Communication Bridges

This blog is a continuation from Amelie’s previous blog that included parent/ caregiver training. In addition to addressing her parents’ questions and concerns, I thought it was important to include suggestions for activities other than requesting for food or toys. I put together an excel worksheet that included the name of the activity, buttons to be kept open on the home (1st) page of SfY, corresponding buttons to be kept open on the 2nd page, and examples of phrases or sentences that can be modeled. The goal here is to model language using age appropriate activities. We weren’t expecting Amelie to formulate sentences like “put on the eyes” right away when playing with Mr. Potato Head. But, the idea is that if a wide variety of vocabulary and language structures were modeled using SfY, it would stimulate receptive language as well as encourage Amelie to use her “talker” for more than just requesting desired objects. It’s really the same old tried and trusted “Modeling Language for Language Stimulation in Young Children” theory that have been used for generations of early intervention specialists and speech-language pathologists, but with a small twist. In addition to verbal language, we also modeled the language structures using “Speak for Yourself.”

I am attaching the excel sheet that includes the activities and toys. I tried to incorporate materials and toys that are present in most households or clinics, or are fairly inexpensive to purchase if needed.

The categories of activities include: 1) Toys/ games/ art, 2) Cooking, 3) Outside, 4) Books, 5) Songs/music, and 6) Everyday Routines. I wanted to include a wide array of activities to ensure that Amelie was using her talker as much as possible during the day.

Of course, an important point to remember is that this is simply a starting point. You can add, change, delete or modify the language and vocabulary in any of the activities based on your client or child. I simply wanted other families and therapists to look at toys and materials they have at home or in their clinics and realize that there are infinite possibilities for using a child’s AAC system to build language beyond requesting. In addition, I would like to note that even though I’ve used “Speak for Yourself” as the AAC system for Amelie, most, if not all of these activities could be used with any other AAC system such as Proloquo2Go or any Dynavox system.

*Disclaimer: I want to state that although I can take credit for most of the content on the spreadsheet above, I have to thank Amelie’s mother for making it pretty and fun to read by formatting it and adding the colors.

Just as we started opening up Amelie’s vocabulary on Speak for Yourself, her parents requested a training session at home. They wanted to make sure they were doing everything they could at home to incorporate her communication system. (For all of you who are wondering; yes this family is truly that awesome!) It was a unique opportunity. Most speech therapists (myself included) define our success by our client’s progress. But sometimes (especially for AAC), success should be measured by a caregiver’s motivation and ability to incorporate the AAC system in all arenas of the child’s life.

The training was scheduled during Amelie’s naptime. Amelie’s parents and her nanny were present. I prepared for the training session by putting together questions and concerns. I listed them below hoping that they may be useful for other therapists and families.

Categories for Speak for Yourself App

1. How soon should we leave a word “open” on SfY?
   As I understand it, a child has to use a word consistently (about 3-4 times) for it to be considered a part of her vocabulary. It should then be left open as a part of her vocabulary. Think of it this way: when a child learns to say a word, she can access it anytime she wants. We don’t take it away and give it to her only when we want her to say it. I would look at teaching words in the SfY the same way. For Amelie we did deviate slightly for a session to work on discrimination as described in the blog “A Voice for Amelie Part 2: Ready to Choose.” As a therapist or parent, you know your client’s or child’s learning patterns and as such you are the best judge of how quickly you can open up words on the SfY. But the important thing to remember is to allow a child to access his/her vocabulary as soon as possible. Assuming that having multiple buttons open at once may overwhelm the child, is at best presumptuous and undermines a child’s true potential.
2. What’s more important, errorless learning or using the device independently?
   My opinion is that independence is more important than always picking the right word correctly. So decreasing the amount of physical prompts as quickly as possible is recommended. Maybe model once or provide a physical prompt once and then step back to see what she can do. Self-corrections are a great way to learn. Think about how typical children learn language. They have errors in articulation and grammar too. If your child/ client has trouble self-correcting, or is looking at you for help, go ahead and model again. The point to remember is that using physical prompts excessively 1) assumes you know what the child wants and, 2) will reduce the opportunities for a child fix a communication breakdown by self correcting.
3. How often and when should my child/ client have access to her communication system?
   Again, think about how often and when a typical child has access to her voice and her words. That’s right…all the time and everywhere. If “Speak for Yourself” is your child/ client’s voice and communication system, it should really be accessible as often as possible. Even if she doesn’t have the words open that seem appropriate for the situation, she should still have the iPad accessible. How great would it be if it were a natural response for her to reach for the iPad when she wants to comment on something, or ask for something? We can always open or program words for her when appropriate. But the goal for now is to hammer in the idea that this app is (at least for now) her voice and her communication system.
4. Besides making requests, how can we incorporate SfY in our daily lives?
   Using the app to model language everyday is key. It will take some getting used-to. The primary mode of learning for any child is imitation. So the more you model using the app, the more she will use it. While it may be really overwhelming to imagine using the app for every conversation, maybe make a list of daily routines during which you can use SfY. For example:
   – Greetings (e.g., Hi Mommy, Bye Sonali)
   – Diaper changes (e.g., Change diaper)
   – Bath time (wash)
   – Getting dressed (Want dress)
   – Getting into the car (e.g., Go out, Go in car)
   – Going to the park (More swing)
   – Nap time (Wear pajamas)
   – Talk about something unexpected that may happen (e.g., go beach)
   – Use it with a friend, neighbor, or extended family (e.g., Hi, How are you?)
5. Should my client/child have time to play and babble with SfY?
   Yes! As often and for as long as possible during the day.

