
Different From a Typical Deaf Child?
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Lack of intentional behavior (causality)
Low rates of social interaction/lack of initiation
Limited actions on objects and toys (mouthing/throwing)
Low rates of turn-taking
Absence of prelinguistic communication
Lack of clear behavioral responses to pure tone signals
Lack of consistent wearing of hearing aids
These children are often “dropped” from AV therapy due to
lack of progress.
-IndividualizationFacilitators/Inhibitors to
Communication Development
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Motor
Vision
Hearing
Cognitive
• Social
• Medical
• Hyper/hypo
sensitivity
Individualization
• Any individual child’s motor, cognitive,
perceptual, social and medical status must be
considered in order to individualize a
communication & language program and
make future decisions for movement
• HANDOUT
Case Examples
DOMAINS/
FACTORS
Child “C”
Child “E”
Child “L”
CHARGE
MOTOR
Rolls to move, little
use of rt. hand
Ambulatory & good
fine motor skills
Began walking 2 days
after implant; good
fine motor skills
VISION
Small field of light
perception in one eye
CVI-Progressive
Improvement
Good with correction
at 12 inches
HEARING
Profound – Bilateral
Implants
CI & Hearing Aid
Not a full insertion
COGNITIVE
Limited actions on
objects-increasing
Very good
interactions with
objects
Stereotyped
behaviors, flipping,
mouthing
SOCIAL
Positive response to
others
Beginning to
coordinate object &
people more
Recognition of
persons
increasing/minimal
MEDICAL
GI Tube and eating; 7
months NICU
Long NIU stay; No
problems now
Trach & multiple
surgeries
AGE AT
IMPLANT
1year, 9 months
2 years, 2 months
4 years, 9 months
Critical Components of “What” We Need to
Target for Practice
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Related Social & Cognitive Behaviors
Auditory Processing
Receptive Communication
Vocal Development
Expressive Communication
Receptive Language
Speech or Augmentative Systems
Expressive Language (morphology &
syntax)
Assessments for Each Domain: A Strength ModelNot a Deficit Model
• Need to determine skills in each area
• Need to determine next skill to teach
• Need to use skills to teach new behaviors
Cognitive & Social Development: Impact on
Communication & Language Development
• “Language cannot get off the ground until some minimal set
of cognitive infrastructures are finally in place, including
cognitive structures that are necessary though (perhaps) not
sufficient for the establishment of reference and predication”
Bates et al., 1995
• Perhaps intentional communication also cannot get off the
ground without some minimal set of cognitive and social
infrastructures. Stremel Thomas
Important Social Factors
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Reacting to the emotions of others
Engaging in the social interaction,
Joint attention
Joint activity
Turn-taking
Awareness other’s communicative intent,
Understanding the “theory of the mind”
Imitation
Important Cognitive Factors
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Anticipation (Based on “cues” and repetition)
Causality (Social and Physical)
Means-End/Tool Use
Object Use, Object Permanence, Spatial Relations
Coordinating Objects and Persons
Imitation
Symbolism (Pretend Play & Representational Gestures)
Understanding that specific symbolic gestures and words
“stand-for” individual objects, locations, actions, and
features.
The Critical Factors of Receptive &
Expressive CommunicationConsiderations of Communication
Before Language
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Forms = A way to communicate
Intents/Functions = A reason to communicate
Content = Something to communicate about
Context = The social and physical environment
in which communication takes place
RECEPTIVE
COMMUNICATION &
LANGUAGE DEVELOPMENT
Levels of Receptive Language (Geers &
Moog, 1990: Examples
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Awareness that the mouth/voice conveys information
Comprehension of a few words or expressions
Ability to learn new word
Ability to acquire new receptive vocabulary in phrases and
sentences
• Comprehension of successive phrases and sentences
* For children with multitple disabilities, other receptive
“Communication” skills may be targeted as well….
Young children first begin to anticipate
events and activities based on nonlanguage forms:
• Young children begin to understand the meaning
of others through facial gestures, intonations,
pitch, movement, and touch when these behaviors
are part of a familiar routine.
• Early in development, children also learn to
associate certain objects, sounds, and smells with
routine, care giving activities.
• What we teach needs to be meaningful.
Points: We need to determine what
aspects of a communication exchange
the child comprehends
• A child with multiple disabilities may have
different receptive and expressive systems.
• We need to assess how children anticipate and
begin to understand meaning.
• Comprehension precedes production fairly
dramatically with typical children.
• We need to use this information in designing
communication & language production for
children with disabilities.
Determining what receptive forms
will support auditory perception of
words
• The child’s vision and cognition play an
important role in determining supportive cues,
• Initially, these cues will be used for
communication,
• Later, they can be used to support the learning
of “receptive verbal words.”
Forms of Receptive
Communication & Support
• Stage 1: Contextual
cues
• Stage 2: Tactile
cues
• Stage 3: Object
cues
• Stage 4: Gesture
cues
• Stage 5: Tangible
symbols
cues
• Stage 6: Sign
Language
• Stage 7: Speech
Contextual Cues
• A combination of auditory, visual, movement,
smell or taste stimuli may serve as a cue if
these have been used in frequent, motivational
routines.
-Participants give examples-
Touch or Tactile Cues
• Cues that do not include objects. The touch
cues should be as natural as possible and be
part of an interaction, as in “up” in which the
mother may slide hands up the child’s outer
rib cage; or rub their hand.
- Participants provide examples-
Object Cues
• Initially, Object Cues should be real objects
that are naturally used in frequent routines.
• We need a means to determine if the child
understands the “meaning” of these cues.
• Later, Object Cues, may “stand for” a part of
an activity (as a chain link on a swing)
- Participant Examples-
Deictic Receptive Gestures
• These gestures establish reference and provide
our intentionality to the child
• Initially and for children with no vision, these
gestures will be “contact” gestures (may
overlap with touch cues).
• Examples: “up” “give me” “take this” “look”
“all done” “push away”
The Importance of Gestural
Development
• Initially, children begin to understand
deictic gestures, such as “up” and “want. ”
• Representational gestures are important for
learning “symbolic” communication.
• Young children often begin to understand
verbal words that are paired with gestures.
Representational Gestures
• These gestures may initially include objects
and later may include the shape of the
hand/object, the function or action of the
object; or an action in a game.
• These gestures may include tactual gestures
for children with little or no vision.
• Examples might include “drink” “open door”
“drum” “pour” “car”
Other Types of Tangible Symbols
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Part-Whole
Pictures
Line drawings
Raised symbols
Abstract symbols (texture/shapes)
Sign Language
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Visual
Tactile
Words
Word combinations (beginning ASL)
ASL grammar
Speech
• As more and more children receive cochlear
implants, we need to focus on the sequence of
auditory perception and speech comprehension.
• Early behaviors may include responding to
motivational environmental cues and toys sounds.
• Verbalizations of different pitch, tones, duration,
patterns within social games; using the child’s name,
simple directions in social interactions.
Auditory Perception
• Auditory perceptual activities can be
implemented while the child is working on
receptive communication
Detection – Use of Listening Cue
Non-Speech Sounds
• Environmental sounds
• Toy sounds
• Animal sounds
Speech Sounds
• Accentuated pitch contours
• Slower cadence
• Repetition (paced)
• Elongated vowels
• Key words exaggerated
• Simplified semantics
• Nancy Mellon (2000) in
J.K. Niparko (Ed)
Discrimination
• Discrimination between environmental sounds
(door bell, door, microwave)
• Discrimination between voices
• Discrimination between inflections that
express different functions (no, teasing,
directive, descriptive talking)
Embedding Opportunities in Routines
Components
Lunch Routine
Play Routine
Detection
Microwave
Toy sounds
Localization
Mom’s voice
Chewy to right/left
Discrimination
Microwave/doorbell
Mom’s/Nurse’s voice
Chewy vs. Shake,
shake,shake, shake
Identification
Get spoon, milk, bib
Get you chewy vs. shoe
Comprehension
Bib off
My turn
Children begin to interpret the
“intent” of their caregiver as:
• You want to play with me (joint activity)
• You want me to turn to my name (calling)
• You want me to stop doing what I am
doing (protest/rejection)
• You want me to respond to you
• You want me to give you this object
• You want me to look at something (joint
attention)
Later, children understand the
meaning of simple phrases by the
way the words are ordered,
“more milk, ” “no milk, ” “pour
milk” “pour juice”
Expressive Communication
• The means by which we interact with
others, express feelings, likes/dislikes,
messages and intents to others. There are
many forms of expressive communication
other than speech or manual signs.
Intentional Communication Acts
Intentional communication acts include:
• an orientation to the other person,
• a clear message,
• a clear intent, and
• continued acts to get message across
Levels of Expressive Language Skills
(Geers & Moog, 1990)
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Awareness that vocalizations are used to communicate
Ability to use a few syllables, words or expressions
Ability to learn new expressive vocabulary
Ability to acquire new vocabulary fairly readily
Ability to join 2-3 words together
Ability to combine verbs and nouns in phrases and sentences
Ability to use sentences with more than 1 type of modifying
word….
* What children with multiple disabilities may need to learn
before these skills….
Understanding How Children with
Disabilities May Initially Communicate
• Children with disabilities often communicate in unique ways
• Children may send messages using one form and receive
messages using another form.
• Children are most likely to learn to communicate their wants
and needs
• Children are most likely to communicate in their own natural
environments
• Children first communicate in the “here and now”
• Children need routines within their natural environments to
learn to communicate
• Children’s receptive communication usually
precedes the development of their expressive
communication.
• Caregivers begin to “interpret” the meaning of
their student’s smiles, vocalizations, facial
gestures before children have any “intent” of
impacting the caregiver.
• Children demonstrate “intentional motor
behaviors” prior to the development of
“intentional communication.”