Other important points to remember:
* If you don’t model using SfY for more than just making requests, she won’t know how to use it for more than just making requests.
** When modeling, think about your goals. If you are targeting 2-3 word utterances, that’s what you want to model.
*** When modeling, you are showing her how to talk using SfY. She isn’t necessarily expected to imitate right away. If she does, that’s great, but if she doesn’t, it doesn’t mean that she isn’t learning. When we model language to a young child, we don’t expect her to imitate the whole sentence right away. She may imitate just a key word, or not say anything at all. She’s still learning.

Amelie began using Speak for Yourself (SfY) independently as long as a single button was open on the screen. She was using it consistently for about two weeks in the therapy room, at home and at school. Despite the enormous success, we knew it was too early to pat ourselves on the back. Having just one button open on the screen while she uses it to make requests wasn’t functional. It was critical that we started opening up the buttons that were familiar so she could discriminate and choose the one she wanted. So during one of her sessions, I tried opening up two buttons (banana and peach). She was familiar with both words. However, the only snack we had was a banana. We didn’t have a peach. We started the session by displaying her snack (banana), and then placing her iPad (now referred to as her “talker”) in front of her. By now, she knew the drill. Like a pro, she hit “eat” which lead her to the secondary page. Now, instead of just one option, there were two. The couple of times she hit “banana” there were no problems. But, when she hit “peach” and I said “Oh, sorry, we don’t have peach today,” there was a meltdown. If she could talk, I know she would be saying, “But I hit the button! What more do you want?!!” After a few episodes, I found myself thinking, “Gosh I wish there was an easier way to do this.” It made me think of an old PECS® training I had attended many years ago. They work on discrimination by pairing a highly desired object with something the child did not care about.

So for the next session, I asked mom to send a food item that Amelie doesn’t like (pickles) along with her favorite snack. So this session I displayed the two snacks and placed her talker in front of her. Once again, hitting “eat” was easy. Again, two options were open on the secondary page: a desired item (banana) and a non-preferred item (pickles). This time, when Amelie hit “pickles” and was presented with pickles, we didn’t have a meltdown. She looked confused. She even tried putting it in her mouth. She spat it out after a few seconds and instead of crying, she reached for her talker again. While this may not seem like a huge deal, to her nanny and I who waited for her outburst with our breaths held, it was an enormous achievement. For the next few trials, every time she hit “pickles,” she shook her head as if to say “no, no, that’s not it,” and then went ahead and hit “banana” instead. Suddenly it seemed that she realized that different buttons meant different words. She understood that because I gave her the pickle when she asked for it. Having her press a button and then say “Oh, I don’t have that,” was too much to process through her frustration. Now that she understands the concept of different buttons for different words, we are seeing a dramatic decrease in tantrums and meltdowns. I can now say, “I’m sorry, there’s no more banana. Would you like grapes instead?” There are no more tantrums. She reaches for her talker and tries again.

Hindsight is always 20/20. I think I should have worked on discrimination earlier than I did. I don’t think Amelie needed the two weeks I gave her to familiarize herself to her talker. Instead of closing all the buttons except the one she was requesting may not have been necessary. In the long run, I don’t think that two weeks is a lot of time lost, but I know that in the future I will push a little harder and move a little faster. While there is the occasional drama when she hits the wrong button sometimes (truthfully, it wouldn’t be Amelie without the drama), the big picture is that she has almost a dozen words on her talker that she can use to make a choice.

Amelie walked into my office four months ago. The little bundle of energy stole my heart right away. Amelie is a 2-year-old little girl with a big personality. She has been diagnosed with developmental delays secondary to hydrocephalus. Her expressive communication was limited to signs for “please,” “want,” and of course, the inevitable, “more.”

After spending a few sessions working on speech sound production, and signs, we noticed some good progress with her imitation of labial sounds /p/, /b/, and /m/. But it was soon obvious to all of us that Amelie’s speech production and her repertoire of signs was insufficient to meet her communication needs. We needed something that was functional, portable, easy to use for both Amelie and her caregivers, and wouldn’t cost an arm and a leg to purchase.

After some research and comparisons, it appeared that the iPad app “Speak for Yourself” might work for Amelie. While everything appeared perfect on paper, we knew we had an uphill battle getting Amelie to use anything other than her signs of “please + more” to request for something. Like we expected, the first few sessions with the app were challenging. Between her protests, she attempted to hit the icons no more than 2-3 times during the entire 45-minute session. While it was discouraging at first, I knew we had to try it a few more times before giving up. For the next session, we closed all but one button on the screen (e.g. eat or give) and then one button on the next screen (e.g. banana or a preferred toy). However, despite all our attempts, Amelie would randomly hit the iPad screen or run her fingers across as if to scroll, or hit the home button. It wasn’t the best start and I felt myself wavering, wondering if I should perhaps try something else instead. But sometimes, you just have to trust yourself. (It certainly helped that Amelie’s parents and nanny are incredibly supportive and like me, felt that we were on the right track and needed to give Amelie a little more time). I decided to try it for another session. I’m not sure what changed, maybe the stars were aligned, or maybe she was hungry and really, really wanted that banana. That day, there were no protests. With minimum support to her elbow, Amelie isolated her finger and hit both buttons (eat and banana) to request her snack consistently for ten consecutive trials. Then, she did it again for grapes, and again for a spinning top, and again for her favorite princess wand. Two weeks later, she was requesting for items using Speak for Yourself on her own without adult support, not only in the clinic, but also at home.

I know that this is only the beginning. I know that we have a long, long way to go. But the mere fact that we have moved beyond signing “please” + “more” for everything, is already a huge step. Most importantly, she now has a communication system that works for her and can grow with her. We finally found a voice for Amelie.

Stay tuned for new blogs to keep you updated on Amelie’s progress with Speak for Yourself.