• Early “intentional” communication occurs in
many forms prior to the development of speech
and language.
Receptive & Expressive Communication
• Research may use the terms: Comprehension
and Production
• The differences in rate of acquisition should
play more a part in our decision-making than
it does.
• Typical children may understand 50-200
words and use only 5-10 words expressively!
(Bates et al., 1995) – we often do not use
these guidelines when teaching signs.
Expressive Communication
Forms
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1. Affective Communication
2. Contingency Communication
3. Instrumental Communication
4. Conventional Communication
5. Emerging Symbolic (Adaptive)
6. Symbolic *
Affective Communication
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Infant Affect
playful
smiling
expressive
interested
calm
sad
fearful
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Caregiver Affect
playful
happy
inviting
observing
comforting
responsive
Contingent Communication
• Child is intentionally acting on toys
• Child uses general excitement as a “causal”
action
• Child imitates action and vocal sounds
already in repertoire
• Child repeats interesting actions on objects
• Increase in joint activity & attention
• Parents provide a linguistic mapping
Forms of Contingent Communication
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General excitement
Body movement
Vocalizations
Facial gestures
Instrumental Communication
• Intentional communication becomes more
apparent
• Criteria for communication is present
• There is an intent to impact another person
• Child terminates signal when goal is
achieved or failure is realized
• Forms: Touching persons & objects;
Manipulating persons & objects, AT devices
The Critical Development of Gestures
• Comprehension and production of gestures is an
early means of expressing intentionality
• Deictic gestures – Establish reference and can only
be interpreted by the content. They can be used with
a variety of objects and events.
• Early deictic gestures may be contact and then more
distal, such as open –handed reaching; reaching to be
picked up.
Conventional Communication
• Child coordinates objects and persons
• Gestures change from reaching to giving to
showing to pointing
• Children increase their rate of prelinguistic
communication acts
• Child applies social actions to objects
• Tool use and imitation also are occurring
• Forms: Extending objects, giving, pointing,
simple gestures as mine, no, all done.
Development of Representational
Gestures
• Symbolic gestures or representational gestures
establish reference and indicate a particular
semantic content.
• Symbolic gestures can be object related or
conventional to represent some concept or
action
An Assessment to Examine the
Development of Gestures
• Based on research by Crais, Watson &
Baranek (2009)
• HANDOUT
Emerging Symbolic Communication
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Representational gestures increase
Vocalizations become “proto words”
Gestures are defined more by the culture
Child begins to use representational play
Children may use more precise movements
if CP is present (eye blinks for yes)
• Pictures or other tangible symbols may be
used.
• Rate of communication acts increase
Symbolic Communication
• Child maintains sustained attention to both
the adult and the object/shift back and forth
• Children are using at least 1 communication
act per minute in an engaged activity
• Children may have 50-100+ words
receptively
• Types of 1-word utterances: existence,
rejection, recurrence, action, state verb
• First words may represent the entire context
Variation in the Rate of
Development
• Gesture & word comprehension
• Gesture & word production
• First word combinations (children go thru a
prolonged period of using single words before
combinations or inflections – 50-200 single
words): Implications!
• First stages of grammar (goes from rote to
rule)
Expressive Communication
Functions
• Early Functions
• Calling or accessing people
• Protesting
• Requesting continuation of an activity once it’s
started and then discontinued
• Requesting an object
• Requesting from a choice of 2 objects or
activities
Expressive Functions
• Later Developing Functions
• Social greeting
• Offering or transferring objects
• Repeating
• Answering questions
• Naming or labeling
Even Later….
• Replying
• Requesting information
• Additional (joking, lying, convincing, etc.)
Communication Mapping
• Select a “sample” child with whom you work
• Determine facilitators and inhibitors for this
specific child
• Fill out only the “Receptive (top)” forms of
communication on the Communication Map
& then fill in the “Expressive forms” (bottom)
and “functions” (middle section) of
communication.
- Handout & Participation Activity-
MacArthur-Bates
Communicative Development
Inventories (CDI)
Fenson et al., (2007) Paul H Brookes, Publisher
• Words and Gestures (Infants: 8-16 months)
Gestures, Actions on Objects, Representational
Play, and 396 Vocabulary Items across 10 semantic
categories
• Words and Sentences (Toddlers: 16-30 months)
680 items based on 22 semantic categories and
grammar
Auditory Lead-Wait-Support-Auditory
Follow-up
• 1. Lead with speech! Say it 1-2 Times (NO MORE)!
• 2. WAIT (1 second for narrative description; 5-7 seconds for
directives for which you expect a response)
• 3. Support with Tactile/Touch Cue prompt while repeating
the word (1 time)
• 4. Say it again – end with speech only, “Bite.”
• Example: (a) Say, “Bite”; Say, “milk” while providing touch
cue,
repeat, “bite…yum-yum.” Later, “You took a bite!”
• Assist Child if no response is made within 7 seconds.